The first case of acute unilateral pan-ureteritis caused by BK polyomavirus in an allogeneic stem cell transplant patient.

Several cases of ureteral obstruction have been reported in stem cell transplant (SCT) patients; however, they were bilateral and concomitant with or preceded by hemorrhagic cystitis. We describe, to our knowledge, a first case of acute unilateral pan-ureteritis caused by BK polyomavirus (BKPyV) in an SCT patient. This case may represent an early phase of BKPyV reactivation. BKPyV infection should be considered as a potential cause of acute unilateral ureteritis even among SCT recipients.

BK virus-associated nephropathy with hydronephrosis in a patient with AIDS: a case report and literature review.

BK virus is ubiquitous worldwide, with infection usually occurring in early childhood. BK virus replicates prolifically under immunosuppressive conditions, causing inflammation along the genitourinary tract and progressing clinically to hemorrhagic cystitis, ureteral stenosis, and tubulointerstitial nephritis. Most BK virusassociated nephropathy occurs in renal allograft patients after kidney transplantation, although some case reports have described BK virus-associated nephropathy in the native kidney, particularly in patients with human immunodeficiency virus infection. Here we present the case of a 49-year-old male with acquired immunodeficiency syndrome (AIDS) and renal dysfunction with hydronephrosis. The renal biopsy showed tubulointerstitial nephritis with lymphoplasmacytic infiltrates and intranuclear inclusions in the tubular epithelium, which are typical findings for BK virus-associated nephropathy. In addition, immunohistochemical staining revealed that the SV40 large T antigen exhibited a nuclear localization in tubular cells. To the best of our knowledge, this is the first case report of BK virus-associated nephropathy combined with hydronephrosis that was diagnosed by biopsy in a patient with AIDS.

BK virus associated pronounced hemorrhagic cystoureteritis after bone marrow transplantation.

Ureteral stenosis due to reactivation of the BK virus (BKV) in a state of immunodeficiency is very rare. More common is the appearance of a hemorrhagic cystitis. This report not only shows bilateral ureteral stenosis after bone marrow transplantation, but also presents severe complications as chronic pelvic pain and impaired kidney function as well as irreparable damage to the whole urinary tract leading to nephroureterectomy, subtrigonal cystectomy and orthotopic ileal neobladder. Finally renal transplantation was required. To our knowledge this is the first case in the literature where such a severe course of BKV associated hemorrhagic cystoureteritis is described.

Unusual case of severe late-onset cytomegalovirus-induced hemorrhagic cystitis and ureteritis in a renal transplant patient.

Cytomegalovirus (CMV) infection is common in solid organ transplant recipients and accounts for the majority of graft compromise. Major risk factors include primary exposure to CMV infection at the time of transplantation and the use of antilymphocyte agents such as OKT3 (the monoclonal antibody muromonab-CD3) and antithymocyte globulin. It most often develops during the first 6 months after transplantation. Although current prophylactic strategies and antiviral agents have led to decreased occurrence of CMV disease in early posttransplant period, the incidence of late-onset CMV disease ranges from 2% to 7% even in the patients receiving prophylaxis with oral ganciclovir. The most common presentation of CMV disease in transplant patients is CMV pneumonitis followed by gastrointestinal disease. Hemorrhagic cystitis is a common complication following hematopoietic stem cell transplantation. The condition is usually due to cyclophosphamide-based myeloablative regimens and infectious agents. Even in these settings, CMV-induced cases occur only sporadically. Ureteritis and hemorrhagic cystitis due to CMV infection after kidney transplantation is reported very rarely on a case basis in the literature so far. We report here a case of late-onset CMV-induced hemorrhagic cystitis and ureteritis presenting with painful macroscopic hematuria and ureteral obstruction after 4 years of renal transplantation. The diagnosis is pathologically confirmed by the demonstration of immunohistochemical staining specific for CMV in a resected ureteral section. We draw attention to this very particular presentation of CMV hemorrhagic cystitis with ureteral obstruction in order to emphasize atypical presentation of tissue-invasive CMV disease far beyond the timetable for posttransplant CMV infection.

Intravesical condylomata accuminata in HIV positive patient.

A 48-year-old HIV positive woman presented with urgency, frequency, recurrent cystitis and episodic macroscopic hematuria. Cystoscopy revealed papillary lesions involving most of the bladder. Histology of bladder biopsies revealed human papilloma virus (HPV) associated condyloma acuminata. We discuss the treatment of this rare lesion and review the literature.

[Ureterostomy cytomegalovirus infection presenting as stoma ulceration in a kidney allograft receptor: a case report]. / Ureteritis por citomegalovirus en receptor de trasplante renal. Informe de un caso con presentación inusual.

