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Adverse Occurrence type:
Post-transplant HHV8-associated disease is rare. The risk of Kaposi sarcoma in recipients of solid organ transplants is increased by up to 1000-fold over that of the general population due to chronic immunosuppression. Most cases are presumed to be due to reactivation of pre-existing infection in the recipient, particularly in areas of higher seroprevalence but robust data is lacking. The exact rate of donor-derived transmission of infection leading to symptomatic disease is unknown; rates vary depending on local epidemiology and investigations performed.
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
The pediatric recipient of the associated liver segment split liver graft was diagnosed with liver KS. This triggered investigations in the adult recipient of the right liver lobe: abdominal MRI revealed multiple rim-enhancing lesions. Liver biopsy of the largest lesion demonstrated a vascular mass containing spindle cells with positive HHV-8 immunostaining. The report describes management of the KS with removal of immunosuppression but due to acute cellular rejection, sirolimus-based immunosuppression was initiated in conjunction with a prednisone taper. Due to continuing rejection, tacrolimus was added to sirolimus and systemic chemotherapy initiated with liposomal doxorubicin and pegfilgrastim; remission was obtained after 13 cycles.
Demonstration of imputability or root cause:
The donor was a 19 year-old male born in Iraq, with previous history of incarceration who dies of opiate overdose, tested retrospectively and found to be HHV8 antibody and DNA positive in blood. HHV-8 PCR and IgG serology performed on archived pre-transplant serum from both recipients were negative. The paper does not describe the diagnosis in the pediatric recipient.
Suggest new keywords:
Fu W, Merola J, Malinis M, et al. Successful treatment of primary donor-derived human herpesvirus-8 infection and hepatic Kaposi Sarcoma in an adult liver transplant recipient. Transplant infectious disease : an official journal of the Transplantation Society 2018;20:e12966.
Expert comments for publication:
This case report describes a well characterised transmission event with the correct tests applied to donor and recipients , including pre-transplant HHV-8 serology. Of note, the donor was found to have HHV-8 DNA detectable in blood, which is not a frequent finding in latent infection. It is not possible to speculate whether or not the infection in the donor might have been recent. Although transmission of infection may not lead to over symptoms, severe donor-derived primary infection has been described and poses management difficulties. This report details successful treatment of donor-derived primary HHV-8 infection and Kaposi sarcoma in a hepatic allograft. This also highlights the fact that early and informed intervention may contribute to improved recipient outocome.