Unusual Kaposi's sarcoma in a renal transplant recipient.

Kaposi's sarcoma (KS) was first described as an ‘idiopathicmultiple pigmented sarcoma of the skin’ by Moritz Kaposiin 1872 [1]. Skin lesions have a dark blue or purplish colouron white skin and often appear pigmented on black skin. Initially,they may be macular and may coalesce to form large plaques.Subsequently, they become infiltrating and may form nodularand fungiform tumours. We present an unusual large     

Transmission of toxoplasmosis by renal transplant

Two renal allograft recipients who had received their organs from the same cadaver donor developed acute toxoplasmosis shortly after transplantation. Neither of the recipients had serologic evidence of previous exposure to Toxoplasma gondii at the time of surgery, but the donor had a positive indirect fluorescent antibody test. One of the recipients died during the fourth week, and multiorgan involvement with toxoplasmosis was demonstrated at autopsy. No evidence of the parasite could be found in the transplanted kidney. In the second recipient the disease was suspected, serologically demonstrated, and successfully treated. We concluded that toxoplasmosis was transmitted by the donor's kidneys, although this mode of transmission was not completely proven.     

Miliary tuberculosis in a Caucasian male transplant recipient and the role of intravenous immunoglobulin as an immunosuppressive sparing agent

Opportunistic infections are a common and anticipated accompaniment of transplantation, but are generally somewhat predictable in their timing and epidemiology. The authors report here a case of miliary tuberculosis occurring within 3 weeks of transplantation, in a patient not expected to be significantly at risk, and with a normal chest X-ray at the time of transplantation. A 25-year-old Caucasian male dialysis patient who received two paediatric kidneys as an en bloc renal transplant developed fever 3 weeks following transplantation; this eventually proved to be miliary tuberculosis. As well as antituberculous therapy and a significant reduction in the patient's conventional immunosuppression, intravenous immunoglobulin was used as anti-rejection prophylaxis. The case highlights the immunosuppressed status of dialysis patients prior to transplantation and the need for broad differential diagnosis in transplant recipients even in the absence of recognized epidemiological factors. The case also emphasizes the role of intravenous immunoglobulin as an anti-rejection therapy that does not add to the patient's immunosuppressive burden.     

Higher risk of urinary tract infections in renal transplant recipients receiving pentamidine versus trimethoprim-sulfamethoxazole (TMP-SMX) for Pneumocystis pneumonia prophylaxis

Urinary tract infection (UTI) is one of the most common infectious complications among renal transplant patients. Trimethoprim-sulfamethoxazole (TMP-SMX) is routinely used as first-line prophylaxis against Pneumocystis pneumonia (PCP) and other opportunistic infections including UTI. Aerosolized pentamidine is an alternate agent used for PCP prophylaxis; however, it does not provide coverage against uropathogens. This is a retrospective study of 81 renal transplant recipients who received TMP-SMX or aerosolized pentamidine for PCP prophylaxis at our center over 1 year. Survival analysis demonstrated increased cumulative incidence of UTI among patients receiving pentamidine for PCP prophylaxis compared to those receiving TMP-SMX (log-rank test P < .001). Univariate and multivariate Cox proportional hazard regression model showed pentamidine prophylaxis (HR 3.740; 95% CI 1.745-8.016; P = .001) and female sex (HR 4.025; 95% CI 1.770-9.154; P = .001) to independently increase UTI risk. Age, induction agent, graft type, diabetes, and delayed graft function (DGF) were not associated with increased risk. This study concludes that the use of pentamidine for PCP prophylaxis compared to TMP-SMX is associated with increased risk of UTI. Secondary UTI prophylaxis may be considered for patients who are unable to tolerate TMP-SMX and who have other risk factors for UTI; however, the efficacy of this has not been studied.     

A renal transplant recipient with multiple facial nodules.

Case A 42-year-old male renal transplant recipient on ciclosporinand steroid developed multiple enlarging nodulocystic lesionson face, neck and retroauricular regions. The lesions had neverbeen present before renal transplant but occurred around 3 monthsafter the operation and had     

Spotting the owl: surreptitious cytomegalovirus disease in a renal transplant recipient

Abstract:  Cytomegalovirus (CMV) is a known cause of ulcerative oral lesions among HIV-infected patients, but such ulcers have not been previously reported in recipients of solid organ transplants. We describe a case of a renal transplant recipient who developed severe CMV-associated oral lesions despite prophylaxis with valganciclovir, and in the absence of detectable CMV viremia. The diagnosis was made only after multiple biopsies of the lesions. The patient recovered upon reducing immunosuppression. Potential pitfalls in making a prompt diagnosis are reviewed. The differential diagnosis of a large oral ulceration in a transplant recipient is broad, but should include CMV infection.     