Cytomegalovirus (CMV) is the most common viral infection affecting transplant patients, but urinary tract involvement has been rare. Only a few cases of symptomatic ureteritis have been reported in renal transplant recipients. In previous reports the presentation of CMV ureteritis is obstructive nephropathy, often in the absence of systemic illness, or rarely it may also mimic allograft rejection with minimal obstructive symptoms. We describe an additional case of CMV ureteritis in a patient with cutaneous ureterostomy. The unusual clinical presentation with urinary infection symptoms and ureterostomy stoma ulceration constitute a very particular presentation. The increasing report cases with CMV ureteritis suggest an increase of this post-transplant complication.

Cytomegalovirus infection may cause ureteral necrosis.

Cytomegalovirus (CMV) infection has protean presentation among immunocompromised patients, but the urinary tract is rarely involved. We report a case of extensive ureteral necrosis in a renal transplant, 12-year-old patient with typical histological feature of CMV inclusions. The role of CMV was confirmed by immunohistochemical analysis and concomitant CMV DNA detection in peripheral blood leukocytes by polymerase chain reaction analysis. CMV infection can, therefore, be regarded as a possible cause of ureteral necrosis in renal transplant recipients.

Ureteritis and cholecystitis: two unusual manifestations of cytomegalovirus disease in renal transplant recipients.

BACKGROUND: Common clinical manifestations of cytomegalovirus (CMV) infection include flu-like symptoms with fever, diarrhea, leukopenia, and elevated liver enzymes. Diagnosis is made by detection of the virus by buffy-coat blood culture or by polymerase chain reaction (PCR) analysis. METHODS: Here we describe two renal transplant recipients who presented with unusual manifestations of CMV disease (cholecystitis and ureteritis). In both patients, no symptoms or signs of systemic CMV infection were present, and they were thought to have other common causes for cholecystitis and ureteral obstruction. RESULTS: Retrospective analysis of peripheral blood by PCR analysis was positive for CMV DNA. Histologic examination of the resected gall bladder and stenotic ureteric segment showed CMV inclusions, confirmed subsequently by in situ hybridization. Thus, we report that CMV infection may present with acute cholecystitis or ureteral obstruction without its classical clinical symptoms. CONCLUSIONS: Because CMV infection is common in transplant patients, the atypical manifestations of CMV should be considered in the differential diagnosis of posttransplant complications. Detection of CMV DNA in the peripheral blood by PCR analysis may help identify these patients.

CMV and BKV ureteritis: which prognosis for the renal graft?

This report describes two cases of ureteral stricture in renal graft recipients related to cytomegalovirus (CMV) and human polyoma BK virus (BKV) ureteritis with the same onset characterized by acute graft failure with no clinical signs of systemic viral infections. The histological analysis did not show other causes of graft impairment (i.e. drug toxicity and acute rejection). Ultrasound scan (US) revealed absent or mild hydronephrosis. The diuretic-MAG3 renal scan showed a urinary flow obstruction. The viral genomes were isolated from urine, peripheral blood and graft or ureteral tissues samples. A percutaneous nephrostomy confirmed the stricture, but it restored urine flow only in the graft affected by CMV ureteritis, the association with a specific antiviral therapy probably produced a stable restoration of graft function. In BKV ureteritis,the graft prognosis was poor; graft loss could be due to the progress of BKV nephropathy. A correct differential diagnosis of the etiologic agent responsible for the ureteritis is mandatory, because treatment and outcome of the infection are different.

Fluorescence urethroscopy following instillation of 5-aminolevulinic acid: a new procedure for detecting clinical and subclinical HPV lesions of the urethra.

OBJECTIVE: To report early clinical experience with intraurethral instillation of 5-aminolevulinic acid (ALA) for the detection of clinical lesions (condyloma acuminata) and subclinical human papillomavirus (HPV) lesions of the urethra, not visible by conventional endoscopy. SUBJECTS AND SETTING: Eighty-four men with clinical diagnosis of condyloma acuminata were examined for urethral HPV lesions at the Department of Urology, Ludwig Maximilian University, Munich, Germany. METHODS: The anogenital areas of the patients were thoroughly examined using a magnifying glass before and after application of 5% acetic acid. Conventional as well as fluorescence urethroscopy were performed 1 h after topical application of 0.1% ALA for 15 min. A sensitive colour charge-coupled device camera for fluorescence video inspection was used with spectral analysis. Biopsies were taken for histological examination and HPV detection by polymerase chain reaction (PCR). RESULTS: Forty-three of 84 men attending our clinic for condyloma acuminata had clinical HPV lesions of the urethra. Condylomas of the proximal urethra were found by conventional endoscopy in eight patients. Fluorescence urethroscopy detected additional subclinical lesions in 13 men. All lesions were HPV infections of the urethra confirmed histologically or by PCR. In nine of these subclinical urethra lesions low-risk HPV types (HPV6, 11, 34) were found. Four lesions were associated with high-risk types (HPV18, 31,52,58). CONCLUSIONS: Fluorescence urethroscopy is a promising diagnostic procedure for detecting subtle clinical and subclinical HPV lesions of the urethra, that are normally not visualized by conventional endoscopy. Generally, urethroscopy is recommended in all cases of externally visible condylomas of the urethra after therapy.

