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Xu S, He K. Hemophagocytic lymphohistiocytosis after solid organ transplantation: A challenge for clinicians. Transpl Immunol 2024; 83:102007. [PMID: 38307154 DOI: 10.1016/j.trim.2024.102007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/04/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare inflammatory disorder with a high mortality rate and a wide range of symptoms. Solid organ transplantation, which provides patients with a unique immunosuppressive state, is a less common predisposing factor for HLH. HLH after solid organ transplantation (HLH-SOT) is very rare and fatal. It is hard to diagnose and treat and extremely understudied. The use of immunosuppressants makes the situation of HLH-SOT more complex. This review summarizes the existing literature on HLH after solid organ transplantation and describes its triggers and symptoms, focusing on its diagnosis and treatment. We performed a literature search of case reports, case series, letters to the editor, and clinical quizzes describing patients with HLH after solid organ transplantation (HLH-SOT). We provide recommendations on the diagnosis protocol and treatment strategy based on the existing evidence.
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Affiliation(s)
- Shanshan Xu
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Engineering Research Center of Transplantation and Immunology, Shanghai, China; Shanghai Institute of Transplantation, Shanghai, China
| | - Kang He
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Engineering Research Center of Transplantation and Immunology, Shanghai, China; Shanghai Institute of Transplantation, Shanghai, China.
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2
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Rolsdorph LÅ, Mosevoll KA, Helgeland L, Reikvam H. Concomitant Hemophagocytic Lymphohistiocytosis and Cytomegalovirus Disease: A Case Based Systemic Review. Front Med (Lausanne) 2022; 9:819465. [PMID: 35514747 PMCID: PMC9063453 DOI: 10.3389/fmed.2022.819465] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 03/25/2022] [Indexed: 12/25/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is an immune mediated life-threatening condition. It is driven by an overactivation of the immune system and causes inflammatory tissue damage potentially leading to organ failure and death. Primary HLH is caused by genetic mutations, while secondary HLH is triggered by external factors. Viral infections are a well-known cause of secondary HLH. Cytomegalovirus (CMV) is a virus in the herpes family known to cause HLH in rare cases. Methods We report a recent case of CMV-induced HLH, followed by a systematic review of described cases of this rare disease entity, through a structured search in the medical database PubMed. All articles were assessed on a predetermined set of inclusion criteria. Results A total of 74 patients (age > 18 years) with CMV-related HLH were identified, 29 men, 42 women, and three patients with unspecified gender. Median age was 37.5 years (range 18-80). Sixty-six patients (88%) had one or more comorbid conditions and 22 patients (30%) had inflammatory bowel disease (IBD), the most frequent comorbidity. Forty patients (54%) received some form of immunomodulating treatment prior to HLH development. The general treatment approach was in general dual, consisting of antiviral treatment and specific immunomodulating HLH treatment approaches. Treatment outcome was at 77% survival, while 23% had fatal outcome. Conclusion The findings highlight the importance of early diagnostic work up and treatment intervention. Ability to recognize the characteristic clinical traits and perform specific HLH diagnostic workup are key factors to ensure targeted diagnostic work and treatment intervention for this patient group.
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Affiliation(s)
- Linn Åsholt Rolsdorph
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Knut Anders Mosevoll
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Lars Helgeland
- Department of Medical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Håkon Reikvam
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Anandh U, Sudhakar G, Afroze S. Cytomegalovirus-related hemophagocytic lymphohistiocytosis after renal transplantation. Indian J Nephrol 2022; 32:92-93. [PMID: 35283568 PMCID: PMC8916156 DOI: 10.4103/ijn.ijn_442_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 04/13/2021] [Accepted: 05/25/2021] [Indexed: 11/23/2022] Open
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Valdés Francí E, Perez Flores I, Candel FJ, Moreno de la Higuera MA, Romero NC, Rodríguez Cubillo B, Lucena Valverde R, Sánchez Fructuoso AI. Hemophagocytic syndrome triggered by donor-transmitted toxoplasmosis as a complication in same-donor recipients of renal transplantation: Case report and review of the literature. Transpl Infect Dis 2021; 23:e13732. [PMID: 34533259 DOI: 10.1111/tid.13732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 07/16/2021] [Accepted: 09/05/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hemophagocytic syndrome (HPS) is an infrequent complication of transplantation caused by an inflammatory response with a benign proliferation of macrophages and defective lytic capability of T lymphocytes and NK cells that can lead to multiorgan failure. Transplant patients are particularly exposed as a result of the increased risk of both infections and malignancies derived from immunosuppressive drugs. There is no consensus for therapy or immunosuppression; mortality is high. We report a case and present a review of all cases of HPS occurring in solid organ transplant recipients. CASE REPORT: We report two cases of infection by Toxoplasma gondii transmitted by the kidney allograft. One of the recipients was seronegative before transplantation and developed disseminated primary toxoplasmosis. An immune reaction compatible with an HPS ensued. Both were treated with Trimethoprim/sulfamethoxazole, immunosuppression was tapered, and after a 2-week period a complete response was obtained. CONCLUSION HPS presents therapeutic challenges in the context of transplantation. If HPS is suspected, the search of a very likely underlying infection should be central to the management.
