Case 44

Published on 18/02/2015 by admin

Filed under Allergy and Immunology

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 1371 times

CASE 44

FG, a 42-year-old patient with fulminant cardiac failure secondary to acute viral myocarditis, receives a heart (via UNOS) from a trauma victim. You are aware incidentally that the lungs, liver, and kidneys of the same donor have been used in other transplants around the globe.

The postoperative course for this patient is essentially unremarkable, and he is discharged home at 10 days after transplantation on a conventional immunosuppressive drug regimen. He returns through the emergency department 7 days later in acute respiratory distress, with oxygen saturation less than 85% and febrile. What are your thoughts, and what will you do?

QUESTIONS FOR GROUP DISCUSSION

RECOMMENDED APPROACH

Implications/Analysis of Clinical History

The myocarditis as the cause of his cardiac failure is a potential issue. Could this infection have recurred causing failure of the transplanted organ with resultant respiratory failure (secondary to cardiac failure)? History regarding possible CMV (cytomegalovirus/ human herpes virus 5) status before the transplant is worth knowing, as is the patient’s drug history (any risk factors for HIV [human immunodeficiency virus] or other unsuspected pathogens?).

Implications/Analysis of Laboratory Investigation

Routine blood work, physical examination, electrocardiogram, and serum levels of cardiac enzymes should be initiated at this time. As noted, a number of cardiac enzymes (e.g., troponin I, creatine phosphokinase, creatine kinase) are released when heart tissue is damaged. Measurement of cardiac muscle enzymes was normal, as was the electrocardiogram, ruling out killing (lysis) of heart cells as the cause of this patient’s problem. You were unable to maintain this patient’s oxygen saturation above 90% without providing artificial breathing support (intubation and ventilation). A chest radiograph shows “patchy” infiltrates throughout the lung fields.

FURTHER READING

Aldallal N. Inflammatory response in airway epithelial cells isolated from patients with cystic fibrosis. Am J Respir Crit Care Med. 2002;166:1248.

Araujo MB, et al. Development of donor specific microchimerism in liver transplant recipient with HLA-DRB1 and -DQB1 mismatch related to rejection episodes. Transplant Proc. 2004;36:953.

Arul A, Murday AJ, Jackson R. Natural killer-like T cell lymphoma, CD56+, following cardiac transplantation. J Heart Lung Transplant. 2004;23:783.

Blusch JH, et al. Infection of nonhuman primate cells by pig endogenous retrovirus. J Virol. 2000;74:7687.

Chalasani G, et al. The allograft defines the type of rejection (acute versus chronic) in the face of an established effector immune response. J Immunol. 2004;172:7813.

Chantranuwat C, et al. Sudden unexpected death in cardiac transplant recipients: An autopsy study. J Heart Lung Transplant. 2004;23:683.

Chen HL, et al. Pediatric fulminant hepatic failure in endemic areas of hepatitis B infection: 15 years after universal hepatitis B vaccination. Hepatology. 2004;39:58.

Cho JH. Advances in the genetics of inflammatory bowel disease. Curr Gastroenterol Rep. 2004;6:467.

Conese M, et al. Neutrophil recruitment and airway epithelial cell involvement in chronic cystic fibrosis lung disease. J Cyst Fibros. 2003;2:129.

Corvol H, et al. Distinct cytokine production by lung and blood neutrophils from children with cystic fibrosis. Am J Physiol Lung Cell Mol Physiol. 2003;284:L997.

D’Haens G, Hlavaty T. Advances in medical therapy for Crohn’s disease. Curr Gastroenterol Rep. 2004;6:496.

De Hertogh G, Geboes K. Crohn’s disease and infections: A complex relationship. MedGenMed. 2004;10:14.

Dransfield MT, Garver RI, Weill D. Standardized guidelines for surveillance bronchoscopy reduce complications in lung transplant recipients. J Heart Lung Transplant. 2004;23:110.

Fateh-Moghadam S. Cytomegalovirus infection status predicts progression of heart-transplant vasculopathy. Transplantation. 2003;76:1470.

Galili U. Interaction of the natural anti-Gal antibody with α-galactosyl epitopes: A major obstacle for xenotransplantation in humans. Immunol Today. 1993;14:480.

Gardner R, et al. Gamma/delta T-cell lymphoma as a recurrent complication after transplantation. Leuk Lymphoma. 2004;45:2355.

Grazia et al Grazia TJ, et al: A two-step model of acute CD4 T-cell mediated cardiac allograft rejection. J Immunol 172:7451.

Halloran PF. Immunosuppressive drugs for kidney transplantation. N Engl J Med. 2004;26:2715.

Helmi M, et al. Aspergillus infection in lung transplant recipients with cystic fibrosis: Risk factors and outcomes comparison to other types of transplant recipients. Chest. 2003;123:800-808.

