Hemorrhagic Cystitis in a Liver Transplant Recipient Secondary to BK Virus

Abstract

Introduction: Solid organ transplant recipients are at increased risk of infections. Knowledge of clinical presentation and risk factors allows early diagnosis and directed therapy. We present the case of a 53-year-old liver transplant recipient male who developed hemorrhagic cystitis due to BK virus while undergoing treatment for acute cellular rejection. Case Description: Our patent is a 53-year-old male who underwent liver transplantation for cirrhosis secondary to hepatitis C. He was treated for hepatitis C post-transplant and achieved Sustained Virologic Response (SVR). The patient also had a history of Chronic Kidney Disease Stage 3. He was hospitalized for worsening liver function tests 2 years after his transplant. A liver biopsy revealed acute cellular rejection (ACR). He was treated with high dose IV steroids followed by oral taper and dual immunosuppression therapy with tacrolimus and mycophenolate. Owing no improvement in liver function tests, a repeat liver biopsy was done and showed findings consistent with severe rejection. The patient was given a second cycle of high dose IV steroids followed by 4 doses of antithymoglobulin antibody. He responded to the treatment with improvement in liver function tests, however developed gross hematuria with bladder spasms. Urine analysis showed moderate blood and pyuria. Urine cultures were negative. Treatment with broad-spectrum antibiotics failed to improve his symptoms. Cystoscopy showed diffusely inflamed bladder with no masses identified. High titers of BK virus (>5,000,000 copies /ml) were identified in urine and low level viremia was also noted by blood PCR (1,200 copies /ml). Adenovirus, another agent responsible for cystitis in immunocompromised induvial was ruled out by negative PCR. Supportive care with IV hydration and pain control resulted in gradual resolution of symptoms over two weeks. As patient was being treated for ACR, immunosuppression regimen was not changed. Kidney functions remained stable throughout hospitalization. Discussion: Cystitis secondary to viruses like BK and adenovirus has been described in renal and allogeneic hematopoietic cells transplantation. Presentation in liver transplant recipients, either at time of transplantation or during treatment of cellular rejection has not been well documented. Our case suggests that BK virus infection should be considered as the potential cause of cystitis in solid organ transplant recipients.