Case Reports in Transplantation The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Concurrent Hepatic Artery and Portal Vein Thrombosis after Orthotopic Liver Transplantation with Preserved Allografts Thu, 10 Apr 2014 08:52:03 +0000 In contrast to early HAT, late HAT has an insidious clinical presentation. Nevertheless, biliary and vascular reconstructions in this late setting are unlikely to improve outcome. Patent portal flow makes an important contribution to the viability of liver in case of late HAT while the allograft reconstitutes intrahepatic arterial flow through neovascularization. Concurrent HAT with PVT without immediate graft necrosis is extremely rare, and allograft and patient survival are seemingly impossible without retransplantation. In fact, hepatopetal arterial and portal venous neovascularization are known albeit obscure phenomena that can preserve posttransplant hepatic function under the extenuating circumstances of complete interruption of blood flow to the graft. We describe two such cases that developed combined HAT and PVT more than six months after OLT with perfect preservation of graft function. The survival of allografts in our cases was due to extensive hepatopetal arterial and portal venous collateralization. Simultaneous HAT and PVT after OLT are rare events and almost uniformly fatal, if they occur early. Due to paucity of such cases, however, underlying mechanisms and etiology remain elusive, and despite radiological diagnosis of these complications, there is no way to predict these events in the wake of stable graft function. Arshad Khan, P. Park, Jose Oberholzer, Ivo Tzvetanov, Raquel Garcia Roca, Ron C. Gaba, Enrico Benedetti, and Hoonbae Jeon Copyright © 2014 Arshad Khan et al. All rights reserved. Graft-versus-Host Disease after Living-Unrelated Kidney Transplantation Wed, 09 Apr 2014 08:46:42 +0000 Graft-versus-host disease (GVHD) is a rare complication after solid organ transplantation and consists of a reaction of donor derived immune cells directed against host tissues. The vast majority of cases reported in the literature involve liver, small intestine and pancreas transplantation. We report a case of GVHD in a 48-year-old man after living-unrelated kidney transplantation at another center. Six months postoperatively he developed a skin rash, anorexia, and diarrhea that resulted in malnutrition and a 90 pound weight loss. At this point he was transferred to our center with a BMI of 16 and severe cachexia. Intravenous hyperalimentation was initiated and an extensive work-up for an infectious etiology was performed and was negative. An esophagogastroduodenoscopy was performed and revealed nodularity of the gastric mucosa, atrophy, and edema in the first and second portion of his duodenum. Biopsy findings were consistent with GVHD. Aggressive immunosuppressive therapy was instituted with a good response. The anorexia and diarrhea resolved, and he was discharged on hospital day 20. Three months later, there had been no recurrence of the diarrhea, the patient had gained an additional 40 pounds, BMI of 25, and a repeat upper endoscopy revealed complete resolution of the initial endoscopic abnormalities. N. Zacharias, M. H. Gallichio, and D. J. Conti Copyright © 2014 N. Zacharias et al. All rights reserved. Isolated Aspergillosis Myocardial Abscesses in a Liver-Transplant Patient Sun, 23 Feb 2014 00:00:00 +0000 Cardiac abscess is an uncommon and fatal complication after transplantation. We report a case of an initially isolated aspergillosis myocardial abscess diagnosed by cardiac magnetic resonance imaging (CMRI). At that time, there was no other biological evidence or other extracardiac manifestations. A three-month course of dual antifungal therapy followed by a single antifungal therapy was empirically given. Six month after admission, Aspergillus fumigatus was isolated for the first time and the patient deceased from a disseminated aspergillosis. Kim-Diêp Dang-Tran, Valérie Chabbert, Laure Esposito, Céline Guilbeau-Frugier, Fabrice Dédouit, Lionel Rostaing, Hervé Rousseau, Phillippe Otal, and Nassim Kamar Copyright © 2014 Kim-Diêp Dang-Tran et al. All rights reserved. Point of Care Perioperative Coagulation Management in Liver Transplantation and Complete Portal Vein Thrombosis Thu, 06 Feb 2014 10:04:13 +0000 Liver transplantation (LT) is a serious hemostatic challenge in patients with portal vein thrombosis (PVT). Advances in monitoring systems have improved surgery in this setting. We report the successful application of a point-of-care (POC) rotational viscoelastic thromboelastometry-guided (TEM) testing system (ROTEM) which allowed management of coagulation during LT in a 64-year-old cirrhotic patient with a model for end-stage liver disease (MELD) score of 16. Perioperatively, the patient showed complete PVT, hepatomegaly, splenomegaly, recanalization of the umbilical vein, and portosystemic shunt. Macroscopic liver and spleen adherences with collateral circulation were evident. Coagulation factors and fibrinolysis were assessed preoperatively and at graft reperfusion to evaluate the need of hemostatic therapy. Based on ROTEM