Hoercher KJ, et al. Cardiac transplantation at the Cleveland Clinic. Clin Transpl. 2003;17:267.

Huo TI, et al. Long-term outcome of kidney transplantation in patients with hepatitis C virus infection. Hepatogastroenterology. 2001;48:169.

Kaufman DB, et al. Immunosuppression: Practice and trends. Am J Transpl. 2004;4:38.

Kaufman SS, et al. Discrimination between acute rejection and adenoviral enteritis in intestinal transplant recipients. Transplant Proc. 2002;34:943.

Lacouture ME, Hsieh FH. Skin rash in a transplant patient receiving multiple drugs. Cleve Clin J Med. 2003;70:1071.

Lin KW, Kirchner JT. Hepatitis B. Am Fam Physician. 2004;69:75.

Loinaz C, et al. Bacterial infections after intestine and multivisceral transplantation. Transplant Proc. 2003;35:1929.

Ludwiczek O, et al. Imbalance between interleukin-1 agonists and antagonists: Relationship to severity of inflammatory bowel disease. Clin Exp Immunol. 2004;138:323.

Magre S, et al. Reduced sensitivity to human serum inactivation of enveloped viruses produced by pig cells transgenic for human CD55 or deficient for galactosyl-α(1-3) galactosyl epitope. J Virol. 2004;78:5812.

Mahmond IM, et al. The impact of hepatitis C virus on renal graft and patient survival: A 9-year prospective study. Am J Kidney Dis. 2004;43:131.

Mazariegos GV, et al. Graft versus host disease in intestinal transplantation. Am J Transpl. 2004;4:1459.

Meloni F. Bronchoalveolar lavage cytokine profile in a cohort of lung transplant recipients: A predictive role of interleukin-12 with respect to onset of bronchiolitis obliterans syndrome. J Heart Lung Transplant. 2004;23:1053.

Neff GW, et al. Outcomes in liver transplant recipients with hepatitis B virus: Resistance and recurrence patterns from a large transplant center over the last decade. Liver Transplant. 2004;10:1372.

Nigen S, Knowles SR, Shear NH. Drug eruptions: Approaching the diagnosis of drug-induced skin diseases. J Drugs Dermatol. 2003;2:278.

Paul LC, et al. Antibodies and chronic organ graft rejection. Ann Transplant. 1997;2:46.

Piazza A, et al. Impact of donor-specific antibodies on chronic rejection occurrence and graft loss in renal transplantation: Post-transplant analysis using flow cytometric techniques. Transplantation. 2001;71:1106.

Quinn G, et al. Porcine endogenous retrovirus transmission characteristics of galactose α1-3 galactose deficient pig cells. J Virol. 2004;78:5805.

Rosen HR, et al. Cutting edge: Identification of hepatitis C virus-specific CD8+ T cells restricted by donor HLA alleles following liver transplantation. J Immunol. 2004;173:5355.

Schwartz KB, et al. Viral hepatitis. J Pediatr Gastroenterol Nutr. 2002;35:S29.

Schwartz KB. Pediatric issues in new therapies for hepatitis B and C. Curr Gastroenterol Rep. 2003;5:233.

Starzl TE, et al. Chimerism and tolerance in transplantation. Proc Natl Acad Sci U S A. 2004;101(Suppl 2):14607.

Starzl TE, Zinkernagel RM. Antigen localization and migration in immunity and tolerance. N Engl J Med. 339, 1905.

Thomas AR, et al. Hepatitis B vaccine coverage among the infants born to women without perinatal screening for hepatitis B virus infections: Effect of the joint statement of thimerosal in vaccines. Pediatr Infect Dis J. 2004;23:313.

Treem WR. Fulminant hepatic failure in children. J Pediatr Gastroenterol Nutr. 2002;35:S33.

Vanclaire J, Cornu Ch, Sokal EM. Fulminant hepatitis B in an infant born to a hepatitis Be antibody positive, DNA negative carrier. Arch Dis Child. 1991;66:983.

Verkman AS, Song Y, Thiagarajah JR. Role of airway surface liquid and submucosal glands in cystic fibrosis lung disease. Am J Physiol Lung Cell Mol Physiol. 2003;284:C2.

Weiner SM, et al. Impact of in vivo complement activation and cryoglobulins on graft. Clin Transpl. 2004;18:7.

Wy AU, et al. Graft versus-host disease after liver transplantation: Documentation by fluorescent in situ hybridization and human leucocyte antigen typing. Clin Transpl. 2000;14:174.

Zheng HX, et al. Interleukin 10 production genotype protects against acute persistent rejection after lung transplantation. J Heart Lung Transplant. 2004;23:541.

Zhong R, et al. Improvement in human decay accelerating factor transgenic porcine kidney xenograft rejection with intravenous administration of GAS914, a polymeric form of alpha GAL. Transplantation. 2003;75:10.