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University of Alabama at Birmingham, Birmingham, AL
PURPOSE: Cytomegalovirus (CMV) remains an important cause of morbidity and mortality in lung transplant recipients. While treatment is indicated for symptomatic patients, the significance of CMV on bronchoalveolar lavage culture (BAL) alone, in the absence of symptoms, antigenemia, or CMV on biopsy, is less clear and has not previously been evaluated. Our aim was to determine the frequency of CMV isolated only on BAL, and then assess the safety of withholding antiviral therapy from asymptomatic recipients.
METHODS: This study is a retrospective review of all lung transplant recipients at a tertiary center over a 4-year period (1999-2003). Data collected include demographics, serologies, bronchoscopy results, occurrence of CMV disease, and time and cause of death post-transplant. We report the incidence of CMV found solely on BAL in asymptomatic recipients, as well as the rate of subsequent CMV disease in these patients.
RESULTS: Over the study period, 147 patients underwent lung transplantation. Average recipient age was 48.3 years. Patients received CMV prophylaxis according to standardized protocol, as determined by serologies. 1,473 surveillance bronchoscopies were performed, and 98 positive BALs for CMV were identified. Of these, 63 occurred in 40 patients who were asymptomatic and without concomitant antigenemia or CMV on biopsy. Over 6-months follow-up from the positive BAL result, during which antiviral therapy was held, 3 of 40 (7.5%) patients developed CMV disease. All 3 had symptoms and positive antigenemia at an average of 70 days (23-105 days) after BAL detection of CMV and 319 days (124-505 days) after transplant. There were no deaths attributable to CMV.
CONCLUSION: We observe a significant proportion of lung transplant recipients (40 of 147, or 27%) with CMV solely on BAL who are otherwise clinically asymptomatic. In the absence of symptoms, antigenemia, or CMV on biopsy, these patients have a low likelihood of subsequent CMV disease over 6 months and can be followed safely without antiviral therapy.
CLINICAL IMPLICATIONS: Asymptomatic lung transplant recipients with CMV detected on BAL alone do not require antiviral therapy.
DISCLOSURE: J.J. Murdock, None.
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