Fibrosing cholestatic hepatitis in renal transplant recipient with CMV infection: A case report

Fibrosing cholestatic hepatitis (FCH) is an uncommon complication of renal transplantation. It is usually associated with hepatitis B and C viral infection. It is further rare in renal transplantation in absence of HBV and HCV infection. To the best of our knowledge, only three cases of FCH in renal transplantation, which were both HBV and HCV negative, have been reported to date. Out of these, two cases were diagnosed to have CMV infection and the third was attributed to azathioprin. We are presenting another case of FCH in a renal transplant recipient with CMV infection.     

Low prevalence of human papillomavirus infection of the cervix in renal transplant recipients

BACKGROUND.: An increased risk of anogenital tract malignancies has beennoted among renal transplant recipients. A high prevalence ofhuman papillomavirus (HPV) infection of the cervix in the femalerenal-transplant population has been assumed based on increasingevidence suggesting that HPV infection is the major risk factorfor cervical intraepithelial neoplasia (CIN) and cervical cancer.It has been assumed that immunosuppression leads to either areactivation of latent HPV or a reduction in the host's abilityto contain a primary HPV infection, thereby increasing the riskof CIN and cervical cancer. The objective of this study wasto evaluate the prevalence of human papillomavirus (HPV) infectionin a population of iatrogenically immunosuppressed renal transplantrecipients. METHODS.: Twenty-one women were recruited from the renal transplant clinicat Presbyterian Hospital and underwent a gynaecological examinationwhich included colposcopy, a Papanicolaou smear, and a cervicovaginallavage. Lavage samples were analysed for HPV DNA using L1 consensusprimers and the polymerase chain reaction (PCR). RESULTS.: No cases of cervical intraepithelial neoplasia (CIN) were detectedin this cohort of 21 immunosuppressed renal transplant recipients.HPV DNA was detected in only a single patient. CONCLUSIONS.: Our data suggests that HPV infection is not highly prevalentamong older, cytologically normal renal transplant recipients,particularly those who are currently monogamous or not presentlysexually active. This study suggests that recent sexual behavioursare more important than past behaviours as a determinant ofHPV status in transplant recipients, and also suggests thateducation concerning the avoidance of high-risk sexual behaviouris an important part of the care of the female renal transplantrecipient. Our data is consistent with previous work suggestingthat the incidence of CIN is declining in transplant recipients,and it also suggests that the prevalence of HPV infection maybe declining as well.     

Pulmonary Rhizopus infection in a diabetic renal transplant recipient

Infectious complications after renal transplantation remain a major cause of morbidity and mortality. Mucormycosis is a rare infection in renal transplant recipients; however, mortality is exceedingly high. Risk factors predisposing to this disease include prolonged neutropenia, diabetes, and patients who are immunosuppressed (Singh N, Gayowski T, Singh J, Yu LV. Invasive gastrointestinal zygomycosis in a liver transplant recipient: case report and review of zygomycosis in solid-organ transplant recipients, Clin Infect Dis 1995: 20: 617). Life-threatening infections can occur, as this fungus has the propensity to invade blood vessel endothelium, resulting in hematological dissemination. We report a case of cavitary Rhizopus lung infection, 2 months after renal transplantation, where the patient was treated successfully with Amphotericin B and surgical resection of the lesions with preservation of his allograft function. In this era of intensified immunosuppression, we may see an increased incidence of mucormycosis in transplant population. Invasive diagnostic work-up is mandatory in case of suspicion; Amphotericin B and, in selected cases, surgical resection are the mainstays of therapy.     

Evaluation of interleukin-6 and interleukin-10 in lung transplant patients with human cytomegalovirus infection

Abstract:  We hypothesized that interleukin-6 (IL-6) in plasma and bronchoalveolar lavage (BAL) might serve as additional diagnostic parameter in lung transplant patients with human cytomegalovirus (HCMV) infection. Therefore, we compared IL-6 levels in HCMV-positive vs. HCMV-negative patients. IL-6 was measured by ELISA in plasma and BAL in 111 patients. Furthermore, we investigated the influence of IL-10 on IL-6 production in HCMV-positive patients. For HCMV–DNA detection in plasma and BAL a quantitative polymerase chain reaction (PCR) assay was used. IL-6 levels were significantly higher in the HCMV-positive group (n = 39; BAL p = 0.045; plasma p = 0.017) in comparison to the HCMV-negative group (n = 72). IL-10 did not correlate with IL-6 concentration (p = 0.146). Donor (D) or recipient (R) HCMV-constellation did not influence IL-6 concentration. IL-6 levels were not influenced by elevated levels of HCMV copies. Our data suggest that IL-6 does not serve as a good diagnostic parameter for existence of HCMV infection in lung transplant patients. Because of the wide range of the IL-6 levels in both groups, we were not able to find a breakpoint differentiating between infected and not-infected patients. Another important finding was that IL-6 production is not dependent of the HCMV status of D/R.     