findings, the patient received 16 g of human fibrinogen concentrate, half preoperatively (with prothrombin complex concentrate 2000 IU, tranexamic acid 1 g, and platelets 2 IU), and two doses of 4 g before and after graft reperfusion; we achieved normalization of all monitored parameters. No ischemia-reperfusion syndrome was present. Postoperatively portal vein flux at Color-Doppler ultrasonography was normal. After a 3-day ICU stay, the patient was moved to the Department of Surgery and discharged on day 14. The postoperative course was uneventful and did not require any further haemostatic therapy. Cristiano Piangatelli, Lucia Faloia, Claudia Cristiani, Ilaria Valentini, and Marco Vivarelli Copyright © 2014 Cristiano Piangatelli et al. All rights reserved. Leukocytoclastic Vasculitis as a Complication of Recombinant Granulocyte Colony-Stimulating Factor Therapy in a Heart Transplant Patient Thu, 30 Jan 2014 11:09:22 +0000 Recombinant granulocyte colony-stimulating factor (rG-CSF) is a myeloid growth factor that is widely used in haematology to recover neutropenia secondary to myelosuppressive chemotherapy. Leukocytoclastic vasculitis is an acknowledged side effect of the above therapy. Its pathogenesis involves many mechanisms that collectively induce an increase in neutrophil function and a subsequent release of cytokines. Here, we report a case of leukocytoclastic vasculitis proven by skin biopsy, following the use of rG-CSF in a heart transplant patient with leukopenia secondary to immunosuppressive therapy. Giovanbattista Ippoliti, Marco Paulli, Marco Lucioni, Marinella Lauriola, and Andrea Maria D'Armini Copyright © 2014 Giovanbattista Ippoliti et al. All rights reserved. Markedly Increased High-Mobility Group Box 1 Protein in a Patient with Small-for-Size Syndrome Wed, 29 Jan 2014 00:00:00 +0000 Background. Small-for-size syndrome (SFSS) occurs in the presence of insufficient liver mass to maintain normal function after liver transplantation. Murine mortality following 85% hepatectomy can be reduced by the use of soluble receptor for advanced glycation end products (sRAGE) to scavenge damage-associated molecular patterns and prevent their engagement with membrane-bound RAGE. Aims. To explore serum levels of sRAGE, high-mobility group box-1 (HMGB1) protein, and other soluble inflammatory mediators in a fatal case of SFSS. Methods. Serum levels of HMGB1, sRAGE, IL-18, and other inflammatory mediators were measured by ELISA in a case of SFSS, and the results were compared with 8 patients with paracetamol-induced acute liver failure (ALF) and 6 healthy controls (HC). Results. HMGB1 levels were markedly higher in the SFSS patient (92.1 ng/mL) compared with the ALF patients (median (IQR) 11.4 (3.7–14.8) ng/mL) and HC (1.42 (1.38–1.56) ng/mL). In contrast, sRAGE levels were lower in the SFSS patient (1.88 ng/mL) compared with the ALF patients (3.53 (2.66–12.37) ng/mL) and were similar to HC levels (1.40 (1.23–1.89) ng/mL). Conclusion. These results suggest an imbalance between pro- and anti-inflammatory innate immune pathways in SFSS. Modulation of the HMGB1-RAGE axis may represent a future therapeutic avenue in this condition. Darren G. Craig, Patricia Lee, E. Anne Pryde, Ernest Hidalgo, Peter C. Hayes, Stephen J. Wigmore, Stuart J. Forbes, and Kenneth J. Simpson Copyright © 2014 Darren G. Craig et al. All rights reserved. Torsion of the Retroperitoneal Kidney: Uncommon or Underreported? Thu, 16 Jan 2014 13:45:06 +0000 Vascular torsion in a renal allograft after placement in the retroperitoneum is rare and has only been reported twice in the literature. It is an extrinsically mediated process that occurs at the vascular pedicle resulting in graft compromise and potential loss. Rapid diagnosis and immediate surgical intervention may salvage allograft function. Herein, we present a unique case of a 42-year-old male that developed renal allograft torsion following a second kidney transplant placed in the retroperitoneum. Immediate detorsion did not resolve allograft dysfunction, and a biopsy revealed acute cellular mediated rejection. After antithymocyte globulin treatment, allograft function was salvaged. A review of the current literature shows that the incidence, morbidity, and long term allograft function of intraperitoneal and extraperitoneal torsion are different. As such, torsion of the retroperitoneal kidney demonstrates encouraging allograft salvage rates. Only the third case reported to date, this serves as a contribution to the growing body of literature in retroperitoneal renal torsion and reviews the risks, medication considerations, diagnostic tests, and treatment modalities in a unique disease process. Michael Sosin, Wuya Lumeh, and Matthew Cooper Copyright © 2014 Michael Sosin et al. All rights reserved. Drug Interaction between Sirolimus and Ranolazine in a Kidney Transplant Patient Thu, 02 Jan 2014 14:01:28 +0000 Purpose. The case of a kidney transplant recipient who experienced a probable drug interaction between sirolimus and ranolazine is reported. Summary. The narrow therapeutic window of immunosuppressive therapy in transplant recipients requires close