Bartonella henselae infection inducing hemophagocytic lymphohistiocytosis in a kidney transplant recipient

Abstract

Bartonella henselae (Bh) is the cause of cat-scratch fever. When infection is symptomatic, it typically presents with singular lymphadenitis and fever. Less commonly, the infection can become disseminated and cause endocarditis, osteomyelitis, and micro-abscesses in multiple sites including liver, spleen, eyes, and brain, especially in immunocompromised patients. Hemophagocytic lymphohistiocytosis (Hlh) is a rare and severe multisystem disorder that may be triggered by infections. In one prior case, Bh, like other infections, has induced Hlh, an immune-mediated disease that can be characterized by septic-like presentation with persistent fevers, hepatosplenomegaly, and pancytopenia. In an immunocompromised transplant recipient, the onset of Hlh can be difficult to discern from a severe presentation of Bh. We report a case of criteria-proven secondary Hlh occurring after Bh infection in an 11-yr-old girl who was 13 months post-renal transplant. The patient developed multi-organ failure, and her severe clinical presentation required a thorough evaluation for infectious and non-infectious possibilities including post-transplant lymphoproliferative disorder and rejection. Early recognition of Hlh allowed for better directed therapies, leading to recovery of the patient and resolution of both Bh and Hlh.

Hemophagocytic lymphohistiocytosis secondary to hemodialysis catheter-related blood stream infection

“…[9] Infections postrenal transplant has been complicated with HLH. [10] However, there is scant literature on bloodstream infections as a cause of HLH. This may be because of lack of clinical suspicion as sepsis can be a presenting feature of blood stream infections and there is a considerable clinical and laboratory overlap between sepsis and HLH.…”

Bartonella henselae infection‐associated vasculitis and crescentic glomerulonephritis leading to renal allograft loss

“…A comprehensive literature search identified 37 reported cases of solid organ transplant recipients who developed Bartonella infections with clinical pictures ranging from typical granulomatous suppurative lymphoid involvement to unusual presentations such as chorioretinitis . In the analysis of 29 cases by Psarros et al.…”

“…Furthermore, an increasing number of putatively immune para‐infectious or post‐infectious disorders have been reported in association with Bartonella infections affecting the central nervous system and other organs (see Table ; ). Specifically, a case of post‐infectious chronic active myocarditis has been reported , as well as renal involvement in the form of immune‐complex mediated or pauci‐immune acute glomerulonephritis .…”

Cytomegalovirus infections, kidney transplantation, and secondary hemophagocytic lymphohistiocytosis

“…In international literature, about 80 HLH cases have been reported in kidney transplant patients (4)(5)(6)(7)(8)(9)(10)(11).…”

“…Most cases were triggered by CMV infection (5,(12)(13)(14)(15)(16) or other herpesviruses such as Epstein-Barr virus, human herpesvirus (HHV)-8, and HHV-6 (4). Other cases were associated with adenovirus, parvovirus B19, BK polyomavirus, tuberculosis, bartonellosis, toxoplamosis, leishmaniasis, babebiosis, and histoplasmosis (4,6,8,9).…”