ArticleFrontiers in medicine2026
A challenging diagnostic journey of antibody-mediated rejection after lung transplantation in a child: a case report.
Article in Frontiers in medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Antibody-mediated rejection (AMR) is a serious post-lung transplant (LTx) complication with a challenging diagnosis. Histopathological findings associated with AMR include variable degrees of capillary inflammation, endotheliitis, and diffuse alveolar damage/organizing pneumonia. AMR has been historically related to anti-HLA donor-specific antibodies (DSA), while the role of non-HLA antibodies remains debated. We report the case of a 15-year-old male undergoing bilateral LTx for cystic fibrosis. Twenty days later, the patient developed moderate acute cellular rejection (ACR); in samples not affected by ACR, diffuse edema, capillary inflammation, and high p-S6RP expression scores were observed in macrophages, endothelial and epithelial cells. Anti-HLA class II DSA [maximum median fluorescence intensity (MFI): 10434] supported a diagnosis of mixed cellular/humoral rejection. After steroid therapy, DSA markedly decreased (maximum MFI: 1534), and ACR resolved, whereas persistent capillary inflammation and high p-S6RP expression in all cell types characterized sequential biopsies, raising suspicion for ongoing subclinical AMR. The persistence of these morphological features, together with sustained p-S6RP overexpression, prompted extended immunological testing, which revealed markedly elevated antibodies against endothelin type A receptor and angiotensin II type 1 receptor (>40 U/mL) in the patient follow-up. This case underscores the pivotal role of histopathological findings in multidisciplinary decision-making and highlights the importance of extended immunological screening. Our findings further support the emerging pathogenic relevance of non-HLA antibodies in the development and persistence of AMR in LTx recipients. The patient ultimately died 25 months after transplantation from progressive chronic lung allograft dysfunction.
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