monitoring for potential drug-drug interactions. The patient, a 57-year-old Caucasian male kidney transplant recipient, was stable for years on sirolimus as his primary immunosuppressive agent and had a history of chronic angina, for which he was prescribed ranolazine. Upon addition and dose escalation of ranolazine, whole blood sirolimus levels more than tripled, rising to immeasurably high concentrations. After holding sirolimus on multiple occasions and reducing dosage more than 50%, blood levels returned to therapeutic range, while continuing ranolazine. Conclusion. Since ranolazine is a documented P-GP and CYP3A inhibitor, and sirolimus a known substrate for both pathways, it is proposed that ranolazine inhibition of P-GP and CYP3A4 contributed to the significant elevation in sirolimus exposure. No alternative causes for the rise in sirolimus exposure were found, and assessment with the Drug Interaction Probability Scale finds this interaction to be probable. Clinicians should be aware of the potential for this interaction to cause elevated sirolimus exposure and subsequent increase in clinical effect or toxicity, in this case overimmunosuppression. Joanna C. Masters, Mita M. Shah, and Ashley A. Feist Copyright © 2014 Joanna C. Masters et al. All rights reserved. Arteriojejunal Fistula Presenting with Recurrent Obscure GI Hemorrhage in a Patient with a Failed Pancreas Allograft Wed, 25 Dec 2013 10:17:04 +0000 We present a case of a patient with a failed pancreaticoduodenal allograft with exocrine enteric-drainage who developed catastrophic gastrointestinal (GI) hemorrhage. Over the course of a week, she presented with recurrent GI bleeds of obscure etiology. Multiple esophago-gastro-duodenoscopic (EGD) and colonoscopic evaluations failed to reveal the source of the hemorrhage. A capsule endoscopy and a technetium-labeled red blood cells (RBC) imaging study were similarly unrevealing for source of bleeding. She subsequently developed hemorrhagic shock requiring emergent superior mesenteric arteriography. Run off images revealed an external iliac artery aneurysm with fistulization into the jejunum. Coiled embolization was attempted but abandoned because of hemodynamic instability. Deployment of a covered endovascular stent into the right external iliac artery over the fistula site resulted in immediate hemodynamic stabilization. A high index of suspicion for arterioenteric fistulae is needed for diagnosis of this uncommon but eminently treatable form of GI hemorrhage in this patient population. Nirmit Desai, Sagar Patel, Chinyere Nwosu, Lok Sung, Carl Tack, Jonathan M. Buscaglia, Edward P. Nord, and Nand K. Wadhwa Copyright © 2013 Nirmit Desai et al. All rights reserved. Renal Transplantation in Secondary Amyloidosis Associated with Tuberculosis Wed, 25 Dec 2013 09:08:55 +0000 Although end-stage renal disease (ESRD) related to AA amyloidosis nephropathy secondary to tuberculosis is most common in our country, there are limited data concerning patient and graft outcome after renal transplantation (RTx). To the best of our knowledge, this is the first report of RTx in ESRD patient with secondary amyloidosis due to tuberculosis from India. A 30-year-old female with past history of pulmonary tuberculosis 3 years back was admitted with complaint of gradually progressive pedal oedema and nausea for 3 months. Renal biopsy was suggestive of secondary renal amyloidosis with vascular involvement and chronic tubulointerstitial involvement. She was transplanted with kidney from her 28-year-old brother with 3/6 human leukocyte antigen match. She had immediate good graft function without any perioperative complications (cardiovascular, infections, rejection and delayed graft function). She was discharged with serum creatinine of 0.8 mg/dL. Her last serum creatinine level was 0.9 mg/dL with cyclosporine level of 100 mg/dL at 9-month followup without any medical or surgical complication. The quality of life also improved after transplantation. With careful selection, ESRD patients with secondary amyloidosis due to tuberculosis are eligible for RTx with favorable outcome and improved quality of life. Vivek B. Kute, Aruna V. Vanikar, Himanshu V. Patel, Manoj R. Gumber, Pankaj R. Shah, Pranjal R. Modi, and Hargovind L. Trivedi Copyright © 2013 Vivek B. Kute et al. All rights reserved. Single-Lobe Living Donor Liver Transplant in a Morbidly Obese Cirrhotic Patient Preceded by Laparoscopic Sleeve Gastrectomy Tue, 10 Dec 2013 18:03:04 +0000 Nonalcoholic steatohepatitis (NASH) is a stage of nonalcoholic fatty liver disease (NAFLD), and, in most patients, it is associated with obesity and metabolic syndrome with progression to end-stage liver disease in about 20% of patients (McCullough (2004); Matteoni et al. (1999); Liou and Kowdley (2006)). It has been estimated that between 20 and 30% of patients with end-stage cirrhosis referred for liver transplantation (LT) evaluation and 30 to 70% of LT recipients exhibit some degree of obesity (Muñoz and ElGenaidi (2005)). Management of obesity in chronic liver disease patients is not only difficult but also preludes them from undergoing major bariatric