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Affiliation(s)
- Elena Valdés Francí
- Nephrology Department, Clínico San Carlos University Hospital, Madrid, Spain
| | - Isabel Perez Flores
- Nephrology Department, Clínico San Carlos University Hospital, Madrid, Spain
| | - Francisco Javier Candel
- Department of Clinical Microbiology and Infectious Diseases, Clínico San Carlos University Hospital, Madrid, Spain
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Choi EJ, Lee SH, Oh CK, Kim YB, Bang JB. Cytomegalovirus-Associated Hemophagocytic Syndrome Diagnosed by Liver Biopsy in a Kidney Transplant Recipient. Yonsei Med J 2021; 62:274-277. [PMID: 33635018 PMCID: PMC7934097 DOI: 10.3349/ymj.2021.62.3.274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 11/27/2022] Open
Abstract
Hemophagocytic syndrome (HPS) is a rare but potentially life-threatening disease in kidney transplant recipients, and is caused by systemic proliferation of macrophages actively phagocytizing other blood cells in the bone marrow, lymph nodes, and the spleen. Here, we report a 40-year-old male kidney transplant recipient who presented with fever, bicytopenia, and elevated liver enzymes 2 months after transplantation. Given that cytomegalovirus antigenemia and real-time polymerase chain reaction tests were positive, liver biopsy was performed under an assumption of cytomegalovirus-induced hepatitis. Hepatic histology revealed multifocal microabscess with cytomegalovirus inclusion bodies, marked Kupffer cell hyperplasia, and erythrophagocytosis by activated macrophages. As laboratory findings such as hyperferritinemia, elevated serum lactate dehydrogenase, low natural killer cell activity, and high soluble interleukin-2 receptor were also compatible with HPS, the recipient was diagnosed as having cytomegalovirus-induced hepatitis combined with reactive HPS. Following intravenous ganciclovir therapy with continuous administration of tacrolimus and corticosteroid, the symptoms resolved and laboratory findings were normalized. As far as we know, this is the first report of cytomegalovirus-induced hepatitis combined with reactive HPS in a kidney transplant recipient that is diagnosed by liver biopsy.
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Affiliation(s)
- Eun Ji Choi
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Su Hyung Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Chang Kwon Oh
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Young Bae Kim
- Department of Pathology, Ajou University School of Medicine, Suwon, Korea
| | - Jun Bae Bang
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea.
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Lange AV, Kazi S, Chen W, Barnes A. Fatal case of macrophage activation syndrome (MAS) in a patient with dermatomyositis and cytomegalovirus (CMV) viraemia. BMJ Case Rep 2018; 2018:bcr-2018-225231. [PMID: 30061130 PMCID: PMC6067131 DOI: 10.1136/bcr-2018-225231] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2018] [Indexed: 12/17/2022] Open
Abstract
We describe a case of an adult with dermatomyositis (DM) who presents with a rash, high fevers, tachycardia and hypotension, initially concerning for an infectious aetiology or a DM flare. She was found to have cytomegalovirus viraemia which improved after starting valganciclovir. After extensive workup and lack of improvement with broad-spectrum antimicrobial therapy, intravenous immunoglobulin and steroids, the patient was diagnosed with macrophage activation syndrome after bone marrow biopsy and levels of soluble CD25 (soluble interleukin (IL)-2 receptor) and IL2 were obtained. Unfortunately, despite therapy with dexamethasone, anakinra and etoposide, the patient decompensated and the patient's family opted for comfort care. The patient subsequently expired in the intensive care unit.
