Rejection, Recurrence, or Something Else?

Since the introduction of liver transplant as treatment for end-stage liver disease, thousands of lives have been saved. To prevent organ rejection, immunosuppression is given chronically and hence, patients are at increased risk for opportunistic infections related to immunosuppression, especially within the first year after the transplant. However, opportunistic infections can occur years after the transplantation. Disseminated nocardiosis is one of these infections, and although the common presentation includes involvement of skin, lungs, and central nervous system. We present an uncommon presentation of nocardiosis in which cholestasis and elevated liver enzymes predominate, mimicking organ rejection and liver disease recurrence. Infectious etiologies, including opportunistic microorganisms, must always be ruled out in patients presenting elevation in liver enzymes and cholestasis after liver transplant as early diagnosis can prevent complications such as re-transplantation and even death.