What type of study is this?

October 17, 2025Open Access

Refractory CMV Enteritis in Small Bowel Transplantation: A Case Highlighting the Challenges of Balancing Immunosuppression and Novel Antiviral Therapies

AAAbdulrahman Al-SaudKing Faisal Specialist Hospital & Research Centre EAEhab AbufarhanehAlfaisal University MAMadain S. AlsaneaKing Faisal Specialist Hospital & Research Centre

Key Points

Despite aggressive antiviral strategies, outcomes for refractory cmv enteritis in small bowel transplant recipients remain poor due to intense immunosuppression.
An 18-year-old male underwent small bowel transplantation but experienced refractory cmv disease despite using multiple antiviral agents.
The complexity of managing cmv disease in transplant patients includes challenges arising from profound immunosuppression and the need for combination therapies.
Novel agents like maribavir and foscarnet showed promising results but did not completely resolve outcomes for patients facing these severe complications.

Abstract

Background: Cytomegalovirus (CMV) remains a formidable complication in small bowel transplantation (SBT) due to the graft’s high immunogenicity and profound immunosuppression required, with refractory disease representing a particularly devastating challenge. Case: We report an 18-year-old male who underwent SBT, complicated by recurrent acute rejection episodes requiring intensive immunosuppression. He developed refractory CMV disease, marked by non-response to first line therapy with ganciclovir—despite the absence of genotypic resistance—necessitating sequential use of foscarnet, dual antivirals, CMV immunoglobulin, and novel agents (maribavir and letermovir). Discussion: This case illustrates the multifactorial drivers of refractory CMV disease in SBT recipients, including donor–recipient serostatus mismatch, profound immunosuppression through T-cell-depleting induction, corticosteroid exposure, and biologic therapy. It highlights the distinction between refractory and resistant CMV, and the role of combination antiviral strategies including novel agents to achieve disease control. Outcomes remain dismal despite aggressive and innovative therapies, underscoring the limited efficacy of interventions in the context of severe immunologic compromise. Conclusions: Refractory CMV enteritis in SBT exemplifies the extreme difficulty of balancing viral control with rejection management. Despite exhausting antiviral strategies, survival remains poor. Highlights: Refractory CMV enteritis is a significant challenge in small bowel transplant recipients due to intense immunosuppression. Persistent CMV disease may occur despite antiviral prophylaxis and the absence of resistant gene mutations. Combination antiviral strategies, including maribavir, demonstrated significant clinical improvement. Profound immunosuppression required to manage acute graft rejection episodes complicates antiviral management and disease clearance. Despite best efforts in CMV management in this population, outcomes may still be compromised by unrelated or compounding factors.

Ask AI

Helpful

Bookmark

View Full Paper