HHV-8 Primary Infection with Kaposi Sarcoma in a Pediatric Liver Transplant Patient

Abstract

Background and aim: Patients under immunosuppressive treatment are in risk of developing malignant tumours. Primary infection or reactivation of Human herpes virus 8 (HHV-8) may predispose to Kaposi sarcoma (KS) after solid organ transplantation. KS in pediatric liver transplant recipients has a low incidence and poor prognosis. We report the clinical presentation of a KS in lymph node following HHV-8 primary infection in a pediatric liver transplant recipient. Case: Boy who received living donor liver transplant for acute liver failure with hepatitis A at 4 years age. 4 months after transplant he started with abdominal pain, distention, fever and was admitted 5 days later with ascitis and polyadenomegalies. He was under usual immunosuppressant with Meprednisone + Tacrolimus (previous level 8.9 ng/ml). Pretransplant CMV and EBV +.With initial diagnosis of peritonitis, we started antibiotic and continued studies. Tacrolimus was discontinued. Within 3 days he showed general improvement but he still had ascitis and polyadenomegalies. We performed a biopsy of one axilar adenomegaly. Usual bacterias, mycobacterium and fungi were negative. Histology: morphologic characteristics of Kaposi disease. We searched HHV-8 in receptor saliva, blood and lymph node; and in donor saliva and blood. HHV-8 PCR was + in lymphocytes, saliva and lymph node and antibodies against HHV-8 were detected by immuofluorescense (IF titer >1:640). Serum before transplant was negative by IF (< 1:40). The liver donor had IF titers > 1:640 and was PCR+ for HHV-8 in blood and saliva. HHV-8 PCR was always positive in donor blood and saliva. The patient blood and saliva were negative 2 months after the diagnosis. These results remained unchanged during 2 years. He had a good outcome, ascitis and polyadenomegalies disappeared without Tacrolimus. A month after diagnosis, he presented liver enzymes 6 folds above normal values. A liver biopsy was performed and with diagnosis of mild acute rejection, he started treatment with Sirolimus (1 mg/m2/day, levels between 5 and 8 ng/ml). Currently, he is 11 year-old, with normal liver results, and he is under Sirolimus monotherapy. Discussion: We report this case as HHV-8 primary infection with Kaposi sarcoma in a patient with liver transplant and it is a remainder that KS should be taken into consideration in the differential diagnosis of posttransplant complications.