For a renal transplant patient on chronic immunosuppression with resolved esophageal symptoms (epigastric pain and intermittent dysphagia), does the presence of minimal CMV-positive cells on esophageal biopsy warrant preemptive antiviral therapy, or is clinical monitoring sufficient?

All things equal, in the average patient, if a patient has rare/minimal CMV-positive cells, it could occasionally represent a minimal infection or an incidental finding. However, in a transplant patient who is on immunosuppression, and especially one who has had recent symptoms (such as dysphagia in this case), then treatment is recommended. I also recommend coordinating the specific treatment and dosing with the patient's transplant nephrology and ID teams.