Case Report: Extracorporeal Photophoresis for Treatment of Severe Cytomegalovirus Infection after Heart Transplantation in a Patient with Giant Cell Myocarditis

Introduction We present the case of a patient (38 years, male) who underwent heart transplantation (HTx) 06/2017 due to giant cell myocarditis (GCM). Post-HTX, the patient suffered from acute cellular rejection (ACR) and antibody mediated reaction (AMR) and developed a severe symptomatic CMV infection with symptomatic organ manifestation. Most likely, the underlying diagnosis of GCM and the resulting alteration of the immune system provoked enhancing donor specific antibodies and thus rejection.The aim of this case report is to demonstrate an example of successful extracorporeal photopheresis (ECP) after HTx as a treatment option for therapy resistant CMV infection and rejection. Case Report Endomyocardial biopsies (EMBs) were taken after 3 weeks and 3, 6, 12, 24, 48 and 70 months after HTx. Severe CMV infection was initially treated with i.v. ganciclovir and human CMV-immunoglobulins, and, thereafter with valganciclovir in the outpatient setting. ECP was started in 11/2019 with initially 8 cycles per month, followed by 2 × 4 cycles per months and 2 cycles monthly thereafter. Clinical follow-ups were performed every 3 months and included blood work, CMV-PCR and echocardiography. After 3 weeks post HTx, AMRII (ISHLT 2013) without hemodynamic compromise was diagnosed, and EMBs showed recurring rejections throughout the course. After 22 months, the patient developed severe CMV infection with organ manifestation (esophagitis, gastritis, parotitis, carditis), which was treated with i.v. ganciclovir and CMV-immunoglobulines. However symptomatic CMV-infection returned in outpatient care despite ongoing oral antiviral therapy. Thus, we started ECP therapy. No severe adverse effects were seen during ECP. After start of ECP, EMBs showed persisting low-grade ACR without hemodynamic compromise and no more signs of AMR. The patient fully recovered from CMV infection and presented asymptomatically at the latest follow up. Summary ECP had shown to be a safe and feasible treatment option for this patient with convincing results regarding both the course of severe CMV infection as well as ACR and AMR.