Successful Liver Transplantation in a Child With Invasive Aspergillus terreus Cholangitis Identified via Plasma Metagenomic Next-Generation Sequencing.

BACKGROUND: Ascending cholangitis, one of the most common complications in patients with biliary atresia (BA) after Kasai hepatoportoenterostomy (HPE), impacts native liver survival. Typically, enteric bacterial flora are the source of infection, and fungal infections of the biliary tree are rare.

CASE REPORT: We report the case of a 3-year-old female with BA status post Kasai HPE who developed Aspergillus terreus cholangitis (complicated by hepatic vein thrombus) identified through plasma metagenomic next-generation sequencing (NGS) of microbial cell-free deoxyribonucleic acid (DNA). Despite improvement in galactomannan (GM) antigen indices while on antifungal therapy with voriconazole and anticoagulation, she experienced complications with the extension of septic thrombus and persistent cholestasis; thrombus tissue sampling later confirmed the diagnosis and antimicrobial sensitivities. Ultimately, native liver explantation succeeded in achieving source control with sustained normalization of GM indices after the completion of voriconazole. Post-transplant, she received routine immunosuppression and infection prophylaxis per institutional protocol and remains well without infectious complications more than 1 year later.

DISCUSSION: This case highlights the important role of newer molecular diagnostic tools in facilitating timely species-level pathogen identification and initiation of targeted therapy (in this case, 35 days prior to confirmed tissue diagnosis), particularly in circumstances where the risk-to-benefit ratio of invasive tissue sampling is unfavorable. Despite the significant morbidity associated with invasive fungal infection, transplantation followed by standard immunosuppression is a reasonable therapeutic option with successful outcomes in patients who are otherwise suitable transplant candidates.