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Leflunomide as part of the treatment for multidrug‐resistant cytomegalovirus disease after lung transplantation: case report and review of the literature

Treatment of cytomegalovirus (CMV) disease in transplant patients is challenging and, with antiviral resistance to first‐line drugs, it remains uncertain which treatment algorithm to follow. Some data suggest that leflunomide, a pyrimidine synthesis inhibitor, can be used to treat resistant CMV infections. We report a 57‐year‐old CMV immunoglobulin‐G (IgG)‐seronegative woman, who received a bilateral lung transplant (LuTx) from a CMV IgG‐positive donor with CMV primary disease. The CMV strain was genotypically resistant to ganciclovir, foscarnet, and cidofovir. After starting leflunomide as add‐on therapy to a multidrug anti‐CMV regimen, viral load declined substantially in 2 months without adverse events. This experience is discussed against the background of existing literature on the use of leflunomide as an anti‐CMV agent in LuTx recipients.