956: MASSIVE FLASH PULMONARY EDEMA FOLLOWING ANTIBODY-MEDIATED REJECTION THERAPY POST-LUNG TRANSPLANT

Abstract

Introduction: Antibody-mediated rejection (AMR) is a complication of orthotopic lung transplantation (OLT) leading to allograft dysfunction through immune activation. We report a patient with bilateral OLT who received daratumumab for AMR and subsequently developed flash pulmonary edema and multisystem organ failure (MSOF) resulting in death. Description: An 18-year-old male with pulmonary veno-occlusive disease status-post remote bilateral OLT presented to a quaternary-care hospital for respiratory distress. Biopsy revealed AMR with elevated donor-specific-antibodies (DSAs). He was started on our institution-specific AMR protocol: systemic steroids, rituximab, a 5–7-day course of plasmapheresis, mepolizumab, and daratumumab. Following daratumumab, the patient developed tachycardia, tachypnea, hypertension, and altered mental status. He was transferred to the PICU in extremis and was emergently intubated. He had massive flash pulmonary edema with copious production of proteinaceous fluid (>1L/hr) impairing ventilation and oxygenation. His arterial pH remained < 7 and pCO2 > 100 mmHg. Echocardiogram demonstrated normal biventricular function, eliminating a cardiogenic source. He continued to have profound hypoxemic and hypercapnic respiratory failure, pulmonary edema, uncompensated shock, acute kidney injury with anuria, disseminated intravascular coagulation, and acute encephalopathy. Due to progressive MSOF, life-sustaining therapies were withdrawn. A unifying diagnosis to explain his MSOF and acute decompensation were never identified. Discussion: There are no reports of flash pulmonary edema after daratumumab administration, however it has been described with other monoclonal antibodies, including muromonab-CD3 (OKT3) [1]. Edema from OKT3 has been attributed to cytokine release syndrome (CRS) [1]. We postulate a similar pathophysiology. Daratumumab, a human CD-38-targeting antibody, induces cell-death via complement and antibody-dependent cytotoxicity, apoptosis, and phagocytosis [2]. We suspect a massive response of the infused monoclonal antibody with the pulmonary DSAs, resulting in localized cell death and lysis, cytokine release, pulmonary vascular inflammation, and uncontrollable pulmonary edema. We hope to gain further insight with immunohistological data on autopsy.