Today Dr. Bien presented an interesting case of abdominal pain, subjective fevers and diarrhea in an immunosuppressed post-solid organ transplant (kidney and liver) patient.
This was a refresher from a Noon Report case on June 28th. Remember, these presentations may be subtle. You should ask about:
- timing from the transplant?
- surgical complications?
- immunosuppression? (any dose changes, the duration)
- prophylaxis? (any dose changes, the duration)
- environemental exposures?
One framework for fever in a post solid organ transplant patient is based on the time they are out from the transplant.
- Early Period (Less than 1 Month): surgical complications (wound infection, line infection, anastomotic leaks); hospital acquired infections (CDiff); donor-derived infections (uncommon with currently testing but include HSV, rabies and West Nile); recipient-derived infections (mainly colonization, ex. Aspergillus and Pseudomonas post-lung transplant)
- Mid Period (1-6 Months): activation of latent infections or relapsed residual infections (CMV, HCV, BK virus, TB); opportunistic infections (Listeria, Nocardia, Legionella, Toxoplasma, Strongyloides, Leishamnia, Trypanosoma cruzi, endemic fungal infections, PJP); anastamotic complications (stenosis, thrombosis or leak); acute rejection (typically within the first 90 days)
- Late Period (After 6 Months): community acquired infections (Asperigillus, endemic infections, Nocardia, Listeria CAP); late viral reactivation (VZV, BK virus, CMV); PTLD (may or may not be from EBV)
Post-Transplant Lymphoproliferative Disorder (PTLD) is the second most common malignancy in solid organ transplant patients after skin cancer. It has been historically linked to EBV. However, the further away from the transplant it occurs, the more likely it is to be EBV negative. A case series was reported of EBV negative PTLD in the Journal of Clinical Oncology in 1998. It is quite heterogenous but typically presents with fever and lymphadenopathy or more commonly extranodal disease. Treatment typically includes the following in a step-wise approach:
- reduction in immunosuppression
- Rituximab if CD-20+
- Chemotherapy (CHOP)
For additional information on post-liver transplant patient management, please see the following article from the Cleveland Clinic.