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Affiliation(s)
| | - Salahuddin Kazi
- Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Weina Chen
- Pathology, Univ Texas SW Med Ctr Dallas, Dallas, Texas, USA
| | - Arti Barnes
- Infectious Diseases, University of Texas Southwestern, Dallas, Texas, USA
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Romiopoulos I, Pyrpasopoulou A, Onoufriadis I, Massa E, Mouloudi E, Kydona C, Giasnetsova T, Gerogianni N, Myserlis G, Solonaki F, Nikodimopoulou M, Mandala E, Antachopoulos C, Roilides E. Fulminant Epstein-Barr virus-associated hemophagocytic syndrome in a renal transplant patient and review of the literature. Transpl Infect Dis 2016; 18:795-800. [PMID: 27496079 DOI: 10.1111/tid.12586] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 03/16/2016] [Accepted: 05/26/2016] [Indexed: 12/24/2022]
Abstract
We describe a rare fulminant case of Epstein-Barr virus-associated hemophagocytic syndrome (HPS) in a 37-year-old female renal transplant patient, indistinguishable from severe sepsis clinically and in the laboratory. HPS involves rapidly escalating immune system activation, resulting in a cytokine cascade, which can, especially in immunocompromised patients, lead to multi-organ failure, and even death. Thirty-two Herpesviridae-associated HPS cases in renal transplant patients have been reported and are reviewed. Overall mortality is 47% (15/32 cases).
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Affiliation(s)
- I Romiopoulos
- Infectious Diseases Unit, Faculty of Medicine, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece
| | - A Pyrpasopoulou
- Infectious Diseases Unit, Faculty of Medicine, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece
| | - I Onoufriadis
- 4th Internal Medicine Department, Faculty of Medicine, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece
| | - E Massa
- Intensive Care Unit, Hippokration Hospital, Thessaloniki, Greece
| | - E Mouloudi
- Intensive Care Unit, Hippokration Hospital, Thessaloniki, Greece
| | - C Kydona
- Intensive Care Unit, Hippokration Hospital, Thessaloniki, Greece
| | - T Giasnetsova
- Intensive Care Unit, Hippokration Hospital, Thessaloniki, Greece
| | - N Gerogianni
- Intensive Care Unit, Hippokration Hospital, Thessaloniki, Greece
| | - G Myserlis
- Transplantation Department, Faculty of Medicine, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece
| | - F Solonaki
- Transplantation Department, Faculty of Medicine, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece
| | - M Nikodimopoulou
- Transplantation Department, Faculty of Medicine, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece
| | - E Mandala
- 4th Internal Medicine Department, Faculty of Medicine, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece
| | - C Antachopoulos
- Infectious Diseases Unit, Faculty of Medicine, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece.,3rd Department of Pediatrics, Aristotle University, Hippokration General Hospital, Thessaloniki, Greece
| | - E Roilides
- Infectious Diseases Unit, Faculty of Medicine, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece. .,3rd Department of Pediatrics, Aristotle University, Hippokration General Hospital, Thessaloniki, Greece.
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Filippone EJ, Farber JL. Hemophagocytic lymphohistiocytosis: an update for nephrologists. Int Urol Nephrol 2016; 48:1291-1304. [DOI: 10.1007/s11255-016-1294-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/11/2016] [Indexed: 12/11/2022]
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Yang Y, Yu B, Chen Y. Blood disorders typically associated with renal transplantation. Front Cell Dev Biol 2015; 3:18. [PMID: 25853131 PMCID: PMC4365751 DOI: 10.3389/fcell.2015.00018] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 03/03/2015] [Indexed: 12/11/2022] Open
Abstract
Renal transplantation has become one of the most common surgical procedures performed to replace a diseased kidney with a healthy kidney from a donor. It can help patients with kidney failure live decades longer. However, renal transplantation also faces a risk of developing various blood disorders. The blood disorders typically associated with renal transplantation can be divided into two main categories: (1) Common disorders including post-transplant anemia (PTA), post-transplant lymphoproliferative disorder (PTLD), post-transplant erythrocytosis (PTE), and post-transplant cytopenias (PTC, leukopenia/neutropenia, thrombocytopenia, and pancytopenia); and (2) Uncommon but serious disorders including hemophagocytic syndrome (HPS), thrombotic microangiopathy (TMA), therapy-related myelodysplasia (t-MDS), and therapy-related acute myeloid leukemia (t-AML). Although many etiological factors involve the development of post-transplant blood disorders, immunosuppressive agents, and viral infections could be the two major contributors to most blood disorders and cause hematological abnormalities and immunodeficiency by suppressing hematopoietic function of bone marrow. Hematological abnormalities and immunodeficiency will result in severe clinical outcomes in renal transplant recipients. Understanding how blood disorders develop will help cure these life-threatening complications. A potential therapeutic strategy against post-transplant blood disorders should focus on tapering immunosuppression or replacing myelotoxic immunosuppressive drugs with lower toxic alternatives, recognizing and treating promptly the etiological virus, bacteria, or protozoan, restoring both hematopoietic function of bone marrow and normal blood counts, and improving kidney graft survival.
