Fever in post-transplant (solid organ) patient

liver

Thanks Diana for an excellent case! Also thanks to our special guests Joseph Ahn and Michael Loudin for their pearls. This was a middle age patient s/p liver transplant 1 month ago presenting with fevers, abdominal pain, and fatigue found to have PTLD.

Main points:

  • (1) the approach to a patient with fevers after a recent solid organ transplant should also include asking questions related to: pre-transplant screening, peri-op course, and transplant-related medications
  • (2) the differential diagnosis of fever in a post-solid organ transplant recipient can be categorized as: (1) infection (2) rejection (3) med-related (4) PTLD or (5) progression of pre-tx underlying dz (for more on infections, see this excellent NEJM & MKSAP17 ID Ch17)
  • (3) use the 3 T's: to narrow down the differential diagnosis - TIME from transplant, TYPE of drugs used, TRANSPLANTED organ

Want to learn more?

Differential dx for post-solid organ transplant and fever

  • (1) infection
    • remember to break down roughly into (1) < 1 month (2) 1-6 months and (3) 6 months+ after the infection (see table below)
    • if < 1 month think: nosocomial (MRSA, GN's, C diff), surgical site (eg post-op bile duct stricture -> abscess formation), and donor related
    • if 1-6 months think: 2/2 opportunistic/ latent reactivation (ask: how much immunosuppression? how are prophylaxis meds being taken?)
    • if > 6 months think: community acquired (may be subtle), latent viral, fungal
  • (2) rejection - acute cellular rejection happens w/in 90 days
  • (3) medication side effect - (eg azathioprine tox)
  • (4) PTLD - illness script: EBV asso B lymphocyte proliferation 2/2 high immunosuppression 1-6+ months post-transplant presenting as mono-like illness +/- lymphadenopathy, abdominal masses
  • (5) progression of underlying disease - viral hepatitis, PBC/PSC, AIH
solid organ timeline

Medications used in post-solid organ transplant

Medications after solid organ transplant can be divided into immunosuppressive medications and prophylaxis medications

Immunosuppressives include:

  • (1) steroids
  • (2) direct cytotoxic (eg azathioprine, MMF)
  • (3) calcineurin inhibitors (eg tacro, cyclosporin)
    • be aware of: pharmacokinetics, nephrotoxicity
  • (4) mTOR inhibitors (eg sirolimus/ rapamycin)
  • (5) lymphocyte depleting (eg ATG - polyclonal, monoclonal Abs eg muronomab)

Prophylaxis usually consists of:

  • TMP-SMX - for PJP (but also toxo, some UTI's, listeria, nocardia)
      • recall that dapsone etc can be used but coverage will be less broad
  • valgancyclovir - if risk for CMV