surgery due to associated high morbidity and mortality. Here, we present a case report of a morbidly obese patient who underwent laparoscopic sleeve gastrectomy followed by single-lobe living donor liver transplantation (LDLT) with a successful outcome. We believe that this is the first report of successful LDLT following planned weight loss to facilitate LDLT. Sunil Taneja, Subash Gupta, Manav Wadhawan, and Neerav Goyal Copyright © 2013 Sunil Taneja et al. All rights reserved. Acute Liver Failure Occurring during the First Trimester of Pregnancy Successfully Treated with Living Donor Liver Transplantation Wed, 04 Dec 2013 18:39:27 +0000 Acute liver failure (ALF) during pregnancy remains difficult to treat, and despite advances in treatment, liver transplantation must be selected as treatment option in certain cases. We report a 30-year-old woman with ALF of unknown etiology, occurring during the first trimester of pregnancy. Her condition was complicated by consciousness disturbance and coagulopathy due to ALF, but she was successfully treated with living donor liver transplantation 7 days after dilatation and curettage. At 9-month followup, she was in good medical condition. Liver transplantation has been reported as one of the treatment options for ALF during pregnancy with the prognosis varying depending on the trimester, from living donor or deceased donor liver transplantation. Of importance is that clinicians always think of emergent liver transplantation as a therapeutic option in ALF even in the first trimester of pregnancy. Naoya Kanogawa, Tatsuo Kanda, Masayuki Ohtsuka, Masato Nakamura, Tatsuo Miyamura, Shin Yasui, Makoto Arai, Hitoshi Maruyama, Keiichi Fujiwara, Makio Shozu, Shigeto Oda, Masaru Miyazaki, and Osamu Yokosuka Copyright © 2013 Naoya Kanogawa et al. All rights reserved. Tacrolimus-Related Cerebral Microbleeds after Lung Transplantation Mon, 02 Dec 2013 11:57:10 +0000 Posterior reversible encephalopathy syndrome is a well-known complication of treatment by tacrolimus. We report 2 cases of lung transplant recipients treated with tacrolimus who developed cerebral microbleeds on T2*-weighted sequences in the acute setting of posterior reversible encephalopathy syndrome. Cerebral microbleeds may be a marker of tacrolimus-induced vasculopathy that may be detected earlier by neuropsychological and magnetic resonance imaging monitoring in transplant recipients treated with tacrolimus. L. Mechtouff, F. Piegay, J. Traclet, F. Philit, P. Boissonnat, M. Hermier, I. Durieu, T.-H. Cho, N. Nighoghossian, and J.-F. Mornex Copyright © 2013 L. Mechtouff et al. All rights reserved. A Case of Alport Syndrome with Posttransplant Antiglomerular Basement Membrane Disease despite Negative Antiglomerular Basement Membrane Antibodies by EIA Treated with Plasmapheresis and Intravenous Immunoglobulin Mon, 02 Dec 2013 11:54:42 +0000 Posttransplant antiglomerular basement membrane (anti-GBM) disease occurs in approximately 5% of Alport patients and usually ends in irreversible graft failure. Recent research has focused on characterizing the structure of the anti-GBM alloepitope. Here we present a case of a 22-year-old male with end-stage renal disease secondary to Alport syndrome, with a previously failed renal allograft, who received a second deceased-donor kidney transplant. Six days after transplantation, he developed acute kidney injury. The serum anti-GBM IgG was negative by enzyme immunoassay (EIA). On biopsy, he had crescentic glomerulonephritis with linear GBM fixation of IgG. With further analysis by western blotting, we were able to detect antibodies to an unidentified protein from the basement membrane. This patient was treated with plasmapheresis twice per week and monthly intravenous immunoglobulin (IVIG) for a total of five months. At the end of treatment, these unknown antibodies were no longer detected. His renal function improved, and he has not required dialysis. We conclude that anti-GBM disease in patients with Alport Syndrome may be caused by circulating antibodies to other components of the basement membrane that are undetectable by routine anti-GBM EIA and may respond to treatment with plasmapheresis and IVIG. Sumiko I. Armstead, Thomas Hellmark, Jorgen Wieslander, Xin J. Zhou, Ramesh Saxena, and Nilum Rajora Copyright © 2013 Sumiko I. Armstead et al. All rights reserved. Renal Mucormycosis: A Rare and Potentially Lethal Complication of Kidney Transplantation Tue, 22 Oct 2013 10:08:18 +0000 Renal mucormycosis is a rare and potentially lethal complication of kidney transplantation. We describe two cases of renal mucormycosis following deceased donor kidney transplantation. This is the second report of renal mucormycosis following kidney transplantation in the United States, and the first case of renal mucormycosis infection presumed to be of recipient origin. Case A had an early presentation of mucormycosis isolated to the kidney allograft. He had an unexpected rise in serum creatinine and leukocytosis necessitating allograft biopsy which showed mucormycosis. He underwent transplant nephrectomy on posttransplant day 11, was treated with amphotericin B, and