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Various toxicities: 4 case reports A study described four patients [including 1 man and 2 women; sex of the remaining patient not stated] aged 39–65 years, who did not respond to cytomegalovirus immune globulin for the treatment of cytomegalovirus (CMV) infection (3 patients), or developed oedema, electrolyte disturbances and kidney failure during treatment with foscarnet, and nausea, vomiting and diarrhoea during treatment with letermovir (1 patient). Case 1: A 59-year-old man underwent bilateral lung transplantation for end-stage chronic obstructive pulmonary disease. He received valganciclovir for CMV prophylaxis. However, approximately 3 weeks post-transplant, his CMV viral load increased. Therefore, the dose of valganciclovir was increased. Following successful treatment, his CMV viral load started increasing again. Therefore, about 4 months post-transplant, he started receiving ganciclovir alongside IV cytomegalovirus immune globulin [Cytotect] 100 units/kg once daily. However, no treatment response was observed, and the viral load increased further. Subsequent analyses for resistance revealed a deletion of amino acid in position AA596 and 597 in the UL-97 gene (baseline mutational status unknown), which was responsible for resistance to ganciclovir. Hence, his treatment was changed to foscarnet. However, about 9 months post-transplant, his kidney function significantly deteriorated, and the CMV viral load increased again. Hence, foscarnet was discontinued, and in February 2018, he started receiving letermovir, with a favourable outcome. Case 2: A 65-year-old woman underwent lung transplantation and started receiving valganciclovir for CMV prophylaxis. However, her CMV viral load subsequently increased; hence, the dose of valganciclovir was increased, and she started receiving ganciclovir and cytomegalovirus immune globulin. She later developed abdominal discomfort; hence, she started receiving IV foscarnet 60 mg/kg every 8 hours. She was diagnosed with CMV gastritis. Analyses also revealed ganciclovir resistance (UL97-gene: A594V; baseline mutational status unknown). The treatment with foscarnet caused a rapid decrease in the viral load, which increased again after about 1 month; moreover, she developed treatment-limiting side effects in the form of oedema, electrolyte disturbances and kidney failure, resulting in the discontinuation of foscarnet. Later, when her viral load increased further, she started receiving oral letermovir 480mg once daily. However, she subsequently developed new-onset mild nausea, vomiting and diarrhoea secondary to letermovir [durations of treatments to reactions onsets and outcomes not stated]. Case 3: A 49-year-old woman received bilateral lung transplant for end-stage chronic obstructive pulmonary disease. She received valganciclovir for CMV prophylaxis. However, soon after transplant, her CMV viral load increased; hence, the dose of valganciclovir was increased. Her CMV load slowly decreased, after which it started increasing again. Hence, she started receiving ganciclovir