Fever and sepsis

Systemic infection can be the most life threatening cause of liver allograft dysfunction. To help organize our pursuit of the cause of an infection, we have divided the investigation into tiers or steps. These tiers are grouped to diagnose the most common infections with the least cost and in the least invasive manner. In general, this type of investigation should be performed in an inpatient setting.

Infection investigation

FIRST TIER - History, physical exam, examine:

(1) surgical wounds,

(2) IV sites (old and new sites),

(3) rectal for perirectal abscess,

(4) parotid glands for masses (i.e., parotiditis or parotid abscess),

(5) mouth for herpetic lesions,

(6) skin lesions (i.e. detection of bullous lesions - herpes zoster),

(7) eye exam for CMV retinitis,

(8) chest for rhonchi,

(9) abdomen for fluid and tenderness, CXR, U/A, and cultures of blood, urine, sputum.

SECOND TIER -

(1) serum amylase,

(2) viral titers EBV, CMV,

(3) abdominal paracentesis for fluid for cell count and differential, gram stain and AFB stains, cultures for aerobic bacterial, fungal, and mycology species,

(4) remove all lines and culture tips,

(5) cholangiogram,

(6) liver allograft biopsy (for rejection and CMV inclusion), and

(7) open all wounds.

THIRD TIER -

(1) sinus films,

(2) Panorex,

(3) check for subscapular abscess,

(4) cut down on old intravenous catheter sites (to diagnose occult suppurative thrombophlebitis),

(5) ultrasound of liver and abdomen,

(6) CT-scan of abdomen,

(7) CT-head then lumbar puncture, 

(8) ECHO for valve vegetation,

(9) autoimmune investigation with RF, ANA, LE prep, and

(10) upper and lower endoscopy for CMV ulcers with biopsy confirmation of distinctive inclusions.

FOURTH TIER -

Abdominal reexploration (usually for patients with specific abdominal symptoms and/or early postoperative patients)

Although most patients show obvious signs of the site of their infections, there are certain infections which on occasion can be subtle. One such infection is meningitis. With either bacterial or viral infections of the meninges the transplant patient's only symptom may be fever. There is routine absence of photophobia, meningeal signs, and/or headaches. Therefore, it is incumbent on the physician taking care of liver allograft recipients to perform a lumbar puncture early to make the diagnosis of meningitis. Recipients are prone to Listeria meningitis, and all empiric treatment should include antibiotic effective against Listeria.

Pneumocystis carinii pneumonia may present as subtle findings of malaise and shortness of breath. With these clinical findings and an ABG that shows hypoxia the recipient should be considered to have this rapidly fatal pneumonia until proven otherwise. The diagnosis is confirmed by chest x-ray findings of hazy, diffuse, nonlobar infiltrates, and bronchoscopic lavage specimen staining positive for Pneumocystis carinii. If the diagnosis is clinically suspected the clinician should understand that these bronchoscopic lavage specimens are only 85% sensitive and 85% specific for this diagnosis (with the gold standard being open lung biopsy). In a highly suspicious setting, the clinician may initiate and continue treatment with a negative bronchoscopic test result.

Occasionally a recipient will have a completely negative investigation despite continuing fevers. Many of these patients have a self-limited episode of systemic CMV. We routinely treat these patients with reduced doses of cyclosporine and prednisone and a 10 day course of DHPG (Gancylovir 350 mg IV q 12 hours, assuming normal renal function). Reductions in immunosuppressive drugs can only be performed safely with the aid of frequent (biweekly) liver allograft biopsies such that acute rejection does not occur. If the fever persists and the patient is more than six months following transplantation, investigation for lymphoproliferative disease, other forms of cancer, and further tests for autoimmune disease should be undertaken.