HYPERAMMONEMIA SYNDROME AFTER LUNG TRANSPLANTATION: A CALL FOR BROADENING OF THE PERI-OPERATIVE ANTIMICROBIAL COVERAGE

TOPIC: Transplantation TYPE: Fellow Case Reports INTRODUCTION: Hyperammonemia is an uncommon but ominous complication among patients with lung transplantation (LT). Herein, we report a case of severe hyperammonemia difficult to manage seizures secondary ureaplasma infection. CASE PRESENTATION: A 68-year-old female chronic hypersensitivity pneumonitis underwent bilateral LT. Peri-operative prophylactic antimicrobials included vancomycin, zosyn, ganciclovir, inhaled amphotericin, and tobramycin. Given history fluoroquinolone intolerance, patient was not on levofloxacin (part the institutional protocol for peri-operative antibiotics). The extubated post-operative day (POD) 4 noted be more somnolent POD 12 which progressively worsened complete obtundation by 15. An ammonia level found elevated 226 umol/L. Liver functions only showed mild elevation in enzymes normal synthetic function. Chest imaging alveolar opacifications while brain (CT MRI) did show any acute abnormalities. Ureaplasma urealyticum PCR checked broncho-alveolar lavage sample 16 initiated given concern atypical infections. With initiation lactulose, levels started decrease, however remained obtunded. Furthermore, she developed generalized tonic clonic 17 requiring levetiracetam lacosamide. Despite adequate stool output, increase again. Thus, continuous renal replacement therapy (CRRT) 18. Within 24 hours CRRT initiation, began showing signs improvement spontaneous eye opening following commands. Ammonia were expectedly lowered range CRRT. urealytica returned positive 19. Patient transitioned dual treatment azithromycin severity illness risk resistance. continued progress weaned off stability levels. subsequently recovered hospital discharge. DISCUSSION: current serves highlight consequences first month, most common causes infection are nosocomial, line associated, or due microbes present donor recipient. Post-transplant bacterial prophylaxis generally include coverage against gram negative organisms, organisms often ignored their overall low suspicion. Transplant donors routinely screened these infections they equally diagnose transplant recipients. CONCLUSIONS: We, therefore, recommend including antibiotics efficacy period all LT patients. REFERENCE #1: Nosotti, M., Tarsia, P., Morlacchi, L. Infections after transplantation. 2018; 10(6): 3849-3868. #2: Matson, K., Sonetti, D. Successful Ureaplasma-induced syndrome post-lung transplant. Transpl Infect Dis. e13022. #3: Beeton, M.L., Spiller, O.B. Antibiotic resistance spp. Isolates: cause concern? Journal Antimicrobial Chemotherapy. 2016. 72: 330-337. DISCLOSURES: My spouse/partner as Employee relationship Abbott Labs Please note: $20001 - $100000 Amit Banga, source=Web Response, value=Salary No relevant relationships Margaret Kypreos, Response