Fever of Unkown Origin as a Sole Manifestation of Pancreas Allograft Rejection

Abstract

Fever in a transplant recipient is almost always suspicious of an infectious etiology. We present a patient with simultaneous pancreas and kidney transplant who had persistent high grade fever for a month which could only be attributed to pancreas allograft rejection. A 56 year old white man with history of simultaneous kidney-pancreas transplant (SPK) a month prior presented with fever of unknown etiology. Patient denied any sick contacts or any localizing signs and symptoms. On examination, his temperature was 102.1 °F. Rest of the examination was unremarkable. His immunosuppression consisted of tacrolimus 3 mg twice daily, mycophenolate 1000 mg twice daily, and Prednisone 10 mg daily. Initial laboratory work up showed serum creatinine 1.8 mg/dl (Baseline serum Cr 1.8-2.0 mg/dl), tacrolimus level 14 ng/dl, serum amylase 82, serum lipase 67, glucose 89 mg/dl, and normal urine analysis. In addition, blood culture, urine culture, and serum cytomegalovirus, Epstein Barr virus and BK virus PCR were negative. Chest X ray and CT scan of abdomen and pelvis did not show any significant pathology. Patient's fever continued unabated in the range of 100-103°F daily for a month despite empirical antibiotic therapy while cultures remained negative. Rest of the negative work-up included an echocardiogram, kidney ultrasound with kidney biopsy, cerebrospinal fluid analysis, tagged white blood cell scan, upper and lower gastrointestinal scopes with biopsy of gastrointestinal mucosa for any viral inclusions. Nuclear PET scan showed increased activity in the pancreas transplant. Pancreas allograft biopsy confirmed pancreas allograft rejection although serum amylase and lipase were normal at the time of biopsy. Fever disappeared after initiation of steroids and has not recurred since discharge from the hospital 3 months ago. In conclusion, pancreas allograft rejection may present as fever of unknown etiology in a pancreas transplant recipient. Serum amylase and lipase may not be the reliable markers of pancreatic transplant rejection.