Recurrent
bile salt export pump (rBSEP) disease has been reported in
progressive familial intrahepatic cholestasis type 2 (PFIC2) patients following
liver transplantation (LT) and is often refractory to standard anti-cellular rejection
immunosuppressants. The mechanism of rBSEP disease is proposed to be a form of type II
hypersensitivity reaction with de novo anti-BSEP
antibodies blocking the function of allograft BSEP. Utilization of C4d has not been evaluated in rBSEP. We describe a girl with 3 episodes of rBSEP with severe
pruritus at 8.9, 10.3, and 11.0 years post-LT, respectively. Patient's serum reacted with normal liver canaliculi by indirect immunofluorescence (IF), whereas patient's liver showed canalicular
immunoglobulin G deposition. The histologic features of all 3 liver biopsies recapitulate PFIC2 with cholestatic
giant cell hepatitis. Canalicular BSEP expression was not detected in areas of feathery degeneration by immunohistochemistry, but was retained in morphologically normal liver. By direct IF, C4d showed diffuse sinusoidal staining in the third biopsy. Patient responded well to
rituximab with or without
intravenous immunoglobulin with subsiding symptoms and normalization of serum
bile acid levels. In conclusion, rBSEP disease should be considered in the differential diagnosis when evaluating for rejection in a PFIC2 patient post-LT presenting with
pruritus. A portion of liver core may be snap frozen in OCT medium for possible direct IF for C4d, that can serve as a
surrogate marker for complement activation and antibody-mediated graft dysfunction.