discharged home on posttransplant day 22. Case B had a late presentation of renal mucormycosis, preceded by a cutaneous manifestation. One year after kidney transplantation he had a nonhealing knee ulcer which on biopsy showed cutaneous mucormycosis. Treatment included aggressive debridement and amphotericin B. Allograft biopsy showed mucormycosis, necessitating transplant nephrectomy. He was discharged to a rehabilitation facility and died from noninfectious causes. Review of the published literature of renal mucormycosis cases following kidney transplantation reveals a mortality rate of more than 50%. The key to successful outcome is early recognition, prompt institution of surgical debridement of all infected tissue, and appropriate antifungal therapy. SreyRam Kuy, Chun He, and David C. Cronin II Copyright © 2013 SreyRam Kuy et al. All rights reserved. Intra-Abdominal Localisation of a Buschke-Lowenstein Tumour: Case Presentation and Review of the Literature Wed, 18 Sep 2013 18:27:35 +0000 Giant condyloma acuminatum or Buschke-Lowenstein tumour is a very rare disease which usually is located in the genital, anorectal, and perianal regions. It is regarded as a type of verrucous carcinoma occurring on anogenital mucosal surfaces where it is locally invasive but displays a benign cytology. We describe a case of a 24-year-old woman with persisting condyloma acuminata progressing to a large intra-abdominal Buschke-Lowenstein tumour. To our knowledge such an advanced stage has only been reported once before. The severity and extent of the tumour both determine the treatment and patient outcome. Treatment was impeded by cachexia, an immunosuppressive state after kidney transplantation and difficulties in establishing a reliable diagnose. Interferon treatment was started which initially led to tumour reduction but was complicated by an interferon-induced pancreatitis, pneumonia, and fasciitis necroticans resulting in death. We present a literature overview on the treatment options for a Buschke-Lowenstein tumour, with emphasis on interferon therapy, with all the advantages and disadvantages. N. E. Wester, E. M. Hutten, C. Krikke, and Robert A. Pol Copyright © 2013 N. E. Wester et al. All rights reserved. Liver Transplantation Using a Graft from a Donor with Situs Inversus Totalis: A Case Report and Review of the Literature Tue, 10 Sep 2013 15:48:07 +0000 It is critical to effectively use every available organ to meet the increasing demands for liver transplantation. Situs inversus is a rare congenital anomaly caused by obstruction of viscus rotation during embryonic development. Situs inversus was once regarded as a contraindication to liver transplantation because of the technical difficulties associated with the unique vascular anatomy and concern about achieving accurate graft positioning. Here, we present a successful case of liver transplantation using a graft from a donor with situs inversus totalis. The related experience will contribute to opening up new realms for the use of such rare organ resources. Xu-Yong Sun, Ke Qin, Jian-Hui Dong, Hai-Bin Li, Liu-Gen Lan, Ying Huang, Song Cao, and Zhuang-Jiang Li Copyright © 2013 Xu-Yong Sun et al. All rights reserved. Successful Kidney Transplantation for End-Stage Renal Disease in Marfan's Syndrome Wed, 04 Sep 2013 15:27:58 +0000 Marfan’s syndrome is a systemic disorder of the connective tissue caused by mutations in the extracellular matrix protein fibrillin-1, with aortic dissection and aneurysm being its most life-threatening manifestations. Kidney transplantation for end-stage renal disease (ESRD) in patients with Marfan’s syndrome has not been reported in the literature, and the rate of the incidence of dissection or aneurysm in the iliac artery is unknown. Here, we present a patient with Marfan’s syndrome with ESRD due to severe renal ischemia caused by massive bleeding from thoracoabdominal aortic dissection leading to transplant surgery of a living kidney procured from the patient’s mother. After kidney transplantation, the renal function normalized without vascular complications, and stable graft function along with negative results for both microhematuria and proteinuria continued for two years. Also, vascular complication such as aneurysm or dissection of the iliac artery was not observed using ultrasonography during the follow-up period. ESRD patients with Marfan’s syndrome might be suitable for kidney transplantation, but long-term and careful observations are needed. Makoto Ryosaka, Kazuya Omoto, Taiji Nozaki, Kazuhiko Yoshida, Yugo Sawada, Hajime Hirano, Tomokazu Shimizu, Hideki Ishida, and Kazunari Tanabe Copyright © 2013 Makoto Ryosaka et al. All rights reserved. Salmonella Appendicitis in Renal Transplantation Wed, 04 Sep 2013 10:26:57 +0000 While appendicitis remains one of the commonest surgical diseases, there are relatively few reports following renal transplantation. A 33-year-old man was admitted with diarrhea, fever, and epigastric pain 7 years following a cadaveric renal transplant. CT scanning confirmed a diagnosis of appendicitis which was removed within 24 hours of admission. Histology and blood cultures