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!
- 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.”
Fever in a Post-Transplant Patient
- 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)
- See this very helpful visual from Jen Babik’s talk on this topic:
- 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