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Sirolimus for Recurrent Giant Cell Myocarditis After Heart Transplantation

A Unique Therapeutic Strategy

Patel, Apurva D. MD, MPH1,*; Lowes, Brian MD, PhD1; Chamsi-Pasha, Mohammed A. MD1,2; Radio, Stanley J. MD3; Hyden, Marshall MD1; Zolty, Ronald MD, PhD1

doi: 10.1097/MJT.0000000000000796
Therapeutic Challenge

Clinical Features: Giant cell myocarditis (GCM) is a rare and a rapidly progressive disorder with fatal outcomes such that patients often require heart transplantation. We present a case of recurrent GCM in a transplanted patient with a history of Crohn disease requiring a novel therapeutic approach.

Therapeutic Challenge: After the orthotopic heart transplantation, GCM recurred on aggressive immunosuppression over the months, which included corticosteroids, basiliximab, tacrolimus, antithymocyte globulin, and rituximab. Although combination immunosuppressive therapy containing cyclosporine and 2–4 additional drugs including corticosteroids, azathioprine, mycophenolate mofetil, muromonab, gammaglobulin, or methotrexate have shown to prolong the transplant-free survival by keeping the disease under control, its role in preventing and treating recurrence posttransplantation is unclear.

Solution: We added sirolimus, a macrolide antibiotic, with properties of T- and B-lymphocyte proliferation inhibition on the above immunosuppressive treatment postrecurrence of GCM. After sirolimus initiation and continuation, the patient has remained disease free.

1Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE;

2Department of Cardiology, Cardiovascular Imaging Institute, The Methodist DeBakey Heart and Vascular Center, Houston, TX; and

3Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE.

Address for correspondence: Research Fellow, Department of Cardiovascular Medicine, University of Nebraska Medical Center, 982265 Nebraska Medical Center, Omaha, NE 68198-2265. E-mail:

The authors have no conflicts of interest to declare.

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