Fatal disseminated Nocardia farcinica infection in a renal transplant recipient

Six years after a renal cadaver transplant, a 20-year-old girl developed multiple painful cutaneous abscesses and bilateral pneumonia secondary to Nocardia farcinica infection. Despite broad in vitro sensitivity to several antibiotic agents and aggressive medical treatment, the patient failed to respond and died after 10 weeks of therapy. We conclude that Nocardia farcinica is a very aggressive organism in immunocompromised patients and is often resistant to antimicrobial agents. Received: 28 April 1999 / Revised: 16 July 1999 / Accepted: 22 July 1999     

Idiopathic thrombocytopenia after cytomegalovirus infection in a renal transplant recipient

Infection with cytomegalovirus (CMV) is a frequent complication of organ transplantation and presents a spectrum of disease ranging from asymptomatic viremia to life-threatening tissue-invasive disease. CMV is also lymphotrophic, with the potential to induce autoimmune disease, although immunosuppressive therapy may prevent or attenuate the clinical course in transplant patients. We report a case of idiopathic thrombocytopenic purpura occurring in a renal transplant recipient after primary CMV infection and discuss the possible mechanisms involved.     

Enterocolitis with pathogenic Escherichia coli infection in renal transplant recipients: Case reports

PURPOSE: We report three cases of enterocolitis associated with pathogenic Escherichia coli infection in renal transplant recipients. METHODS/RESULTS: Patients presented with abdominal pain and diarrhea at 1, 3 and 7 years after living-related renal transplantation. Pathogens of enterocolitis were identified by stool culture as verotoxin-2-producing O157:H7 E. coli, non-verotoxin-producing E. coli 06 and 0125. All patients were basically treated with fluid replacement with additional fosfomycin administration in the patient with O157:H7 E. coli infection. Immunosuppressive drugs were kept at maintenance doses throughout the treatment. CONCLUSION: All patients recovered uneventfully within 10 days after the onset of enterocolitis without severe complications.     

Congenital cytomegalovirus infection after recurrent infection in a mother with a renal transplant

A woman with a renal transplant developed a systemic cytomegalovirus infection. She recovered and 3 years later she became pregnant. She had 3 days of fever in the first trimester. She delivered an infant severely affected with congenital cytomegalovirus infection. The incidence of symptomatic congenital cytomegalovirus infection in infants born to immunosuppressed mothers who develop reactivated cytomegalovirus during their pregnancy seems high. Received April 22, 1996; received in revised form September 3, 1996; accepted October 22, 1996     

Nocardiosis in renal transplant recipients in Kuwait

BACKGROUND.: Nocardiosis has emerged as an important bacterial disease amongrenal transplant recipients, leading to considerable morbidityand mortality. Apart from the increasing problem of resistancein pathogenic nocardiae, the spectrum of species causing diseasehas enlarged in recent years. There are no published reportson nocardiosis from Middle-East countries. METHODS.: A retrospective review of case records of 513 renal transplantrecipients between January 1989 and January 1995 was done inthe transplant unit of our hospital. Information was collectedon clinical details, type of donor, immunosuppressive therapy,prophylaxis, and outcome. Isolation of Nocardia species fromappropriate clinical specimens was the sole criterion for diagnosis. RESULTS.: Nocardiosis was diagnosed in six recipients with a disease incidenceof 1.2%. Four patients had received unrelated kidneys. Co-morbidconditions were diabetes mellitus (3), viral hepatitis (2) andneutropenia (1). Clinical manifestations included deep-seatedskin abscesses and pulmonary disease in three each. Cerebralabscess and meningitis were found in two patients with pulmonarydisease. Pathogens were Nocardia asteroides in four and N. otitidiscaviarum and N. farcinica in one each. In contrast to invitro susceptibility results, clinical response was differentin that five patients who received trimethoprim-sulphamethoxazole(TMP-SMX) alone (2) or in combination with cefuroxime (3) respondedwell. CONCLUSION.: The study stresses a high index of suspicion for nocardiosisin susceptible hosts who present with cutaneous abscess, pulmonaryinfiltrative lesions, and cerebral manifestations. TMP-SMX incombination with cefuroxime seems to be a highly effective therapy.It does not appear mandatory to reduce or discontinue immunosuppressivetherapy during treatment of nocardiosis.