Fever in a Post-Transplant Patient

Hello everyone,

Today we discussed a case of a middle-aged man 7 months status post liver transplant, on tacrolimus and mycophenolate, who presented with systemic symptoms & headache, found to have disseminated cocci!

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 TOP PEARLS:

  • Post-transplant fever can be categorized into big categories: infection, rejection, med effect, progression of underlying disease, and PTLD
  • Risk and types of infection after transplant changes over time!
  • Peruse the NEJM article on “Infections in solid-organ transplant recipients.”
    http://www.nejm.org/doi/pdf/10.1056/NEJMra064928

Fever in a Post-Transplant Patient

  1. Infection

 

  • It’s more difficult to recognize infection in transplant recipients than in patients with normal immune function.
  • Risk of infection after transplant changes over time, with modifications in immunosuppression. Broadly, think in terms of 4 broad categories: 1) donor derived infections; 2) recipient derived infections; 3) nosocomial infections; 4) community infections
  • See this chart from NEJM article, Infections in Solid-Organ Transplant Recipients (PMID 18094380, link: http://www.nejm.org/doi/pdf/10.1056/NEJMra064928)

Picture1.png

  • See this very helpful visual from Jen Babik’s talk on this topic:

Picture2.png

2. Rejection

 

  • Acute cellular rejection: within 90 days of liver transplantation
  • Late cellular rejection: often associated with low concentrations of immunosuppressive medications, and have been associated with reduced graft survival.
  • Clinical presentation: fever, malaise, abdominal pain, hepatosplenomegaly, ascites
  • Liver biopsy is the gold standard for diagnosis – 3 major histological features: 1) inflammatory infiltrate in the portal triad; 2) nonsupprative cholangitis involving interlobar bile duct epithelium; 3) endotheliitis

3. Medication Effect

Cyclosporine/ Tacrolimus toxicity: headache, fatigue, nephrotoxicity, fever (20-48%)

4.  Progression of Underlying Disease

5. PTLD (Post-Transplant Lymphoproliferative Disorders)

 

  • Lymphoid or plasmacytic proliferations status post solid organ or allogeneic hematopoietic cell transplantation secondary to immunosuppression.
  • Related to EBV (although EBV negative disease can occur) à abnormal proliferation of EBV infected B cells
  • Risk factors include: degree of immunosuppression, EBV serostatus of recipient, treatment with ATG

 

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