Abstract: PO2203
Autoimmune Encephalitis with Concurrent Epstein-Barr Virus Infection in a Renal Transplant Patient
Session Information
- Transplantation: Clinical - Noninvasive Biomarkers, Immune Regulation, and Fascinomas
November 04, 2021 | Location: On-Demand, Virtual Only
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 1902 Transplantation: Clinical
Authors
- Zheng, Danyi, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, United States
- Pai, Akshta, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, United States
- De Golovine, Aleksandra, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, United States
Introduction
Epstein-Barr virus (EBV) infection following renal transplant is typically associated with post-transplant lymphoproliferative disorder (PTLD). Autoimmune encephalitis (AE) is caused by antibodies against N-methyl-D-aspartate receptor (NMDAR), a ligand-gated ion channel with a crucial role in synaptic transmission. We describe a patient who developed encephalitis 1 year after renal transplant with cerebral spinal fluid (CSF) analysis positive for NMDAR antibodies and evidence of EBV infection on brain biopsy without PTLD or malignant processes. To our knowledge, this is the 1st case with tissue evidence of EBV infection on brain biopsy in renal transplant.
Case Description
A 70 year-old female with end stage renal disease from Type 2 Diabetes mellitus who received a deceased donor renal transplant one-year prior was admitted for 3 weeks of progressively worsening mentation. Immunosuppression included tacrolimus, mycophenolate mofetil, and prednisone. Brain MRI did not reveal any acute findings. EEG showed generalized slowing consistent with diffuse encephalopathy. CSF analysis showed lymphocytic pleocytosis and elevated protein level. The infectious workup was negative except for positive EBV PCR in CSF. Cytometry did not reveal any evidence of PTLD. CSF autoimmune panel demonstrated NMDAR1 antibody. Brain biopsy showed a chronic inflammatory process with features of EBV infection. EBV-infected cells were detected in tissue specimen via in-situ hybridization with EBV-encoded small RNA. Patient initially received ganciclovir, amBisome, and broad-spectrum antibiotics. Treatment then changed to steroids, IVIG and plasmapheresis for autoimmune encephalitis, all of which were stopped and ganciclovir was restarted when brain biopsy was positive for EBV. Unfortunately, patient did not show any clinical improvement possibly due to delayed diagnosis and went home with hospice care.
Discussion
EBV Encephalitis without PTLD following renal transplant is uncommon. Only a few cases have described renal transplant patients with encephalitis and concomitant findings of NMDAR antibodies and EBV DNA in CSF study. The relationship between EBV infection and AE remains unclear; however, EBV infection may play a role in the pathogenicity of NMDAR antibodies. AE can occur in the setting of chronic immunosuppression and should not be overlooked to avoid delay in diagnosis and treatment.