Leucocytosis before liver transplant, source could be hiding
Published in the Indian Journal of Anesthesiology, the authors present a case of a 47-year-old male with diabetes mellitus and ethanol-related chronic liver disease operated upon for living donor LT with high total leucocyte count (TLC).

Immediate preoperative investigations including his preoperative cardiovascular evaluation with transthoracic echocardiography (TTE) were not suggestive of any infection and were unremarkable. The patient was diagnosed with aortic valve vegetation after LT.

The patient developed spontaneous bacterial peritonitis (SBP) while waiting for LT. While ascites and SBP were treated, blood culture grew coagulase-negative Staphylococcus aureus and Staphylococcus haemolyticus. His TLC was 19,000 cells/mm3. Appropriate culture-based antibiotics were started and subsequent blood cultures were negative for bacterial growth, but TLC remained high (15,000 cells/mm3).

Haematology workup was done, but no explanation could be found for persistent high TLC in the absence of any other tests suggestive of infection. Antibiotics were stopped more than a week before surgery, and repeat blood and body fluids' cultures, done as protocol 48 h before LT, were negative for bacterial growth.

In view of deteriorating clinical condition, the patient was taken up for LT. Surgery was uneventful. Immunosupression was initiated. On postoperative day (POD) 2, the patient developed atrial fibrillation with respiratory distress requiring endotracheal intubation and mechanical ventilation. Chest X-ray was suggestive of fluid overload. Post-LT heart failure[1] was ruled out.

Antibiotics were upgraded and he was weaned off mechanical ventilation on POD 7. On POD 9, he developed de novo diastolic murmur. TTE demonstrated aortic regurgitation (AR). Mobile aortic valve vegetation was diagnosed upon transesophageal echocardiography (TEE). Blood cultures again grew Staphylococcus haemolyticus. An extended course of antibiotic was planned and continued. The patient gradually improved and was discharged home. His AR persists and he has been advised surgical management.

Key takeaways:-
- Whether IE was present before LT or it occurred after surgery, the exact clinical course can only be speculated.

- However, in view of this case report, and due to high mortality associated with the diagnosis, the authors suggest a closer examination of heart with TEE, as part of preoperative examination before LT in patients with unexplained leucocytosis and to be aware of such possibility in the postoperative period after liver transplant.

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