following surgery confirmed Salmonella type b appendicitis. Patient was safely discharged home 5 days following hospital admission. B. Malone, S. Kleyman, A. Sanni, N. Sumrani, and D. Distant Copyright © 2013 B. Malone et al. All rights reserved. Severe Necrotizing Adenovirus Tubulointerstitial Nephritis in a Kidney Transplant Recipient Wed, 28 Aug 2013 11:36:46 +0000 Adenoviruses (AdV) are emerging pathogens with a prevalence of 11% viruria and 6.5% viremia in kidney transplant recipients. Although AdV infection is common, interstitial nephritis (ADVIN) is rare with only 13 biopsy proven cases reported in the literature. We report a case of severe ADVIN with characteristic histological features that includes severe necrotizing granulomatous lesion with widespread tubular basement membrane rupture and hyperchromatic smudgy intranuclear inclusions in the tubular epithelial cells. The patient was asymptomatic at presentation, and the high AdV viral load (quantitative PCR>2,000,000 copies/mL in the urine and 646,642 copies/mL in the serum) confirmed the diagnosis. The patient showed excellent response to a combination of immunosuppression reduction, intravenous cidofovir, and immunoglobulin therapy resulting in complete resolution of infection and recovery of allograft function. Awareness of characteristic biopsy findings may help to clinch the diagnosis early which is essential since the disseminated infection is associated with high mortality of 18% in kidney transplant recipients. Cidofovir is considered the agent of choice for AdV infection in immunocompromised despite lack of randomized trials, and the addition of intravenous immunoglobulin may aid in resolution of infection while help prevention of rejection. Ravi Parasuraman, Ping L. Zhang, Dilip Samarapungavan, Leslie Rocher, and Alan Koffron Copyright © 2013 Ravi Parasuraman et al. All rights reserved. Primary Angioplasty for Cardiac Allograft Vasculopathy Presenting as ST-Elevation Acute Myocardial Infarction during Endomyocardial Biopsy Tue, 27 Aug 2013 15:44:50 +0000 Cardiac allograft vasculopathy is still a major issue, with significative mortality in heart transplant patients, and the best therapeutic options are not yet established. The progressively higher survival rates after transplantation have made it a major concern. This is a case report about a patient who underwent cardiac transplantation due to chagasic cardiomiopathy. During an endomyocardial biopsy more than 2 years after the transplant, the patient arrested in ventricular fibrillation, with ST-elevation in anterior leads after defibrillation. The angiography showed total occlusion of proximal left anterior descending artery, promptly treated with primary angioplasty, with excellent angiographic and clinical results. Bruno Ramos Nascimento, Thalles Oliveira Gomes, Júlio César Borges, Guilherme Rafael Sant’Anna Athayde, Sílvio Amadeu de Andrade, and Maria da Consolação Vieira Moreira Copyright © 2013 Bruno Ramos Nascimento et al. All rights reserved. Treatment of Recurrent Posttransplant Lymphoproliferative Disorder of the Central Nervous System with High-Dose Methotrexate Thu, 01 Aug 2013 13:10:38 +0000 Posttransplant lymphoproliferative disorder (PTLD) is a frequent complication of intestinal transplantation and is associated with a poor prognosis. There is currently no consensus on optimal therapy. Recurrent PTLD involving the central nervous system (CNS) represents a particularly difficult therapeutic challenge. We report the successful treatment of CNS PTLD in a pediatric patient after liver/small bowel transplantation. Initial immunosuppression (IS) was with thymoglobulin, solucortef, tacrolimus, and mycophenolate mofetil. EBV viremia developed 8 weeks posttransplantation, and despite treatment with cytogam and valganciclovir the patient developed a polymorphic, CD20+, EBV+ PTLD with peripheral lymphadenopathy. Following treatment with rituximab, the lymphadenopathy resolved, but a new monomorphic CD20−, EBV+, lambda-restricted, plasmacytoid PTLD mesenteric mass emerged. Complete response of this PTLD was achieved with 6 cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy; however, 4 months off therapy he developed CNS PTLD (monomorphic CD20−, EBV+, lambda-restricted, plasmacytoid PTLD) of the brain and spine. IS was discontinued and HD-MTX (2.5–5 gm/m2/dose) followed by intrathecal HD-MTX (2 mg/dose ×2-3 days Q 7–10 days per cycle) was administered Q 4–7 weeks. After 3 cycles of HD-MTX, the CSF was negative for malignant cells, MRI of head/spine showed near-complete response, and PET/CT was negative. The patient remains in complete remission now for 3.5 years after completion of systemic and intrathecal chemotherapy. Conclusion. HD-MTX is an effective therapy for CNS PTLD and recurrent PTLD that have failed rituximab and CHOP chemotherapy. Clare J. Twist and Ricardo O. Castillo Copyright © 2013 Clare J. Twist and Ricardo O. Castillo. All rights reserved. Aspergillus Tracheobronchitis Causing Subtotal Tracheal Stenosis in a Liver Transplant Recipient Thu, 25 Jul 2013 13:51:37 +0000 Invasive aspergillosis is recognized as one of the most