Sepsis Following Liver Biopsy in a Liver Transplant Recipient: Case Report and Review of Literature

Abstract

Percutaneous liver biopsy is a relatively safe procedure with low complication rates. Infections following liver biopsy are uncommon and can lead to a poor outcome. There are limited data on liver biopsy-related infections among liver transplant (LT) recipients. Also, there is a paucity of data regarding the use of prophylactic antibiotics in LT patients undergoing percutaneous liver biopsy. We report a case of systemic sepsis following percutaneous liver biopsy in a LT recipient with choledochojejunal anastomosis. This was followed by severe rejection and deterioration of liver function and recurrence of primary sclerosing cholangitis (PSC) to the extent that he has been listed for retransplantation. This case report emphasizes the potential risk of sepsis in LT recipients with bilioenteric anastomosis undergoing percutaneous liver biopsy. This increased risk may warrant periprocedural broad spectrum antibiotic prophylaxis, in this subgroup of patients.

Keywords: ALT, Alanine transaminase; AST, Aspartate transaminase; BD, Twice daily; DDLT, Deceased donor liver transplant; FFP, Fresh frozen plasma; I.V., Intravenous; LFTs, Liver function tests; LT, Liver transplant; MMF, Mycophenolate mofetil; MRCP, Magnetic resonance cholangiopancreatography; MRI, Magnetic resonance imaging; MU, Million units; OD, Once daily; PSC, Primary sclerosing cholangitis; PTBD, Percutaneous transhepatic biliary drainage; TDS, Three times daily; TLC, Total leucocyte count; liver biopsy; liver transplantation; sepsis.

Figure 1

Showing patient's LFT/TLC values, hospital course and interventions. (TLC: total leucocyte count median range [4000––11000 cells/microliter]; AST: aspartate aminotransferase U/L [5–40]; ALT: alanine aminotransferase U/L [5–45]; ALP: alkaline phosphatase U/L [80–240]; total serum bilirubin mg/dL [0.2–1.2]).

Figure 2

Sections from liver explant show cirrhotic liver with nodules, separated by fibrous septae (arrows) [A x 40]. The portal tracts show interface hepatitis with regenerative bile ducts [B × 200], and hepatocytes show extensive canalicular cholestasis (arrows) [C ×100]. One subhepatic bile duct shows epitheliotropic dense lymphoid cell infiltrate (arrows) [D x 40].

Figure 3

a: Index post-transplant liver biopsy shows, however, normal liver biopsy cores without significant inflammation in the portal tracts with normal portal vein branches and bile ducts [E and F × 40; G and H × 100]. b: Last post-transplant liver biopsy taken during recent flair shows expansion and dense inflammation of all portal tracts, lymphocytic bile duct infiltration (arrows) [I x 200], portal venulitis (arrows) [J × 200], central venulitis and perivenular hepatocyte necrosis (arrows) [K x 200]. The reticulin stain does not show significant fibrosis [L x 100]. CD8 stain shows lymphocytic venulitis and bile duct injury (arrows) [M ×200], suggesting recurrence of severe acute cellular rejection.

Figure 4

a: Ultrasound image showing 2 x 2 cm an echoic lesion in segment VI of liver with irregular margins (arrow). b: Ultrasound-guided aspiration of the liver lesion yielded 10 mL of bilio-haemorrhagic fluid.

Figure 5

Cholangiogram through percutaneous transhepatic biliary drainage (PTBD) catheter showed smooth strictures of the perihilar ducts (arrows) with mild p.