Abstract: SA-PO882
Heartland Virus-Induced Hemophagocytic Lymphohistiocytosis in a Kidney Transplant Recipient
Session Information
- Transplantation: Clinical - Case Reports
November 05, 2022 | Location: Exhibit Hall, Orange County Convention Center‚ West Building
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Levine, Zoey, Washington University in St Louis, St Louis, Missouri, United States
- Rajashekar, Gaurav, Washington University in St Louis, St Louis, Missouri, United States
Introduction
Heartland virus (HRTV) is a tick-borne phlebovirus first discovered in 2009 in Missouri. Field studies identified Amblyomma americanum or the Lone Star tick as the most likely vector for HRTV. Since then, more than 50 cases of Heartland disease have been reported from 11 states in Central and Southeastern United States during the months of April to September, corresponding strongly with the geographical and seasonal distribution of A americanum. Kidney transplant recipients are particularly susceptible to opportunistic infection due their degree of immunosuppression.
Case Description
Here we present a case of a 58-year-old male with a past medical history of end stage renal disease secondary to IgA nephropathy, post kidney transplant in 2006 from a living unrelated donor, on a prednisone and tacrolimus, deep vein thrombosis on warfarin, parotidectomy due to squamous cell carcinoma of the parotid gland presented to the hospital with fever, fatigue, and diarrhea for six days. Labs showed acute kidney injury with a serum creatinine 2.7 mg/dL (baseline of 1.2-1.3 mg/dL), thrombocytopenia (platelet 88 k/mm3), and anemia (hemoglobin 7.4 g/dl). Additional labs showed elevated ferritin > 190 000 ng/ml, Lactate dehydrogenase > 2000 units/L, triglycerides > 240 mg/dl, and low fibrinogen < 120 mg/dl. On further inquiry, he reported recent turkey hunting, handling dead mice and exposure to ticks. Based on lab analysis, a bone marrow biopsy was performed which showed normocellular marrow with hemophagocytic macrophages and no evidence of lymphoproliferative process confirming our initial suspicion of Hemophagocytic Lymphohistiocytosis (HLH). Given his recent social history and exposures, an extensive infectious workup was performed and was positive for Heartland Virus infection, a known tick-borne cause of HLH, prevalent in the state of Missouri. Treatment was initiated with high-dose dexamethasone and decreased level of chronic immunosuppression. Kidney function improved and laboratory parameters normalized.
Discussion
The case emphasizes the importance of prompt evaluation for HLH in severe heartland virus infection. However, there are many diagnostic challenges that can delay management and worsen survival outcomes. Social history is crucial in estabilishing a framework to diagnose a case. HLH presents with non-specific and variable findings that can be caused by Heartland virus disease.