Do not underestimate cryptosporidium: case report of a rare cause of acute liver failure in transplant recipients

BACKGROUND: Cryptosporidium infection, usually self-limited in immunocompetent individuals, can lead to severe complications in immunosuppressed patients, such as solid organ transplant recipients. Biliary tract infection is a rare but potentially devastating complication, with limited therapeutic options. CASE PRESENTATION: We report the case of a woman who developed fatal liver failure secondary to Cryptosporidium-induced cholangiopathy fifteen years after liver transplantation. The patient, maintained on triple immunosuppression, initially presented with diarrhea and acute renal failure. PCR on stool identified Cryptosporidium spp., and immunosuppression minimization combined with specific therapies were initiated with temporary improvement. Despite sequential antiparasitic therapies, recurrent diarrhea and progressive liver enzyme elevation ensued. Serial liver biopsies revealed portal and lobular inflammation with granulomas and biliary injury, evolving toward hepatic failure and fibrosis. Profound and persistent lymphopenia was observed throughout the course. CONCLUSIONS: This case underscores the underestimated risk of Cryptosporidium infection in liver transplant recipients and its potential to cause irreversible biliary damage and liver failure. Early recognition, and prompt targeted therapy are crucial to improve the outcomes in this life-threatening complication.