significant opportunistic infections after liver transplantation. Diagnosis of invasive aspergillosis in transplant recipients has been proven to be challenging, and optimal approach to the treatment of invasive aspergillosis is still controversial. We here present an unusual case of Aspergillus tracheobronchitis in the setting of liver transplantation. A 47-year-old female patient with persistent dry cough after liver transplantation developed respiratory insufficiency and was readmitted to the intensive care unit 55 days after liver transplantation. A CT scan revealed subtotal tracheal stenosis; bronchoscopy was performed, and extended white mucus coverings causative of the tracheal stenosis were removed. Microbiological assessment isolated Aspergillus fumigatus. The diagnosis was obstructive Aspergillus tracheobronchitis. The patient was started on a treatment of voriconazole 200 mg orally twice daily, adjusted to a trough level of 1–4 mg/L. For further airway management, a tracheal stent had to be implanted. The patient is alive and well 28 months after liver transplantation. Invasive aspergillosis should be considered a possible etiology in liver transplant patients presenting with unspecific symptoms such as persistent dry cough. Optimal strategies for improved and early diagnosis as well as prophylaxis need to be defined. Sonia Radunz, Carmen Kirchner, Jürgen Treckmann, Andreas Paul, and Fuat H. Saner Copyright © 2013 Sonia Radunz et al. All rights reserved. Intracardiac Thrombosis during Adult Liver Transplantation Wed, 24 Jul 2013 09:39:10 +0000 Intracardiac thrombosis (ICT) and pulmonary embolism (PE) during adult liver transplantation are rare but potentially lethal complications. They are often overlooked because of significant diagnostic challenges. The combination of hemodynamic compromise and transesophageal echocardiography (TEE) findings allows for correct diagnosis. A large variety of putative risk factors for ICT and PE have been suggested, but these events are considered to be multifactorial. There are different proposed treatment modalities for these devastating complications. Unfortunately, in spite of growing knowledge in this area, intraoperative and postoperative mortalities remain very high. The retrospective nature of the study of these events makes the case reports extremely valuable. Marina Moguilevitch and Carlene Broderick Copyright © 2013 Marina Moguilevitch and Carlene Broderick. All rights reserved. Inferior Epigastric Artery Pseudoaneurysm in a Kidney Transplant Recipient Mon, 22 Jul 2013 11:23:59 +0000 Pseudoaneurysm of inferior epigastric artery (IEA) is a very rare clinical entity. We reported a case of combined kidney transplant and pseudoaneurysmectomy in a young HBV-HCV-HIV recipient. This case emphasizes the possibility of planning a safe and correct surgical treatment and the best timing to treat IEA pseudoaneurysm. An exhaustive preoperative radiological study in all patients candidate to kidney transplant could identify the possible aortoiliac disease both stenotic or dilatative even if it is rare and helps to define the best treatment options. M. Tozzi, B. Molteni, M. Franchin, G. Ietto, G. Soldini, V. Bertocchi, and G. Carcano Copyright © 2013 M. Tozzi et al. All rights reserved. Treatment of Acute Tacrolimus Toxicity with Phenytoin in Solid Organ Transplant Recipients Thu, 13 Jun 2013 15:36:14 +0000 The pharmacokinetics of tacrolimus are influenced by many factors, including genetic variability, acute infections, liver dysfunction, and interacting medications, which can result in elevated concentrations. The most appropriate management of acute tacrolimus toxicity has not been defined though case reports exist describing the therapeutic use of enzyme inducers to increase tacrolimus metabolism and decrease concentrations. We are reporting on the utilization of phenytoin to assist in decreasing tacrolimus concentrations in a case series of four solid organ transplant recipients with acute, symptomatic tacrolimus toxicity presenting with elevated serum creatinine, potassium, and tacrolimus trough concentrations greater than 30 ng/mL. All four patients had the potential causative agents stopped or temporarily held and were given 300 to 400 mg/day of phenytoin for two to three days. Within three days of beginning phenytoin, all four patients had a decrease in tacrolimus concentration to less than 15 ng/mL, a return to or near baseline creatinine concentration, and lack of phenytoin-related side effects. Therefore, phenytoin appears to be a safe and potentially beneficial treatment option in patients with symptomatic tacrolimus toxicity. Arin S. Jantz, Samir J. Patel, Wadi N. Suki, Richard J. Knight, Arvind Bhimaraj, and A. Osama Gaber Copyright © 2013 Arin S. Jantz et al. All rights reserved. De Novo Fibrillary Glomerulonephritis (FGN) in a Renal Transplant with Chronic Hepatitis C Thu, 13 Jun 2013 12:13:17 +0000 Chronic hepatitis C viremia (HepC) has been associated with numerous renal manifestations both in native kidneys and in the setting of renal transplantation. Glomerulonephritis (GN) of the renal allograft in the setting of HepC