retinitis, duodenal and/or colonic involvement, or dissemi-Cytomegalovirus (CMV) is a significant cause of morbidity nated disease. [2][3][4] CMV infection after OLT has been linked to in immunosuppressed patients. It is characterized in the liver decreased patient survival, particularly in studies published by parenchymal microabscesses, usually containing CMV-inbefore the availability of CMV-specific antivirals. 2,3,5-10 Stratta fected cells. However, not all hepatic microabscesses are due et al. 6 found that CMV infection in OLT recipients is associto CMV infection. In 1992, we described ''mini'' microabscess ated with increases in the duration of the peritransplant hos-(MMA) syndrome, a distinct clinical syndrome that occurs pital stay (38-80 days) and the average costs of these admisin transplanted livers. This report analyzes the clinical and sions (US$100,000-250,000).
laboratory features of 57 cases of MMA syndrome occurring
CMV infection usually occurs in the first 3 months after in 52 patients and compares these with 19 biopsy-proven OLT. 2,4,6 CMV infection of the liver tends to be focal and cases of CMV infection. The diagnosis of MMA syndrome can may affect hepatocytes, bile duct epithelium, endothelium, only be made histologically. The microabscesses are smaller or any combination of these sites. Infected cells often contain and more numerous than in CMV infection, and there are no a single large eosinophilic nuclear inclusion surrounded by viral inclusions present. CMV DNA could not be detected in a halo, and/or numerous amphophilic granular cytoplasmic liver biopsy specimens with MMAs by using ''nested'' polyinclusions. 11 In the hepatic lobule, the infected cells are often merase chain reaction (PCR), indicating that MMA syndrome surrounded by a collection of neutrophils, forming a miis not caused by CMV infection. The pattern of liver enzyme croabscess. Occasionally a microabscess may lack morphoand bilirubin elevation is predominantly hepatocellular, with logically infected cells. 12 In this setting, the presence of mitransaminase levels elevated, on average, six to eight times croabscesses, even in the absence of typical CMV infected the upper limit of normal. The clinical features of MMA syncells, could be interpreted as evidence of CMV infection. drome are that it predominantly affects female (40 of 52 pa-Currently, CMV infection in OLT recipients can usually tients) orthotopic liver transplant (OLT) recipients of all ages be successfully treated with ganciclovir. 3,6,13 Because of the (range, 11 months to 66.9 years). MMA syndrome is unrelated significant costs of untreated CMV infection in OLT recipito the indication for initial OLT and tends to occur later after ents, several groups have stressed the need for a high index transplantation than CMV infection (median, 91 days postof suspicion for CMV infection post-OLT and have supported OLT vs. 32 days for CMV hepatitis). Although the etiology an aggressive approach to the diagnosis and treatment of of MMA syndrome is not clear, it does not appear to adversely CMV infection. 2,8,13,14 However, ganciclovir therapy is expenaffect graft or patient survival. (HEPATOLOGY 1997;26:192sive in terms of both nursing time and the cost of the drug.
197.)
Intravenous therapy with ganciclovir also carries the risk of systemic bacterial infection and other complications of Cytomegalovirus (CMV) infection is a major cause of morintravenous access in this already-compromised population. bidity in immunosuppressed patients, particularly transplant In 1992, we described a novel lesion, ''mini''-microabrecipients. 1 In orthotopic liver transplant (OLT) recipients, scesses (MMAs), seen in 14 liver biopsy specimens from CMV infection can result in hepatitis, pneumonitis, chorio-OLT recipients. 15 When MMAs were first seen, they were considered evidence of CMV infection and treated accordingly. However, as our experience grew, MMAs appeared
Abbreviations: CMV, cytomegalovirus; OLT, orthotopic liver transplant; MMA, minihistologically and clinically distinct from CMV-associated microabscess; AST, aspartate transaminase; ALT, alanine transaminase; PCR, polymermicroabscesses. MMAs were smaller and more numerous ase chain reaction; CI, confidence interval.