This *** patient with a history of transplant, on immunosuppression, presents with *** concerning for acute rejection vs infection. Differential diagnosis includes ***.  I considered, but think unlikely, emergent causes of these symptoms in an immunosuppressed patient, including opportunistic infections, donor-related infections such as CMV, but think these are unlikely.

Plan: basic labs, hold immunosuppression, gentle fluid resuscitation, discuss with transplant team, low threshold for empiric antibiotics and/or pulse dose steroids.

 

 

Pearls: 

• Most immunosuppression regimens include steroids (out to about 6 months, but can be longer depending on the organ), calcineurin inhibitors (cyclosporine, tacro), and an antiproliferative med (MMF, AZA).
• Post-transplant lymphoproliferative disorder: your meds knock down your T cell lines so much that your other cell lines escape their checkpoints. Can be mild (a few extra monos) to severe lymphoma.
• Immunosuppressive medications also have a lot of other organ-specific side effects:
  • HTN/DM
  • GERD/gastritis/gastroparesis (from MMF, steroids).
  • Osteoporosis – easy fractures on the ddx
  • Renal: 25% will develop CKD w/in 1 year. This is from the calcineurin inhibitors.
• Management:
  • get a tacro/CSA level if they are having an AKI; otherwise, not useful.
  • Hold immunosuppression until d/w transplant team
  • Give stress dose steroids IF on prednisone.
  • BSA and consider antifungals especially if infection source considered to be pulmonary, or if they’ve had prior fungal infections