Four cases of CMV ureteritis: emergence of a new pattern of disease?

Although cytomegalovirus (CMV) infection is common in renal transplant recipients, urinary tract involvement has been rare. Only six cases of symptomatic ureteritis have been reported in renal transplant recipients and all within the last five years. We describe an additional four cases of CMV ureteritis. The presentation of CMV ureteritis is obstructive nephropathy often in the absence of systemic illness. Presentation may also mimic allograft rejection with minimal obstructive symptoms. We hypothesize that CMV ureteritis is an emerging complication of CMV disease, possibly due to changes in transplant practice.

Cytomegalovirus ureteritis as a cause of renal failure in a child infected with the human immunodeficiency virus.

Cytomegalovirus (CMV) infection is common in patients infected with human immunodeficiency virus. Hemorrhagic cystitis and tubulointerstitial nephritis have been recognized as complications of CMV infection, and these complications lead to hematuria and compromised renal function. We describe a case of CMV infection of the ureters in a child with vertically acquired human immunodeficiency virus infection; the child presented with severe suprapubic pain, and prolonged macroscopic hematuria and intermittent acute renal failure developed subsequently.

Cynomolgus polyoma virus infection: a new member of the polyoma virus family causes interstitial nephritis, ureteritis, and enteritis in immunosuppressed cynomolgus monkeys.

Polyoma virus infection causes acute interstitial nephritis and ureteral stenosis in humans but has rarely been noted in other species. In the present study, a hitherto unknown polyoma virus was detected in 12 of 57 cynomolgus monkeys after 3 to 11 weeks of immunosuppression given to promote acceptance of renal allografts or xenografts. This virus, termed cynomolgus polyoma virus (CPV), is antigenically and genomically related to simian virus 40 (SV40). The tubular epithelial nuclei of the collecting ducts in the medulla and cortex reacted with an antibody for the SV40 large T antigen and by electron microscopy contained densely packed paracrystalline arrays of 30- to 32-nm diameter viral particles. A polymerase chain reaction analysis of DNA extracted from affected kidneys detected polyoma virus sequences using primers for a highly conserved region of the large T antigen of polyoma virus. Sequence analysis showed 7 base substitutions and 3 to 5 deletions in the 129-nucleotide segment of amplified products, compared with the corresponding portion of SV40, yielding 84% homology at the amino acid level. CPV caused interstitial nephritis in six renal allografts, a xenograft kidney, and six native kidneys. Infected animals showed renal dysfunction and had tubulointerstitial nephritis with nuclear inclusions, apoptosis, and progressive destruction of collecting ducts. CPV was detected in the urothelium of graft ureters, associated with ureteritis and renal infection. Viral infection was demonstrable in smooth muscle cells of the ureteric wall, which showed apoptosis. One animal had diarrhea and polyoma virus infection in the smooth muscle cells of the muscularis propria of the intestine. Spontaneous resolution occurred in one case; no animal had virus detected in tissues more than 3 months after transplantation. Thus, immunosuppression predisposes cynomolgus monkeys to a polyoma virus infection with clinical consequences quite similar to BK virus infection in humans, including renal dysfunction. We also suggest that this may be the pathogenetic basis for the significant incidence of late onset, isolated ureteral stenosis observed in these recipients.

Ureteritis por citomegalovirus en receptor de trasplante renal. Informe de un caso con presentación inusual / Ureterostomy cytomegalovirus infection presenting as stoma ulceration in a kidney allograft receptor: a case report

La infección por citomegalovirus (CMV) es la infección viral más frecuente en pacientes trasplantados, pero es muy inusual el compromiso del tracto urinario. Sólo se han informado unos pocos casos de uretritis por CMV en trasplantados renales. En los informes previos la presentación clínica más habitual es nefropatía obstructiva, a menudo en ausencia de enfermedad sistémica, o, algunas veces, puede simular un episodio de rechazo con mínimos síntomas obstructivos. Nosotros describimos un caso más de uretritis por CMV en un paciente trasplantado renal con ureterostomía y una presentación muy inusual caracterizada por síntomas de infección de vías urinarias y ulceración en la boca de la ureterostomía. El número incrementado de informes de ureteritis por CMV en trasplantados renales plantea la posibilidad de un aumento en la incidencia de esta complicación post-trasplante (AU)

Cytomegalovirus (CMV) is the most common viral infection affecting transplant patients, but urinary tract involvement has been rare. Only a few cases of symptomatic ureteritis have been reported in renal transplant recipients. In previous reports the presentation of CMV ureteritis is obstructive nephropathy, often in the absence of systemic illness, or rarely it may also mimic allograft rejection with minimal obstructive symptoms. We describe an additional case of CMV ureteritis in a patient with cutaneous ureterostomy. The unusual clinical presentation with urinary infection symptoms and ureterostomy stoma ulceration constitute a very particular presentation. The increasing report cases with CMV ureteritis suggest an increase of this post-transplant complication (AU)