most commonly manifests as type 1 membranoproliferative GN (MPGN), either representing recurrence of the original disease or arising de novo. Other GNs were reported after transplantation in the patient with HepC including membranous nephropathy and thrombotic microangiopathy, as well as an enhanced susceptibility to transplant glomerulopathy. We describe the first case of de novo fibrillary GN in a renal transplant patient with HepC where the primary renal disease was biopsy proven type 1 MPGN. We discuss this relationship in detail. Edward J. Filippone, Christine Chmielewski, Rakesh Gulati, Eric Newman, and John L. Farber Copyright © 2013 Edward J. Filippone et al. All rights reserved. Cellular Transplantation Alters the Disease Progression in Becker’s Muscular Dystrophy Thu, 06 Jun 2013 12:30:27 +0000 Becker’s Muscular Dystrophy (BMD) is a dystrophinopathy manifested as progressive muscle degeneration. Autologous Bone Marrow Mononuclear Cells (BMMNCs) have shown some myogenic potential. The paracrine effects of the BMMNCs reduce the inflammation and are thought to reduce muscle degeneration. We treated a 39 year old dental surgeon suffering from BMD. Muscle strength was reduced when measured using modified Medical Research Council’s Manual Muscle Testing (mMRC-MMT). Static sitting balance was poor. He was wheelchair dependent for ambulation and moderately independent in Activities of Daily Living (ADL). Functional Independence Measure (FIM) score was 93. Musculoskeletal Magnetic Resonance Imaging (MRI-MSK) showed moderate fatty infiltration in the muscles. Three cellular transplantations were carried out. Clinical assessment and the investigations were repeated. Progressive increase in the muscle strength was noted. Ambulation was independent using push-knee splints and minimal assistance when weary. Static and dynamic balance in sitting and standing improved. FIM score increased from 93 to 105. There was no increase in the degree of fatty infiltration, as seen on the MRI-MSK. The case study provides evidence for the putative benefits of cellular therapy in altering the disease progression in BMD. It also suggests augmented clinical benefits of combination of cellular therapy and rehabilitation. Alok Sharma, Amruta Paranjape, Hemangi Sane, Khushboo Bhagawanani, Nandini Gokulchandran, and Prerna Badhe Copyright © 2013 Alok Sharma et al. All rights reserved. Strongyloides stercoralis and Organ Transplantation Mon, 27 May 2013 10:50:19 +0000 Strongyloides is a parasite that is common in tropical regions. Infection in the immunocompetent host is usually associated with mild gastrointestinal symptoms. However, in immunosuppressed individuals it has been known to cause a “hyperinfection syndrome” with fatal complications. Reactivation of latent infection and rarely transmission from donor organs in transplanted patients have been suggested as possible causes. Our case highlights the importance suspecting Strongyloides in transplant recipients with atypical presentations and demonstrates an incidence of donor derived infection. We also review the challenges associated with making this diagnosis. Bhalaghuru Chokkalingam Mani, Moses Mathur, Heather Clauss, Rene Alvarez, Eman Hamad, Yoshiya Toyoda, Mark Birkenbach, and Mustafa Ahmed Copyright © 2013 Bhalaghuru Chokkalingam Mani et al. All rights reserved. Transitional Cell Carcinoma of the Kidney Graft: An Extremely Uncommon Presentation of Tumor in Renal Transplant Recipients Sun, 26 May 2013 14:53:34 +0000 Purpose. Transitional cell carcinoma (TCC) affecting the graft after renal transplantation is a very infrequent way of presentation of this tumor. Our aim is to present our single institution experience with 2 cases, as well as to perform a review of the literature about this tumor after the transplant. Materials and Methods. TCC of the graft developed in 2 of 1365 patients from 1977 to 2010, both cases in women. Data were analyzed for incidence, clinical presentation, treatment, and outcomes. Results. Both cases occurred in 2 mid-age women and resulted to be high grade and locally advanced TCCs, representing an incidence of 0,14% (2/1365). Clinical presentation was urinary obstruction for the first case and incidental ultrasound finding for the second. Preoperative staging was made with CT, cytology, pyelography, ureterorenoscopy, and biopsy. Treatment performed was nephroureterectomy of the graft with bladder cuff and regional lymphadenectomy. Pathological examination showed in both cases a locally advanced and high grade urothelial carcinoma of the pelvis allograft. After 24 and 14 months of followup, both patients are disease free. Conclusions. TCC of the kidney graft is an infrequent tumor that has only been reported in a few cases in the literature. It usually appears at a lower age, more often locally advanced, and with poor differentiation. A multidisciplinary approach to treatment should be required in these cases. Vital Hevia, Victoria Gómez, Sara Álvarez, Víctor Díez Nicolás, Carmen Gómez del Cañizo, Andrea Orosa, Cristina Galeano Álvarez, and F. J. Burgos Revilla Copyright © 2013 Vital Hevia et al. All rights reserved.