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Affiliation(s)
- Yu Yang
- Department of Urology, First Affiliated Hospital of PLA General Hospital Beijing, China
| | - Bo Yu
- Department of Urology, First Affiliated Hospital of PLA General Hospital Beijing, China
| | - Yun Chen
- BrightstarTech, Inc. Clarksburg, MD, USA
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10
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Poudel A, Lew J, Slayton W, Dharnidharka VR. Bartonella henselae infection inducing hemophagocytic lymphohistiocytosis in a kidney transplant recipient. Pediatr Transplant 2014; 18:E83-7. [PMID: 24829973 DOI: 10.1111/petr.12235] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Bartonella henselae (Bh) is the cause of cat-scratch fever. When infection is symptomatic, it typically presents with singular lymphadenitis and fever. Less commonly, the infection can become disseminated and cause endocarditis, osteomyelitis, and micro-abscesses in multiple sites including liver, spleen, eyes, and brain, especially in immunocompromised patients. Hemophagocytic lymphohistiocytosis (Hlh) is a rare and severe multisystem disorder that may be triggered by infections. In one prior case, Bh, like other infections, has induced Hlh, an immune-mediated disease that can be characterized by septic-like presentation with persistent fevers, hepatosplenomegaly, and pancytopenia. In an immunocompromised transplant recipient, the onset of Hlh can be difficult to discern from a severe presentation of Bh. We report a case of criteria-proven secondary Hlh occurring after Bh infection in an 11-yr-old girl who was 13 months post-renal transplant. The patient developed multi-organ failure, and her severe clinical presentation required a thorough evaluation for infectious and non-infectious possibilities including post-transplant lymphoproliferative disorder and rejection. Early recognition of Hlh allowed for better directed therapies, leading to recovery of the patient and resolution of both Bh and Hlh.
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Affiliation(s)
- Atul Poudel
- Department of Pediatrics; University of Florida; College of Medicine and Shands Children`s Hospital; Gainesville FL USA
| | - Judy Lew
- Department of Pediatrics; University of Florida; College of Medicine and Shands Children`s Hospital; Gainesville FL USA
| | - William Slayton
- Department of Pediatrics; University of Florida; College of Medicine and Shands Children`s Hospital; Gainesville FL USA
| | - Vikas R. Dharnidharka
- Department of Pediatrics; University of Florida; College of Medicine and Shands Children`s Hospital; Gainesville FL USA
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Bode SF, Lehmberg K, Maul-Pavicic A, Vraetz T, Janka G, Stadt UZ, Ehl S. Recent advances in the diagnosis and treatment of hemophagocytic lymphohistiocytosis. Arthritis Res Ther 2012; 14:213. [PMID: 22682420 PMCID: PMC3446494 DOI: 10.1186/ar3843] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening disease of severe hyperinflammation caused by uncontrolled proliferation of activated lymphocytes and macrophages secreting high amounts of inflammatory cytokines. It is a frequent manifestation in patients with predisposing genetic defects, but can occur secondary to various infectious, malignant, and autoimmune triggers in patients without a known genetic predisposition. Clinical hallmarks are prolonged fever, cytopenias, hepatosplenomegaly, and neurological symptoms, but atypical variants presenting with signs of chronic immunodeficiency are increasingly recognized. Impaired secretion of perforin is a key feature in several genetic forms of the disease, but not required for disease pathogenesis. Despite progress in diagnostics and therapy, mortality of patients with severe HLH is still above 40%. Reference treatment is an etoposide-based protocol, but new approaches are currently explored. Key for a favorable prognosis is the rapid identification of an underlying genetic cause, which has been facilitated by recent immunological and genetic advances. In patients with predisposing genetic disease, hematopoietic stem cell transplantation is performed increasingly with reduced intensity conditioning regimes. Current research aims at a better understanding of disease pathogenesis and evaluation of more targeted approaches to therapy, including anti-cytokine antibodies and gene therapy.
