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Severe chronic norovirus diarrheal disease in transplant recipients: Clinical features of an under‐recognized syndrome
Author(s) -
Avery Robin K.,
Lonze Bonnie E.,
Kraus Edward S.,
Marr Kieren A.,
Montgomery Robert A.
Publication year - 2017
Publication title -
transplant infectious disease
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.69
H-Index - 67
eISSN - 1399-3062
pISSN - 1398-2273
DOI - 10.1111/tid.12674
Subject(s) - medicine , norovirus , diarrhea , vomiting , immunosuppression , nausea , abdominal pain , wasting , gastroenterology , immunology , virus
Background Norovirus ( NV ) infection has been reported as a cause of severe chronic diarrhea in transplant recipients, but this entity remains under‐recognized in clinical practice, leading to diagnostic delays. Transplant clinicians should become familiar with this syndrome in order to facilitate early detection and management. Methods Demographic, clinical, and outcomes variables were summarized from a series of transplant recipients with positive stool NV reverse transcription polymerase chain reaction ( RT ‐ PCR ) assays at Johns Hopkins in 2013‐2014. Factors associated with longer duration of symptoms were compared using random forest analysis. Results Thirty‐one of 193 (16%) transplant recipients who were tested for NV had positive stool RT ‐ PCR s. Symptoms included diarrhea (100%), nausea/vomiting (58%), abdominal pain (52%), and wasting (35%). Acute kidney injury occurred in 23%, and persisted in 21% after 6 months. Median duration of diarrheal symptoms was 4 months (range, <1‐20) and 11/31 (35.4%) patients had relapses after improvement. Wasting, incompatible kidney transplant status, and plasmapheresis were associated with longer diarrhea durations. Treatments included nitazoxanide (in 74%), reduction of immunosuppression (58%), and intravenous immunoglobulin (32%). Six patients died, but no deaths were attributed to NV . Conclusions It is important for clinicians to recognize that NV can cause severe chronic diarrhea in transplant recipients. In this series, receipt of a human leukocyte antigen‐ and/or blood type‐incompatible kidney transplant, and plasmapheresis were associated with longer symptom duration.