Early diagnosis and successful treatment of cytomegalovirus peritonitis in children with primary nephrotic syndrome: case series and literature review

Figures & data

Figure 1. Abdominal plain film of case 1.

Table 1. Results of peritoneal fluid analysis and culture in 4 cases of NS with CMV peritonitis.

Laboratory test	Case 1	Case 2	Case 3	Case 4
Appearance	Light red and turbid	Semi clear	Clear	Clear
WBC (10^6/L)	38.0	7.0	54.0	40.0
Mononuclear cell (%)	65.0	ND	77.0	85.0
Multinuclear cell (%)	35.0	ND	23.0	15.0
Rivalta test	2+	+/−	–	+
ALB (g/l)	0.3	1.0	0.2	0.2
Lactic dehydrogenase (u/l)	51.0	31.0	9.0	13.0
Adenosine deaminase (u/l)	3.2	2.5	1.4	1.7
Glucose (mmol/l)	6.6	6.9	8.5	5.2
Bacterial, fungal culture	–	–	–	–
Acid-fast bacilli smear	–	–	–	–

ND mean not done, − mean negative, + mean positive.

Figure 2. Chest radiograph of case 2.

Figure 3. Renal biopsy of case 3. (A) Epithelial cells of renal tubule showed granular and vacuolar degeneration (H&E staining, ×4). (B) Mild proliferation of mesangial cells and stromal cells (H&E staining, ×400). (C & D) electron microscopy image showing minimal change disease, extensive fuzing of podocyte processes of the epithelial cells (arrow).

Figure 4. Chest radiograph of case 4.

Table 2. Summary of relevant data of four patients in the literature.

project	Patient 1 [2]	Patient 2 [3]	Patient 3 [4]	Patient 4 [5]
Age (years)	35	24	29	37
Gender	Female	Male	Male	Female
Underlying disease	After kidney transplantation	After liver transplantation	AIDS	After kidney transplantation
Immunosuppression treatment	Tacrolimus, MMF, methylprednisolone, basiliximab steroid pulse, gusperimus hydrochloride therapies	Methylprednisolone, tacrolimus, MMF, prednisolone, cotrimoxazole, mesalazine	No	Tacrolimus, alemtuzumab, methylprednisolone
Clinical manifestation	Urinary retention, Abdominal pain	Fever, nausea, vomiting, abdominal pain, diarrhea	Fever, abdominal pain, sore throat, nausea, vomiting	Abdominal pain
Physical examination	Abdominal tenderness	Herpes labial, abdominal bulge and tenderness, shifting dullness	Diminished bowel sounds, abdomen was rigid, tender and rebound tenderness	Tenderness, turbid ascites
Laboratory test of blood	Slight elevation of CRP, CMV PP65 antigen (+)	CMV DNA (−), CMV pp65 antigen (−)	Elevation of ALT	Decreased WBC, CMV PP65 antigen (+)
Basis of diagnosis	Peritoneum showed CMV viral inclusion bodies through histopathological examination	CMV DNA was detected in ascites (500 copies/ml)	Peritoneum showed CMV viral inclusion bodies through histopathological examination	CMV DNA was detected in ascites (>25 × 10^6 copies/ml)
Antiviral treatment	Intravenous GCV (5 mg/kg twice daily , 12d), oral VGCV (450 mg qd, 3w)	Intravenous GCV (10 mg/kg/day , 1w), oral VGCV(900 mg bid, 2w; 900mg qd, 3w)	GCV (detail was unknown)	Intravenous GCV (150 mg twice daily)
Prognosis	Symptoms disappeared after 12 days, without recurrence for 5 years	Symptoms disappeared in 1 week, without recurrence for 1 years	Death	Symptoms disappeared

Hotta K, Fukasawa Y, Wada Y, et al. Cytomegalovirus peritonitis after kidney transplantation diagnosed through histopathological examination. Transpl Infect Dis. 2017;19(4):e12708.

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Lankarani KB, Taghavi SA, Pahlavan SM, et al. Cytomegalovirus peritonitis without gut perforation but with concomitant colitis after a liver allograft transplant. Exp Clin Transplant. 2017;15(1):106–109.

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Wilcox CM, Forsmark CE, Darragh TM, et al. Cytomegalovirus peritonitis in a patient with the acquired immunodeficiency syndrome. Dig Dis Sci. 1992;37(8):1288–1291.

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Data availability statement

All meaningful data generated or analyzed in this study are included in the manuscript.