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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



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