TOPIC: Transplantation
      TYPE: Fellow Case Reports
      INTRODUCTION: Antibody mediated rejection is one cause of allograft dysfunction in lung transplant patients1. The diagnosis requires a combination of clinical features, serologic evidence of donor specific antibodies, and pathology1. Here we present a rare case of presumed antibody mediated rejection in a lung transplant recipient manifesting as biopsy proven eosinophilic pneumonia.
      CASE PRESENTATION: 45-year-old woman 3 years post bilateral lung transplant for cystic fibrosis who was admitted with new onset dyspnea, hypoxia, multifocal infiltrates. Bronchoalveolar lavage showed 42% eosinophils. Pathologic examination confirmed eosinophilic pneumonia and did not demonstrate capillaritis nor acute cellular rejection. Infection, including extensive fungal and helminth evaluation, was negative. Antibody evaluation demonstrated new onset de novo DSA at high mean fluorescence intensity (MFI). The patient later admitted to noncompliance with her immunosuppression. She was treated with pulse dose steroids, plasmapheresis/intravenous immunoglobulin followed by rituximab with resolution of her infiltrates and hypoxia.
      DISCUSSION: Eosinophilic alveolitis has been correlated with acute cellular rejection2. Graft eosinophilia was described in nine patients following transplantation, five of which were thought to be due to severe acute cellular rejection3. However, to our knowledge, eosinophilic pneumonia has not been reported as a manifestation of antibody mediated rejection. Commonly known causes of eosinophilic pneumonia include helminth infections, fungal infections, medications and toxins, vasculitis, among others; these were excluded in our patient.
      CONCLUSIONS: The new, very elevated DSA, exclusion of other common causes, and response to treatment are compelling evidence that the eosinophilic pneumonia in our patient was, in fact, an atypical presentation of antibody mediated rejection.
      REFERENCE #1: 1. Levine DJ, Glanville AR, Aboyoun C, Belperio J, Benden C, Berry GJ, Hachem R, Hayes D Jr, Neil D, Reinsmoen NL, Snyder LD, Sweet S, Tyan D, Verleden G, Westall G, Yusen RD, Zamora M, Zeevi A. Antibody-mediated rejection of the lung: A consensus report of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2016 Apr;35(4):397-406. doi: 10.1016/j.healun.2016.01.1223. Epub 2016 Feb 10. PMID: 27044531.
      REFERENCE #2: 2. Bewig B, Stewart S, Böttcher H, Bastian A, Tiroke A, Hirt S, Haverich A. Eosinophilic alveolitis in BAL after lung transplantation. Transpl Int. 1999;12(4):266-72. doi: 10.1007/s001470050221. PMID: 10460872; PMCID: PMC7096104.
      REFERENCE #3: Yousem SA. Graft eosinophilia in lung transplantation. Hum Pathol. 1992 Oct;23(10):1172-7. doi: 10.1016/0046-8177(92)90036-3. PMID: 1398645.
      DISCLOSURES: No relevant relationships by Ojobumijo Agbaji, source=Web Response
      No relevant relationships by Disha Geriani, source=Web Responseresearch relationship with United Therapeutics Please note: 2016- ongoing Added 04/19/2021 by Reda Girgis, source=Web Response, value=Grant/Researchresearch relationship with Pfizer Please note: 2014-2020 Added 04/19/2021 by Reda Girgis, source=Web Response, value=Grant/Research
      Speaker/Speaker's Bureau relationship with Boehringher Ingelheim Please note: 2016-ongoing Added 04/19/2021 by Reda Girgis, source=Web Response, value=Honoraria
      Speaker/Speaker's Bureau relationship with Genentech Please note: 2016-ongoing Added 04/19/2021 by Reda Girgis, source=Web Response, value=Honoraria
      No relevant relationships by Ryan Hadley, source=Web Response
      No relevant relationships by Edward Murphy, source=Web Response