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.
QUESTIONS FOR GROUP DISCUSSION
RECOMMENDED APPROACH
Implications/Analysis of Family History
We are not provided with any family history for the patient.
Implications/Analysis of Clinical History
Acute and Chronic Rejection
Chronic rejection occurs with release of a variety of mediators, including fibroblast growth factor and endothelial growth factor, which can cause an insidious fibrosing/proliferative reaction relatively refractory to immunosuppressive treatment. This could affect the heart, causing secondary lung failure (and the respiratory distress). However, the kinetic picture (<4 weeks after transplant) does not suggest this as a likely explanation.
Implications/Analysis of Laboratory Investigation
Side Effects of Drug Therapy
Could this disorder represent one of a possible number of side effects of the treatment he received for the transplant? In general, we know that chronically immunosuppressed populations show an increased frequency of malignancy, drug toxicity, and infections (Fig. 44-1).
Additional Laboratory Tests
The chest radiograph was consistent with an infiltrate, but biopsy showed no signs of malignancy.
Drug toxicity (or idiosyncratic drug effects) remains a possible explanation of this patient’s clinical presentation. Tacrolimus has been associated with fibrotic reactions, but this is very early for such an effect. Moreover, checking his file, you find he is not on tacrolimus as immunosuppressant!
There is no eosinophilia, which is often seen in the case of hypersensitivity reactions.
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