Chetan Mittal

Currently recommended BK virus (BKV) plasma viral load cutoff of ≥4 log10/mL underestimates the diagnosis of BKV-associated nephropathy: a single transplant center experience.

BK virus (BKV)‐associated nephropathy (BKVAN) is a major cause of renal dysfunction and graft loss in renal transplant recipients. Monitoring plasma BK viral load (BKVL) is the recommended screening tool to predict BKVAN. American Society of Transplantation (AST) guidelines define a BKVL of ≥4 log10/mL (10,000 copies) as presumptive BKVAN and recommend reduction in immunosuppression. We evaluated the clinical sensitivity of the quantitative BKV DNA assay in predicting risk for BKVAN using the AST‐recommended BKVL cutoff.

Ewingella Americana: An Emerging True Pathogen

Infections caused by Ewingella americana have been rarely reported in the literature. Most of the cases that have been reported were among the immunocompromised patients. We report a case of E. americana causing osteomyelitis and septic arthritis of the shoulder joint in a previous intravenous drug abuser. The causative pathogen was identified by synovial fluid analysis and culture.

Heparin‐induced thrombocytopenia: is it a graft‐threatening complication?

Heparin‐induced thrombocytopenia (HIT), a prothrombotic complication of heparin therapy, can lead to serious thromboembolic events and cause significant morbidity and mortality. We aim to study the prevalence of HIT in the transplant population at our institute. This is a retrospective, single‐center study which looked into the transplant database over a 25‐year period. In patients with clinical suspicion of HIT, the 4T score was used, and laboratory tests such as ELISA HIT antibody and functional serotonin release assay, along with clinical manifestation of thromboembolic events were reviewed. Medical records of 2800 patients who underwent transplantation from January 1985 to December 2010 were reviewed. HIT antibody assay was performed in 262 patients from this group in which HIT was suspected. Of these, only 48 patients were HIT antibody positive along with moderate to high 4T score. The mean 4T score was 6.75 ± 1.4. Thrombotic complications were seen in 11 patients, with the highest in cardiac transplant recipients. Direct thrombin inhibitor (DTI) therapy was used in only eight patients who had thrombotic event. No other complications or mortality was reported in any of the HIT antibody‐positive transplant patients. To our knowledge, this is the first study of its kind that has shown very low incidence of HIT in the transplant population except for in cardiac transplant recipients.

Metastatic squamous cell carcinoma in a bone marrow transplant recipient

We report a case of 53year old female with history of acute myelogenous leukemia, for which she underwent allogeneic peripheral blood stem cell transplant; her course was complicated by chronic graft versus host disease. Seven years later she presents with squamous cell carcinoma of the skin which metastasize to her heart. Here, in this case we tend to highlight the aggressive nature of the squamous cell carcinoma in an immunocompromised individual.

Wide-Area Transepithelial Sampling in Barrett’s Esophagus: Ready for Primetime?

Marcia Cruz-Correa, Section Editor David Schwartz, Section Editor 65 66 STAFF OF CONTRIBUTORS 67 68 69 70 71 72 73 74 75 Douglas Adler, Salt Lake City, UT Joseph Anderson, White River Junction, VT Johanna L. Chan, Houston, TX Matthew A. Ciorba, St. Louis, MO Massimo Colombo, Milan, Italy Gregory A. Cote, Charleston, SC Evan S. Dellon, Chapel Hill, NC Alex Ford, Leeds, United Kingdom David S. Goldberg, Philadelphia, PA Samir Gupta, San Diego, CA

Mo1845 Is Colonization With Non-Toxigenic Clostridium difficile Organism Protective Against Toxigenic Strains?

Background: Clostridium difficile infection (CDI) requires production of toxins A and/or B to manifest clinically but not all strains produce these specific virulence factors. Nontoxigenic C. difficile strains (NT-CD) cause asymptomatic colonization of gastrointestinal tract. Studies using hamster model have demonstrated that colonization with NT-CD decreases risk of subsequent infection with toxigenic strains (T-CD). The aim of this study was to investigate if use of two-step stool toxin assay can determine if colonization with NT-CD protects against CDI.Methods:CDI testing involves a two-step stool assay: Glutamate dehydrogenase (GDH) and toxin ELISA followed by PCR. GDH detects the presence of both T-CD and NT-CD. The ELISA and PCR tests detect presence of toxins A and B. Two groups of patients tested for clinically suspected CDI were identified GDH negative / toxin negative (G-T-) (No CDI or colonization) and GDH positive / toxin negative and PCR negative (G+T) (Colonization with NT-CD). Only patients with high risk for CDI (Age > 50 years, ≥ 2 hospitalizations and recent antibiotic use) were included. Patients with prior history of CDI or current infection (GDH positive and toxin or PCR positive) were excluded. Based on previous studies, CDI rate in patients colonized with NT-CD is about 1% as compared to 15% in those not colonized. Chart review was performed retrospectively from October 2013 to include a total of 100 subjects in each group (80% power and 95% Confidence intervals). Incidence of CDI in one year follow up period after initial negative toxin assay was assessed. Chi-square test for binomial data and 2 tailed t-test for continuous data were used. Results: A total of 200 patients (Age = 68.7 ± 11.8 years, 57.5% women) were included. 9 CDI occurred in G+Tgroup compared to 7 CDI in G-Tgroup (p=0.79). The recurrence rates were 22.2% (2 cases) in G+T-group and 14.2% (1 case) in G-T-group (p=0.69). Hospitalization rates were similar between two groups (3.45 ± 2.1 days in G+T-and 3.65 ± 2 days in G-T-group, p=0.49). The average length of stay was 7.39 ± 4 days in G+Tcompared to 7.73 ± 4.7 days in G-T-group (p=0.58). Discussion: Our study indicates that colonization with NT-CD does not protect against future CDI or reduce recurrence of CDI. This is contradictory to previous animal studies supporting protective effects of NT-CD. The explanation for this discordance could be that protective effect of NT-CD may be related to specific strains of NT-CD. Moreover unlike in animal studies, human microbiome may be impacted by several additional factors like exposure to antibiotics and frequent hospitalizations, leading to acquisition of toxigenic strains. It would be interesting to study in future if fecal microbiota transplantation works by favoring colonization with specific NT-CD strains to prevent recurrent CDI .

New onset pulmonary hypertension in a patient with primary biliary cirrhosis postorthotopic liver transplant

Case A 64-year-old female with primary biliary cirrhosis underwent uncomplicated piggyback duct-to-duct orthotopic liver transplant. Her pretransplant course was complicated by ascites, variceal bleed, and hepatic encephalopathy with a pretransplant model for end-stage liver disease score of 18. She underwent a preoperative screening dobutamine echocardiogram, which demonstrated normal ejection fraction at 67%, and normal pulmonary artery systolic pressure of 36 mmHg with no areas of inducible ischemia. Pretransplant pulmonary function testing showed a normal spirometry with reduced diffusion capacity at 41% predicted. Chest computed tomography and ventilation perfusion scan were normal, ruling out significant parenchymal disease or chronic thromboembolic disease. Autoimmune serology showed positive antinuclear antibody (1 : 320 titer) and positive antimitochondrial antibody (1 : 160 titer). She manifested no clinical signs of connective tissue disease. Intraoperative hemodynamic monitoring was consistent with high-output state, without evidence of either high-output failure or portopulmonary hypertension (POPH).