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Affiliation(s)
- Sebastian Fn Bode
- Centre of Chronic Immunodeficiency, University Medical Center Freiburg, D-79106 Freiburg, Germany
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Ardalan M. Rare presentations of cytomegalovirus infection in renal allograft recipients. Nephrourol Mon 2012; 4:431-6. [PMID: 23573461 PMCID: PMC3614274 DOI: 10.5812/numonthly.1844] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 07/19/2011] [Accepted: 07/27/2011] [Indexed: 01/15/2023] Open
Abstract
Cytomegalovirus is the most common viral infection after kidney transplantation. Clinical presentations of cytomegalovirus infection range from asymptomatic infection to organ-specific involvement. Most symptomatic infections manifest as fever and cytopenia. The gastrointestinal tract is the most common site of tissue-invasive infection, often presenting as diarrhea or gastrointestinal bleeding. Gastrointestinal obstruction, perforation, thrombosis of large gastrointestinal veins, splenic artery thrombosis, and pancreatitis are rare gastrointestinal presentations of cytomegalovirus infection. Renal-allograft ureteral stricture and skin involvement are other rare presentations of cytomegalovirus infection. hemophagocytic syndrome, thrombotic microangiopathy, adrenal insufficiency, and renal allograft artery stenosis are other rare symptoms of cytomegalovirus infection.
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Affiliation(s)
- Mohammadreza Ardalan
- Department of Nephrology, Tabriz University of Medical Sciences, Tabriz, IR Iran
- Mario Negri Institute of Pharmacological Research, Bergamo, Italy
- Corresponding author: Mohammadreza Ardalan, Department of nephrology, Tabriz University of Medical Sciences, Tabriz, IR Iran. Tel.: +98-4113344339, Fax: +98-4113344280, E-mail:
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Lo MM, Mo JQ, Dixon BP, Czech KA. Disseminated histoplasmosis associated with hemophagocytic lymphohistiocytosis in kidney transplant recipients. Am J Transplant 2010; 10:687-91. [PMID: 20121728 DOI: 10.1111/j.1600-6143.2009.02969.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Transplant patients are susceptible to infectious complications due to chronic immunosuppression. We present two cases of persistent fever, weight loss and pancytopenia in kidney transplant recipients (originally concerning for posttransplant lymphoproliferative disease) that were later diagnosed with disseminated histoplasmosis on bone marrow and lymph node biopsy. In both patients, pancytopenia was due to hemophagocytic lymphohistiocytosis (HLH) which has rarely been described in association with histoplasmosis and not previously reported in kidney transplant recipients with this fungal infection. The diagnosis of histoplasmosis can be complex due to nonspecific symptomatology, delays in isolating histoplasma by fungal culture and false-negative antibody titers in immunocompromised patients. A review of the literature including the clinical features of histoplasmosis in immunosuppressed patients (prevalence, current diagnostic testing and treatment options) as well as the association of HLH in immunocompromised states are discussed.
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Affiliation(s)
- M M Lo
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children's Hospital and Medical Center, Cincinnati, OH, USA
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Ponticelli C, Alberighi ODC. Haemophagocytic syndrome--a life-threatening complication of renal transplantation. Nephrol Dial Transplant 2009; 24:2623-7. [PMID: 19525363 DOI: 10.1093/ndt/gfp282] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Marinella MA. Hematologic abnormalities following renal transplantation. Int Urol Nephrol 2009; 42:151-64. [PMID: 19301140 DOI: 10.1007/s11255-009-9558-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2009] [Accepted: 03/03/2009] [Indexed: 11/27/2022]
Abstract
Recipients of renal allografts are surviving longer and, consequently, may experience a variety of complications related not only to the transplanted kidney, but also to the hematopoietic system. Common hematologic complications in the renal transplant patient include abnormalities of one cell line, such as post-transplantation erythrocytosis or anemia, that are often treatable with simple measures. Conversely, pathologies involving the leukocyte and platelet population often exist in the context of pancytopenia, which may be a manifestation of systemic infection (e.g., cytomegalovirus, human herpesvirus 8) or malignancy (post-transplantation lymphoproliferative disorders). Uncommon, but life-threatening, processes complicating renal transplantation include hepatosplenic gammadelta T-cell lymphoma and viral-induced hemophagocytic syndrome, both of which are associated with severe pancytopenia and, often, death. Since this patient population is often managed in a multidisciplinary fashion by nephrologists, infection specialists, transplant surgeons, hematologists, and internal medicine physicians, a succinct review of this topic is warranted.
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Affiliation(s)
- Mark A Marinella
- Wright State University School of Medicine, Dayton, OH 45429, USA.
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16
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Bouza E, Loeches B, Muñoz P. Fever of Unknown Origin in Solid Organ Transplant Recipients. Infect Dis Clin North Am 2007; 21:1033-54, ix-x. [DOI: 10.1016/j.idc.2007.09.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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