Acute Pericarditis Presenting Concurrently with Acute Cellular Rejection in a Lung Transplant Recipient

ABSTRACT

Introduction: Acute pericarditis is frequently encountered in the immediate post-operative period following lung transplant, however when seen following recovery it is often in the context of infection. We present a case of a patient 12 years out from lung transplant who presented with findings compatible with acute pericarditis, ultimately diagnosed with acute cellular rejection (ACR). Case Report A 60 year old man 12 years post bilateral lung transplant for smoking related COPD with CLAD, stage I, BOS phenotype and prior history of probable antibody-mediated rejection (AMR), presented to the emergency department with acute onset dyspnea (<24h), pleurisy, and a leukocytosis. CT angiogram of his chest revealed no evidence of pulmonary embolism, but new bilateral ground glass and consolidative opacities. Infectious studies, including COVID-19, were negative. Multiple EKGs demonstrated diffuse ST elevations without reciprocal changes. Serial high sensitivity troponin assays were negative, and transthoracic echocardiogram did not reveal any findings compatible with myocardial injury. Once ischemia was excluded he underwent bronchoscopy with biopsies, which demonstrated A2 ACR. Screening for donor specific antibodies indicated new C1q-binding class II HLA antibodies. He was treated for acute pericarditis with colchicine and prednisone. He also received high dose methylprednisolone for ACR, as well as IVIG and rituximab for possible AMR. His chest pain and pleurisy dramatically improved after the first dose of methylprednisolone. The initial insult was thought to be an interruption of immunosuppression coupled with cigarette use. This case represents a novel presentation of ACR with concurrent findings of acute pericarditis. Symptoms of pericarditis and rejection can overlap and this case highlights that the two entities can present simultaneously.