SCCM Resource Library-Toxoplasmosis-associated Hemophagocytic Lymphohistiocytosis in a Liver Transplant Recipient

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The document presents a case report of a 42-year-old Chinese female liver transplant recipient who developed secondary hemophagocytic lymphohistiocytosis (HLH) due to toxoplasmosis, a condition never before reported in liver transplant patients. Despite the rare incidence of toxoplasmosis in liver transplant recipients compared to heart and kidney transplants, the condition bears significant diagnostic challenges and high mortality rates.<br /><br />The patient initially presented with symptoms of hepatitis B-related acute-on-chronic liver failure and underwent liver transplantation on December 5th, 2021. Post-surgery, she faced complications including high fever, oliguria, and infections from multidrug-resistant bacteria and cytomegalovirus. Despite treatment, her condition deteriorated, leading to neurological symptoms, multi-organ failure, and eventually secondary HLH, confirmed by meeting six out of eight HLH-2004 criteria and receiving an H-score of 287 points.<br /><br />Toxoplasmosis was identified postmortem through metagenomic next-generation sequencing (mNGS), despite the negative serum toxoplasma IgM but positive IgG. This case underscores the diagnostic challenges posed by latent infections and nonspecific symptoms in immunosuppressed patients.<br /><br />Discussion notes the critical need for early and accurate diagnosis of toxoplasmosis-associated HLH in liver transplant recipients. Diagnostic delays due to nonspecific symptoms can lead to fatal outcomes, as seen in this case. mNGS is emphasized as a valuable diagnostic tool. Recommendations include routine prophylaxis with trimethoprim/sulfamethoxazole to prevent such infections and monitoring immunosuppressive drug dosages in high-risk patients.<br /><br />Despite advancements, 85% of secondary HLH cases in liver transplant patients result in mortality. Enhanced surveillance, prophylactic treatments, and the development of more effective therapeutic strategies are essential to improve outcomes in these high-risk patients. The importance of differential diagnosis in patients presenting with unexplained fever and neurological symptoms post-transplant is highlighted, advocating for comprehensive diagnostic approaches including bone marrow aspiration, cerebral MRI, and serological examinations.

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Infection, 2024, 0:15:00

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Toxoplasmosis is a rare parasitic infectious disease in solid organ transplant recipients. The disease is characterized by difficulties in diagnosis and high mortality. However, there have been no reported cases of hemophagocytic lymphohistiocytosis (HLH) caused by toxoplasmosis in liver transplant patients. Here, we present a case of an adult female liver transplant recipient who experienced a fatal outcome and developed secondary HLH following confirmation of toxoplasmosis through metagenomic next-generation sequencing (mNGS). The patient exhibited symptoms including high fever, skin rash, unconsciousness, and multi-organ failure. The condition met six out of eight criteria for HLH according to the HLH-2004 diagnostic criteria. Additionally, the H-score for this patient was 287 points, confirming the diagnosis of HLH. This represents the first reported case of toxoplasmosis-associated secondary HLH in an adult liver transplant recipient in China.

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Content Type Article

Knowledge Area Infection

Membership Level Nonmember

Membership Level Associate

Membership Level Professional

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Tag Infectious Diseases

Year 2024

Keywords

liver transplant

secondary HLH

toxoplasmosis

diagnostic challenges

high mortality

metagenomic sequencing

immunosuppressed patients

prophylactic treatments

neurological symptoms

differential diagnosis

Article

Infection

Infectious Diseases

2024

Nonmember

Associate

Professional

Select

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