An Unusual Case of Early Cytomegalovirus Retinitis with UTI, Invasive Pulmonary Aspergillosis, Klebsiella Pneumonia in a Renal Allograft Recipient

Abstract

Cytomegalovirus (CMV) remains the most common opportunistic infection after a kidney transplant. CMV retinitis is a rare manifestation of CMV invasive disease and is potentially threatening to vision in immunocompromised individuals. Invasive aspergillosis (IA) is one of the major causes of invasive fungal infection in kidney transplant recipients. Posttransplant CMV significantly increases the risk of IA in solid organ transplants. However, simultaneous or superadded opportunistic infections are rare and often delay the diagnosis. We report a case of early CMV retinitis in a renal transplant recipient, who initially developed extended-spectrum beta-lactamase-positive Escherichia coli cystitis at 2 weeks posttransplant. At 4 weeks posttransplant, he developed CMV retinitis managed with intravenous and intravitreal ganciclovir. At around 6 weeks, he developed persistent low-grade fever and pancytopenia without any specific systemic symptoms with initial sterile cultures sterile and normal imaging except for high-resolution computed tomography chest, which was suggestive of fungal pneumonia. Bronchoscopy and bronchoalveolar lavage were done, which came positive for aspergillus colonies. The patient improved with Amphotericin B, which was later changed to oral voriconazole. A few days later, the patient again deteriorated with new-onset fever, cough, and expectoration, which were diagnosed with Klebsiella pneumonia by imaging supported by sputum culture, which was managed by appropriate antibiotics. CMV and IA are both uncommon opportunistic infections and simultaneous or superadded infection with bacterial pneumonia is very rare. In the presence of persistent symptoms, early suspicion of another infection is crucial for patient management and long-term prognosis.