Fever, Hepatosplenomegaly and a Skin Nodule in a Kidney–Pancreas Transplant Recipient

Abstract

A 52-year-old woman presented with 1 month of malaise, fevers, myalgia and abdominal distension. Six years previously she had undergone simultaneous pancreas and repeat kidney transplantation for type 1 diabetes mellitus. The patient had been maintained on tacrolimus and mycophenolate mofetil with good function of both grafts and no episodes of rejection. She had lived with her husband and the same cat for over 20 years and denied any recent bites or scratches. There was no history of recent travel. Physical examination was notable for hypotension, icterus, a 4 mm erythematous nodule on her lip (Figure 1) and tender hepatosplenomegaly. Laboratory studies showed renal dysfunction (serum creatinine 3.4 mg/dL vs. 1.1 mg/dL at baseline) and hepatic dysfunction (serum total bilirubin 2.5 mg/dL, AST 60 U/L, ALT 102 U/L, GGT 234 U/L). Abdominal imaging showed hepatosplenomegaly without focal masses or biliary dilatation, small ascites and normal appearance of both renal and pancreatic allografts. Bacterial and fungal cultures were negative, and so were serologic and polymerase chain reaction (PCR)-based tests for cytomegalovirus (CMV), Epstein–Barr virus and viral hepatitis. The patient required hemodialysis for worsening kidney function, and intensive care for persistent hypotension and progressive hepatic dysfunction. A transjugular liver biopsy showed numerous randomly distributed cystic blood-filled spaces (Figure 2, arrows) between areas of normal parenchyma. A shave biopsy of the lip lesion demonstrated vascular proliferation consistent with bacillary angiomatosis. Warthin–Starry staining of biopsy specimens (Figure 3, circles) was positive for bacilli, and a diagnosis of disseminated infection with Bartonella species was made. Figure 1 Skin nodule. Figure 2 Liver biopsy: Hematoxylin and eosin stain. Figure 3 Liver biopsy: Warthin–Starry stain.