Joshua Steele, DO, MS1, Thomas Birris, MD2; 1Spectrum Health Lakeland, Saint Joseph, MI; 2Great Lakes Gastroenterology, Saint Joseph, MI
Introduction: Immunosuppression therapy after solid organ transplant is a known risk factor for colorectal cancer (CRC), but there is scarce literature on screening recommendations for these patients after transplantation. Review of the literature suggests that earlier screening and shorter intervals may be necessary to prevent the development of advanced CRC prior to presentation.
Methods: 46 year old Caucasian female with history of kidney transplant, 35 years prior from living sister, and CKD V on immunosuppression presented to the ED with persistent cough and intermittent fevers for 1 months duration. Chest xray on admission showed progressive bilateral interstitial/airspace disease consistent with interstitial lung disease vs infection. She was started on IV antibiotics and admitted for further evaluation. She started to show slow improvement in her respiratory status over the next few days with decreasing procalcitonin and subjective improvement in symptoms but on hospital day 8 she acutely decompensated, requiring BiPAP. She was urgently dialyzed for fluid removal. CT chest was obtained that showed both intrathoracic and abdominal adenopathy consistent with metastatic disease versus opportunistic infection. The next day she was intubated for worsening respiratory status and underwent bronchoscopy. She was transferred to the ICU and remained intubated on vasopressor support without improvement over the next few days. On hospital day 13, her BAL from bronchoscopy resulted positive for malignant cells with immunophenotype most consistent with adenocarcinoma of colorectal origin. The following day, she underwent imaging that showed a mass in the ascending colon with extensive metastatic disease. Care was ultimately withdrawn and she passed a few days later. Discussion: The association between post transplant immunosuppression and development of CRC is one that has been seen in multiple case reports, but not well studied. This case is the first reported solid organ transplant recipient presenting with ILD as the initial presentation for metastatic CRC. This case helps raise the question of higher CRC risk requiring earlier screening in transplant patients. One 3-site, single institution cancer registry found that most post-transplant CRCs are right sided and develop on average 6.1 years after transplant. About 25% present with stage IV disease (1). While the exact cause is unknown, theories have been discussed about the role of calcineurin inhibitors and Azathioprine.
Disclosures: Joshua Steele indicated no relevant financial relationships. Thomas Birris indicated no relevant financial relationships.