Introduction Noroviruses are a common cause of acute gastrointestinal illness worldwide and can be life-threatening in immunocompromised patients e.g. intestinal transplantation (ITx).1,2No treatment is currently available for Norovirus infection.
Method The Noroviral status of 85 paediatric ITx recipients at Birmingham Children’s Hospital (1993–2014) was recorded and the first episode of gastroenteritis was identified.
Results 20 patients developed Noroviral gastroenteritis (12F:8M). 7 patients received isolated ITx, 11 combined liver and ITx and 2 multivisceral transplant. The mean age at transplantation was 7.2 yrs (range 11 months – 10 yrs) and at diagnosis of Noroviral infection 10.15 yrs (range 1–17 yrs). The mean time interval of transplantation and Noroviral infection was 2.15 yrs (range 2 months- 15 yrs). The time of hospitalisation varied significantly depending on the co-morbidities (5–114 days). 9 patients received intensified immunosuppression within the last 3 months prior to Noroviral infection due to rejection, PTLD, GvHD or other autoimmune process. All patients presented with increased stool output, while 5 also presented with vomiting and 9 with dehydration. The immunosuppressive regime included Tarolimus and Prednisolone in 13 patients and a combination of Tacrolimus, Prednisolone, MMF, Sirolimus, Infliximab and Azathioprine in the rest. 6 patients developed rejection, 5 had a concomitant stool infection, 2 were diagnosed with PTLD and 7 had a systemic infection. 7 patients required parenteral nutrition (PN) and 14 received oral human immunoglobulins (OHIG) as part of their treatment. The outcome for 2 patients was death (both diagnosed with PTLD). All other patients managed to re-establish enteral feeds with 4 needing extra overnight IV fluids or PN.
On average, the children treated with OHIG were younger with a shorter time interval between Noroviral gastroenteritis and ITx. OHIG reportedly shortens the period of diarrhoea3but we did not observe a shortened hospitalisation time. The histopathological appearances of norovirus can mimic rejection2and it is important to correlate clinically.
Conclusion Norovirus is a significant pathogen in ITx and differentiation from rejection is crucial. OHIG may have a role in the treatment of ITx recipients.
Disclosure of interest None Declared.
Bok K, Green KY. N Engl J Med. 2012;367(22):2126–2132
Kaufman SS, et al. J Pediatr Gastroenterol Nutr., 2005;40(3):328–333
Florescu DF, et al. Pediatr Transplant. 2011;15(7):718–21