Abstract: SA-PO1170
Secondary Hemophagocytic Lymphohistiocytosis After Kidney Transplantation: An Unexpected Infectious Trigger
Session Information
- Transplantation: Clinical - Infectious Diseases
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Kaur, Divmehar, Tufts Medical Center, Boston, Massachusetts, United States
- Madariaga, Hector M., Tufts Medical Center, Boston, Massachusetts, United States
Introduction
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that may occur in kidney transplant recipients in the setting of opportunistic infection and often mimics severe sepsis, leading to delayed diagnosis. We present a case of a donor-derived adenovirus infection complicating the clinical course of both kidney recipients from the same donor.
Case Description
A 64-year-old man with ESRD underwent deceased donor kidney transplantation. Early course notable for delayed graft function but subsequent recovery.
Three weeks post-transplant, he presented with fevers, chills, and worsening pancytopenia unexplained by usual culprits (medications, common viruses), with course complicated by severe ileus requiring hemicolectomy and end ileostomy creation. Concurrently,he developed persistent fevers despite broad-spectrum antimicrobials, progressive cytopenias, and markedly elevated inflammatory markers, raising concern for hemophagocytic lymphohistiocytosis (HLH).
Simultaneously, an enquiry revealed that the recipient of the donor’s contralateral kidney was critical in the ICU with urosepsis, adenovirus with possible disseminated histoplasmosis.This raised concern for a donor-derived infection. Our patient’s serum adenovirus PCR subsequently returned with a high-grade viremia. Bone marrow biopsy confirmed HLH with hemophagocytic histiocytes.
Overall, the clinical picture was consistent with donor-derived adenovirus-triggered HLH.
Treatment included high-dose corticosteroids and intravenous immunoglobulin. His course was further complicated by Achromobacter xylosoxidans peritoneal infection, recurrent intra-abdominal hematomas, and recurrent ostomy mucosa bleeding requiring multiple interventions in the setting of steroid use. Despite a prolonged and morbid hospitalization, the patient ultimately recovered and was discharged.
Discussion
HLH after kidney transplantation is a rare but often fatal hyperinflammatory syndrome that can mimic severe sepsis, delaying diagnosis. While post-transplant infectious evaluation appropriately prioritizes CMV, EBV, and BK virus, rarer pathogens such as adenovirus are not routinely monitored and may delay recognition of evolving HLH. Persistent systemic inflammation, unexplained cytopenias, and multisystem involvement despite unrevealing standard workup should prompt consideration of atypical viral triggers and donor-derived infection in transplant recipients.