American Journal of Transplantation Images in Transplantation – Continuing Medical Education (CME) Each month, the American Journal of Transplantation will feature Images in Transplantation, a journal-based CME activity, chosen to educate participants on current developments in the science and imaging of transplantation. Participants can earn 1 AMA PRA Category 1 Credit™ per article at their own pace. This month’s feature article is titled: “Right Homonymous Hemianopsia and Seizures in a Liver Transplant Recipient.” Accreditation and Designation Statement This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Blackwell Futura Media Services, the American Society of Transplant Surgeons and the American Society of Transplantation. Blackwell Futura Media Services is accredited by the ACCME to provide continuing medical education for physicians. Blackwell Futura Media Services designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Statement of Need The differential diagnosis for transplant patients with nonspecific neurological symptoms is broad. However, it includes potentially fatal infections. Prompt diagnosis and treatment is therefore essential. Purpose of Activity This activity is intended to improve competency in the diagnosis and management of central nervous system infections in liver transplantation recipients. Identification of Practice Gap The condition presented is frequently fatal and often not diagnosed until autopsy. Moreover, findings on computer tomography scan can be interpreted erroneously as a different disease process. Early recognition of the disease and aggressive treatment of this condition may significantly improve patient survival rates. Learning Objectives Upon completion of this educational activity, participants will be able to: • Understand this complication’s risk factors, potential symptoms and time course, thereby facilitating timely diagnostic evaluation. • Describe diagnostic testing options and key neuroimaging and pathology findings associated with this condition. • Determine optimal medical and/or surgical treatment options, including immunosuppression management, for treating this high-risk condition in posttransplant patients. Target Audience This activity has been designed to meet the educational needs of physicians and surgeons in the field of transplantation. Disclosures No commercial support has been accepted related to the development or publication of this activity. Blackwell Futura Media Services has reviewed all disclosures and resolved or managed all identified conflicts of interest, as applicable. Editor-in-Chief Allan D. Kirk, MD, PhD, FACS, has no relevant financial relationships to disclose. Editors Sandy Feng, MD, PhD, has no relevant financial relationships to disclose. Douglas W. Hanto, MD, PhD, has no relevant financial relationships to disclose. Authors Carrie Thiessen, MD, PhD, Roger Patrón-Lozano, MD, Michael Schilsky, MD, and Manuel I. Rodríguez-Dávalos, MD, have no relevant financial relationships to disclose. ASTS Staff Mina Behari, Director of Education, has no relevant financial relationships to disclose. This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by the American Journal of Transplantation. The peer reviewers have no relevant financial relationships to disclose. The peer review process for the American Journal of Transplantation is blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review. Instructions on Receiving CME Credit This activity is designed to be completed within an hour. Physicians should claim only those credits that reflect the time actually spent in the activity. This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months. Follow these steps to participate, answer the questions and claim your CME credit: • Log on to https://www.wileyhealthlearning.com/ajt • Read the learning objectives, target audience and activity disclosures. • Read the article in print or online format. • Reflect on the article. • Access the CME Exam, and choose the best answer to each question. • Complete the required evaluation and print your CME certificate.

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Continuing Medical Education

Right Homonymous Hemianopsia and Seizures in a Liver Transplant Recipient A 26-year-old woman with a history of Factor V Leiden heterozygosity and celiac disease was transferred to our center for management of idiopathic liver failure. Before arrival she received 6 weeks of high-dose oral steroids for presumed autoimmune hepatitis. At our facility, a transjugular liver biopsy was complicated by hepatic hemorrhage resulting in cardiac arrest, intubation, need for pressor support, abdominal compartment syndrome and large-volume transfusion. The patient recovered following left hepatic artery embolization and large-volume paracentesis. Shortly thereafter, she received an orthotopic liver transplant with caval replacement and duct-to-duct anastomosis. Her immunosuppression included basiliximab induction, a steroid taper, mycophenolate mofetil and tacrolimus. Fluconazole 100 mg daily was administered prophylactically for 10 days. Her initial postoperative course was uncomplicated. However, on postoperative day 11, the patient reported headaches and right homonymous hemianopsia. A noncontrast head computer tomography (CT), head/neck CT angiogram and noncontrast magnetic resonance imaging (MRI) revealed left occipital lobe changes consistent with cytotoxic edema and infarction (Figure 1A–C). Following a stroke work-up, aspirin 325 mg daily was started. Two days later, she had a grand mal seizure. Rim-enhancing lesions in the left occipital lobe were identified on repeat brain MRI (Figure 1D). Her tacrolimus was changed to cyclosporine to decrease the seizure risk. Ceftazidime, vancomycin and metronidazole were empirically started. The next morning, the patient was found unresponsive. She was intubated and administered mannitol, dexamethasone and levetiracetam. After transfer to the surgical intensive care unit, the patient was awake but remained lethargic and confused. C. Thiessen, R. Patrón-Lozano, M. Schilsky and M. I. Rodríguez-Dávalos* Department of Surgery, Division of Transplantation and Immunology, Yale School of Medicine, New Haven, CT * Corresponding author: Manuel I. Rodríguez-Dávalos, [email protected]

Figure 1: Neuroimaging. (A) Axial noncontrast computer tomography demonstrating hypodensity in the left occipital lobe. Note that the lesion does not precisely follow the vascular distribution of the posterior cerebral artery. (B) Axial diffusion-weighted magnetic resonance imaging (MRI) reveals hyperintensity in the left occipital lobe consistent with cytotoxic edema and recent infarct confirmed by corresponding hypointensity on the apparent diffusion coefficient map (C). (D) Axial T1-weighted, gadolinium enhanced MRI shows two confluent, rim-enhancing lesions abutting the occipital horn of the left lateral ventricle. There is associated midline shift and effacement of the ipsilateral hemispheric sulci.

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Questions 1.

Based on the history and the figures, what is the most likely etiology of this patient’s symptoms and imaging findings?

a. b. c. d. e.

Candida Cerebral vascular accident Aspergillus Glioblastoma multiforme Cryptococcus

2.

What is the best test to confirm the diagnosis?

a. b. c. d. e.

Brain MRI Biopsy Peripheral fungal blood cultures Serum galactomannan assay Lumbar puncture

3.

What is the optimal treatment for this disorder?

a. b. c. d. e.

Fluconazole Amphotericin Surgical resection Surgical resection and antifungal therapy Anti-seizure medication and supportive care

4.

Which of the following should be performed during definitive surgery to treat this condition?

a. b. c. d. e.

Biopsy only Abscess aspiration only Resection of necrotic tissue only Abscess aspiration and resection necrotic tissue, avoiding disruption of the abscess wall Aspiration of pus and resection necrotic tissue including the abscess wall

5.

Voriconazole therapy for this condition:

a. b. c. d. e.

Results in a 50% survival rate Is associated with better outcomes than amphotericin B Does not require any adjustments to the immunosuppression regimen Has better central nervous system penetration than amphotericin B Can be discontinued after 3 months

To complete this activity and earn credit, please go to https://www.wileyhealthlearning.com/ajt

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