Mycophenolate mofetil/tacrolimus
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Heartland virus infection: case report A 72-year-old man developed Heartland virus infection during immunosuppressive therapy with mycophenolate mofetil and tacrolimus. In May 2017, the man presented with fatigue and low grade fever. He had undergone orthotopic heart transplant in 2010 due to ischaemic cardiomyopathy. Following transplant he was maintained on immunosuppressants tacrolimus and mycophenolate mofetil [routes and dosages not stated]. A clinical examination following presentation showed elevated creatinine and mildly elevated AST with a WBC count of 2.6×109/L. Thereafter, he was hospitalised. The man was started on empiric treatment with cefepime, vancomycin and doxycycline. Mycophenolate mofetil was withdrawn. Initially, the manifestations improved partially. However, on day 3 of hospitalisation, he became febrile. Further laboratory parameters including WBC count and liver enzyme levels were worsened. On day 5, he became somnolent and his mental status altered. Investigations revealed CSF protein 93 mg/dL and CSF glucose 56 mg/d. CT scan of the chest, abdomen and pelvis showed a large left‐sided retroperitoneal haematoma extending into the left psoas and ilio-psoas muscles. Additionally, his Hb dropped and creatine kinase was elevated. He developed swelling on the left cheek. The CT scan findings were indicative of myositis of the left masseter muscle. From clinical presentation, tick borne illness was suspected. On day 7 of hospital admission, a PCR testing revealed Heartland virus. His immunosuppressants were considered to be risk-factors for Heartland virus [duration of treatment to reaction onset not stated]. Thereafter, tacrolimus dose was reduced. He was treated with packed infusion of RBCs and platelets. Over the following week, his condition improved and the fever resolved. Additionally, significant improvement in blood parameters was noted. He was eventually discharged to a rehabilitation facility. A repeat RT-PCR did not detect viral RNA; however, he had low levels of heartland virus specific neutralising antibodies. Of note, other infectious work up results were negative. The complications associated with Heartland virus infection had resolved. Author comment: "Tick‐borne infections represent a significant health risk each year in the United States. Immunocompromised patients are typically at risk of more severe disease manifestations than their immunocompetent counterparts. Here we report a case of a newly emerging phlebovirus, Heartland virus, in a heart transplant recipient." Hevey MA, et al. Heartland virus infection in a heart transplant recipient from the Heartland. Transplant Infectious Disease 21: No. 4, Aug 2019. Available from: 803438021 URL: http://doi.org/10.1111/tid.13098 - USA
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Reactions 7 Dec 2019 No. 1782
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