Rutgers New Jersey Medical School Cooper City, FL, United States
Fayssa Salomon, MD1, Ali Wakil, MD1, Mujtaba Mohamed, MD1, Gopala Koneru, MD2, Nikolaos Pyrsopoulos, MD, PhD, MBA1 1Rutgers New Jersey Medical School, Newark, NJ; 2Rutgers New Jersey Medical School, Jersey City, NJ
Introduction: Toxoplasmosis in immunosuppressed has high fatality rate. It occurs rarely after liver transplantation and can result from primary infection or reactivation. For pretransplant seropositive recipients, reactivation of latent infection can present a risk in the setting of immunosuppression but the diagnosis is often difficult and requires an integrative approach. We present the case of a liver transplant patient with initial presentation of aplastic anemia as a manifestation of disseminated toxoplasmosis.
Case Description/Methods: A 64 year old Hispanic female underwent liver transplantation for decompensated NASH cirrhosis worsened by acute hepatitis A infection. The patient was treated with tacrolimus, mycophenolate mofetil and prednisone. Oral valacyclovir and trimethoprim-sulfamethoxazole were initiated for prophylaxis. Immediate post-operative course was uncomplicated until patient developed progressive pancytopenia in second month post transplant. Bactrim was switched to atovaquone in the setting of leukopenia. Ten weeks post transplant, she experienced a seizure episode which led to findings of ring enhancing lesions on right temporal lobe on brain MRI. Lumbar puncture was unrevealing. She was empirically treated for herpetic illness and fungal infections. Due to worsening pancytopenia, bone marrow biopsy was performed and revealed aplastic anemia. Infectious workup was negative for coccidioides, Q Fever, Adenovirus, Enterovirus and JC Virus. The identity of Toxoplasma was confirmed by PCR. Before liver transplantation, the patient had positive toxoplasma IgG but negative IgM. Tissue biopsy of brain lesions were not obtained due to high risk of bleeding considering profound thrombocytopenia. She was initiated on treatment though unfortunately patient passed 13 weeks post transplant.
Discussion: Toxoplasma infection in immunocompromised patients usually result from the reactivation of latent cysts into invasive tachyzoites. The transmission of infection from a seropositive donor to a seronegative recipient is 20% in liver transplant patients. For pretransplant seropositive recipients, reactivation of latent infection is rare. There is no clear-cut guideline for initiation or duration of prophylaxis which is usually done with trimethoprim-sulfamethoxazole. A combination of serological screening and chemoprophylaxis can help implement preventive measures. A serological and PCR follow-up of high-risk patients will help in timely detection of the disease and ultimately better outcome.
Fayssa Salomon indicated no relevant financial relationships.
Ali Wakil indicated no relevant financial relationships.
Mujtaba Mohamed indicated no relevant financial relationships.
Gopala Koneru indicated no relevant financial relationships.
Nikolaos Pyrsopoulos indicated no relevant financial relationships.
Fayssa Salomon, MD1, Ali Wakil, MD1, Mujtaba Mohamed, MD1, Gopala Koneru, MD2, Nikolaos Pyrsopoulos, MD, PhD, MBA1. P0765 - Disseminated Toxoplasmosis in a Post Liver Transplant Patient Manifested as Aplastic Anemia, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.