An immunosuppression tightrope: Successful heart transplantation after giant cell myocarditis in a patient with HIV complicated by recurrent giant cell myocarditis and Kaposi sarcoma

Giant cell myocarditis (GCM) is a rapidly progressive immune-mediated disease that is usually fatal without cardiac transplantation. 1 Lumish HS Clerkin KJ Marboe C et al. Giant cell myocarditis patients undergoing heart transplantation have high rates of rejection, infection and cardiac allograft vasculopathy: case series. J Heart Lung Transplant. 2018; 37: S422-S423 Abstract Full Text Full Text PDF PubMed Google Scholar The risk of recurrent GCM after orthotopic heart transplantation (OHT) is 20% to 25%, so patients are often maintained on higher amounts of chronic immunosuppression. 2 Scott RL Ratliff NB Starling RC Young JB Recurrence of giant cell myocarditis in cardiac allograft. J Heart Lung Transplant. 2001; 20: 375-380 Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar Patients with human immunodeficiency virus (HIV) infections were historically considered to be prohibitively high risk for solid-organ transplantation because of concerns about their immunocompromised state, but modern anti-retroviral treatments have allowed for successful transplantation in patients with well-controlled HIV infections. 3 Mehra MR Canter CE Hannan MM et al. The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: a 10-year update. J Heart Lung Transplant. 2016; 35: 1-23 Abstract Full Text Full Text PDF PubMed Scopus (719) Google Scholar There is little experience with the treatment of GCM with OHT in a patient with a coexisting HIV infection. This case study highlights the complex immunosuppression balance required to prevent recurrent GCM while concurrently avoiding HIV-related opportunistic infections.