This document discusses fever in post-transplant patients. It identifies the main causes of post-transplant fever as infection, rejection of the transplant, drug-induced fever, and post-transplant lymphoproliferative disorders (PTLD). It notes that the risk and types of infection change over time after transplantation. PTLD is a lymphoid or plasmacytic proliferation that can occur after transplantation due to immunosuppression and is sometimes associated with Epstein-Barr virus. PTLD can present as early lesions, polymorphic PTLD, or monomorphic PTLD meeting criteria for lymphoma.

1. Fever in a Post-Transplant
Patient
A Review – September 27, 2017
Matthew Fabiszak, D.O., PGY2

2. Pearls
• Post-transplant fever can be categorized into big categories:
• Infection
• Rejection
• Drug induced
• Post-Transplant Lymphoproliferative Disorders
• Risk and types of infection after transplant changes over time!

3. Infection
• It’s more difficult to recognize infection in transplant recipients than
in patients with normal immune function.
• Risk of infection after transplant changes over time, with
modifications in immunosuppression.
• Broadly, think in terms of 4 broad categories:
• Donor derived infections
• Recipient derived infections
• Nosocomial infections
• Community infections

5. Classic Timeline of Infections Post-transplant

6. Rejection
• Acute cellular rejection:
• Within 90 days of transplantation
• Late cellular rejection:
• Associated with low concentrations of immunosuppressive medications, and
associated with reduced graft survival.
• Biopsy is the gold standard for diagnosis

7. Medication Effect
• Cyclosporine/Tacrolimus toxicity
• Headache, fatigue, nephrotoxicity, fever (20-48%)

8. Post-Transplant Lymphoproliferative Disorders
(PTLD)
• Lymphoid or plasmacytic proliferations status post solid organ or
allogeneic hematopoietic cell transplantation secondary to
immunosuppression.
• Theorized to be related to EBV (although EBV negative disease can
occur 20-30% of cases)
• Risk factors include:
• Degree of immunosuppression
• EBV serostatus of recipient
• Treatment with anti-thymocyte globulin

9. Post-Transplant Lymphoproliferative Disorders
(PTLD)
• Early lesions
• This presents as an infectious mononucleosis-type acute illness characterized
by polyclonal B cell proliferation with no evidence to suggest malignant
transformation.
• Polymorphic PTLD
• Polyclonal or monoclonal lymphoid infiltrates that demonstrate evidence of
malignant transformation but do not meet all of the criteria for one of the B
cell or T/NK cell lymphomas recognized in immunocompetent patients.
• Monomorphic PTLD
• Monoclonal lymphoid proliferations that meet the criteria for one of the B cell
or T/NK cell lymphomas recognized in immunocompetent patients.

10. Post-Transplant Lymphoproliferative Disorders
(PTLD)
• Clinical presentation:
• Constitutional symptoms such as fever, weight loss, and fatigue are common
• Abnormal laboratory results:
• Unexplained anemia, thrombocytopenia, or leukopenia
• Elevated level of serum lactate dehydrogenase (LDH)
• Hypercalcemia
• Hyperuricemia
• Monoclonal protein in the serum or urine

11. Sources
• http://www.nejm.org/doi/pdf/10.1056/NEJMra064928
• https://www.uptodate.com/contents/infection-in-the-solid-organ-
transplant-recipient?source=search_result&search=Post-
Transplant%20fever&selectedTitle=1~150
• https://www.uptodate.com/contents/epidemiology-clinical-
manifestations-and-diagnosis-of-post-transplant-lymphoproliferative-
disorders?source=search_result&search=Post-
Transplant%20Lymphoproliferative%20Disorders&selectedTitle=1~86
• https://ucsfmed.wordpress.com/2016/11/14/fever-in-a-post-
transplant-patient/