The Ohio State University College of Medicine Columbus, OH
Madeleine Davis, BA1, Vivek Mendiratta, MD2, Nicole O'Bleness Gray, APP3, Martha Yearsley, MD3 1The Ohio State University College of Medicine, Columbus, OH; 2The Ohio State University Wexner Medical Center, Dublin, OH; 3Wexner Medical Center, Columbus, OH Introduction: Antibody-mediated rejection (AMR) of a liver allograft is a rare complication following liver transplantation, especially when compared to other major organ transplants such as the heart or kidney. We report a novel case of AMR seven months post-orthotopic liver transplant due to suspected infection.
Case Description/
Methods: A 58-year-old female, 7-months-post orthotopic liver transplant due to Hepatitis C-associated liver cirrhosis, was admitted with elevated LFTs, fever, and flank pain. Endoscopic ultrasound-guided liver biopsy revealed active hepatitis and fibrin ring granulomas. PCR detection of infectious organisms on the biopsy revealed positive bacterial DNA on 16s rDNA analysis.
Laboratory evaluation identified positive Bartonella IgG (1:512) with a negative PCR and positive Brucella IgM. Calculated panel-reactive antibodies (cPRA) increased from 0% to 93%, with de novo donor-specific antibodies (DSA).
Her LFTs remained elevated despite a course of intravenous solumedrol 500 mg QD and doxycycline. A second and third biopsy demonstrated resolution of the fibrin rings but the new appearance of biliary-related changes, ductopenia, and a positive C4d. Discussion: Our patient’s initial findings of fever, leukocytosis, and elevated LFTs suggested acute infectious hepatitis, further supported by her 1st biopsy findings demonstrating a positive bacterial PCR and fibrin ring granulomas of which bacterial infections, namely Coxiella Burnettii and Bartonella, are some of the most common causes. Moreover, the patient’s infectious workup indicated a possible Bartonella infection, although Q-fever is a possible alternative etiology given the known cross-reactivity between antibodies. Regardless, empiric treatment with doxycycline successfully resolved the patient’s fevers and led to resolution of her fibrin ring granulomas on follow-up biopsies, implicating an atypical infectious hepatitis as the likely precipitant.
Despite the resolution of her infection, her LFTs did not improve in the following weeks. Her 2nd and 3rd biopsy findings as well as her new DSAs were consistent with a new development of AMR. Therefore, we propose that this case represents a novel mechanism of AMR of an allogeneic liver transplant due to an atypical infectious trigger, as evidenced by the evolution of our patient’s liver biopsies, with fibrin ring granulomas subsequently transitioning to characteristic chronic rejection histology, as AMR developed following the initial insult.
Disclosures: Madeleine Davis indicated no relevant financial relationships. Vivek Mendiratta indicated no relevant financial relationships. Nicole O'Bleness Gray indicated no relevant financial relationships. Martha Yearsley indicated no relevant financial relationships.
Madeleine Davis, BA1, Vivek Mendiratta, MD2, Nicole O'Bleness Gray, APP3, Martha Yearsley, MD3. P1707 - An Unexpected Trigger: Atypical Infectious Hepatitis Inducing Antibody-Mediated Rejection in a Liver Transplant Recipient, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
