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Abstract: PO2445

John Cunningham Virus (JCV) in Renal Allograft Recipients (RAR)

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • Saleem, Bushra Z., Rutgers The State University of New Jersey, New Brunswick, New Jersey, United States
  • Puri, Sonika, Rutgers The State University of New Jersey, New Brunswick, New Jersey, United States
  • Mondal, Zahidul H., Rutgers The State University of New Jersey, New Brunswick, New Jersey, United States
Introduction

Both JCV and BK virus belong to Polyoma virus (PV) family and can lead to opportunistic infection in RAR. BK nephritis in RAR is well described in literature (incidence 1- 10 %) in contrast to JCV nephropathy (JCVN) which is a rare entity. Here we describe two cases of JCV in RARs.

Case Description

Case 1: 44-year-old woman with PMH of HTN and ESRD received her first renal transplant in 2009 followed by antibody mediated rejection (AMR) resulting in graft dysfunction. She received a preemptive second renal transplant in 12/2015 followed by multiple RA biopsies within first few months due to elevated serum creatinine (s.cr). The biopsies showed borderline CMRs, acute AMRs and eventually chronic active AMR. Treatment regimen included steroids, rituximab, IVIG and plasmapheresis. Despite repeated treatments, her s.cr remained elevated leading to another biopsy in 6/2016 showing viral cytopathic changes suspicious for PVN. SV40 stain was negative as was serum BK titer. Immunosuppression (IS) was reduced and a biopsy was repeated in 8/2016 that stained positive for SV40. Given repeatedly negative serum BK, serum JCV titer was sent, which was positive and peaked at 350659 copies/ml on 9/2016. Titer improved to 66153 after 2 doses of Cidofovir however, later deteriorated to 334240. She had no neurological involvement. Despite Cidofovir, her renal function deteriorated rapidly requiring bilateral RA nephrectomies with pathology showing JCVN. IS was discontinued following which JCV titer became undetectable.
Case 2: 59-year-old man with PMH of HTN and ESRD who received renal transplant in 4/2013 followed by baseline s.cr of 1.6 mg/dl. He was on Myfortic, Sirolimus and Prednisone for IS. He presented with rising s.cr in 9/2019 (2.1mg/dl). He underwent RA biopsy in 11/2019 showing viral cytopathic changes, positive SV40 consistent with PVN. BK by PCR resulted negative x 2 but JCV titer returned at 3896 copies/ml. Myfortic was discontinued. Repeat JCV titer trended down to 2603 in 3/2020. Further follow up was delayed due to COVID-19 pandemic.

Discussion

The diagnosis of JCVN is challenging and easy to miss. Index of suspicion should be high with positive viral cytopathic changes ( +/- SV40 stain) on allograft biopsy and negative serum BK. Currently there is no definitive therapy for JCV. Early diagnosis and reduction in IS are critical. Cidofovir may be of utility.