Combined cellular and antibody-mediated rejection of orthotopic heart transplant following influenza A infection

Viral infections have been associated with acute allograft rejection in solid organ transplant recipients. Influenza infection upregulates host proinflammatory cytokines, suggesting the host immune response can precipitate graft rejection. Pandemic influenza, specifically, was associated with rejection in multiple renal allograft recipients. However, cardiac allograft rejection has not been reported in association with endemic influenza. We present the case of a man in his mid-30s, transplanted 5 years prior, who developed new heart failure 4 weeks after PCR-confirmed influenza A infection. Endomyocardial biopsy revealed concomitant high-grade acute cellular rejection and antibody-mediated rejection. Despite a pretransplant panel reactive antibody of 0%, a negative virtual crossmatch and consistently therapeutic tacrolimus levels, de novo donor-specific antibodies developed. Even with aggressive therapy, he died as a result of graft failure. Transplant recipients must be regularly vaccinated, and clinicians should maintain a high degree of suspicion of graft failure in the immediate aftermath of influenza infection.