Mycobacterium llatzerense Lung Infection in a Liver Transplant Recipient: Case Report and Review of the Literature

Nontuberculous mycobacteria are increasingly encountered pathogens in organ transplant recipients. We report the first case of human disease attributed to Mycobacterium llatzerense that occurred in a liver transplant recipient in the midwestern United States who developed pneumonia and describe the treatment of this patient.     

Varicella Infection Following Varicella Vaccination in a Liver Transplant Recipient

Varicella infection may result in significant morbidity and mortality in patients who have received an orthotopic liver transplant (OLT). It is unclear if vaccinating these patients against varicella-zoster virus (VZV) infection is safe or effective. We report on a liver transplant recipient with no prior history of VZV infection who was given the varicella vaccine after an indirect VZV exposure. The patient was subsequently hospitalized twice for treatment of cutaneous varicella infection. We will discuss VZV infection, particularly in relation to liver transplantation, and review the prophylaxis and management of VZV infection after OLT.     

Coronary Revascularization in Lung Transplant Recipients With Concomitant Coronary Artery Disease

Coronary artery disease (CAD) is not uncommon among lung transplant candidates. Several small, single‐center series have suggested that short‐term outcomes are acceptable in selected patients who undergo coronary revascularization prior to, or concomitant with, lung transplantation. Our objective was to evaluate perioperative and intermediate‐term outcomes in this patient population at our institution. We performed a retrospective, observational cohort analysis of 898 lung transplant recipients between 1997 and 2010. Pediatric, multivisceral, lobar or repeat transplantations were excluded, resulting in 791 patients for comparative analysis, of which 49 (median age 62, 79.6% bilateral transplant) underwent concurrent coronary artery bypass and 38 (median age 64, 63.2% bilateral transplant) received preoperative percutaneous coronary intervention (PCI). Perioperative mortality, overall unadjusted survival and adjusted hazard ratio for cumulative risk of death were similar among both revascularization groups as well as controls. The rate of postoperative major adverse cardiac events was also similar among groups; however, concurrent coronary artery bypass was associated with longer postoperative length of stay, more time in the intensive care unit and more postoperative days requiring ventilator support. These results suggest that patients with CAD need not be excluded from lung transplantation. Preferential consideration should be given to preoperative PCI when feasible.     

Severe Hepatitis C Infection in a Renal Transplant Recipient Following Hepatitis C Genotype Mismatch Transplant

We report a case of a 32-year-old female with histologically and clinically inactive chronic hepatic C infection, who received a cadaveric renal transplant from a hepatitis C-positive donor with a different genotype. The genotype mismatch (genotype 1 to genotype 2) and change to tacrolimus-based immunosuppression resulted in severe hepatitis C infection characterized by a 10-fold increase in transaminase levels and grade 3 inflammation histologically. Our report highlights the risk of genotype-mismatch transplants in solid organ transplantation.     

Diagnosis and Management of Atypical Mycobacterial Infection after Laparoscopic Surgery

Atypical mycobacterial infections at the laparoscopic port site are a frequent problem encountered in patients undergoing laparoscopic surgery. In this study we concentrate on the clinical diagnosis, management and prevention of this problem. In this series we assess 19 patients presenting with port hole infections after laparoscopic surgery and were treated with a combination of oral clarithromycin and ciprofloxacin. Seven patients who had persistent nodules were given injections of amikacin directly into the infection foci along with standard oral therapy. Most of the patients treated with standard oral therapy for 28 days showed recovery. The patients with persistent nodules 4 weeks after completion of therapy were treated with injections of amikacin directly into the nodule which lead to resolution of symptoms. For prevention of infection, proper sterilization and storage of instruments is recommended. Laparoscopic port hole infections is a preventable problem and can also be treated by nonsurgical method.     

Disseminated Monkeypox Infection in a Kidney Transplant Recipient: A Case Report

Monkeypox is a rapidly spreading infection worldwide and is a public health concern, especially with newly reported fatality cases. The characteristics and disease course of monkeypox infection in transplant recipients remain elusive because no case reports have been published detailing its clinical presentation and outcome in this population. We report a case of a kidney transplant recipient who developed end-stage renal disease secondary to HIV-associated nephropathy and manifested monkeypox infection after kidney transplantation. The patient had severe clinical manifestations, including disseminated vesicular skin rash, diffuse mucosal involvement, urine retention, proctitis, and bowel obstruction. We also highlight several clinical considerations regarding the use of tecovirimat, a novel antiviral therapy with activity against orthopoxviruses that has been used in the United States to treat monkeypox infection.     

Lepromatous Leprosy in a Heart Transplant Recipient

Northern Louisiana is not an area for indigenous cases of leprosy. Limited data are available on the occurrence of leprosy in organ transplant recipients. No cases have been reported in heart transplant recipients. Mr J.R. is a 68-year-old man from Shreveport, Louisiana. He underwent orthotopic heart transplantation in March 1996. He presented in March 2000 with a maculopapular skin rash and intermittent hand swelling for 5 months. He also complained of intermittent burning of his feet for a year. The skin lesions were of two types – a fine red migratory, intermittent maculopapular rash over the upper torso and a raised, larger, violaceaous lesion on his hands. Neurological examination revealed complete loss of protective sensation in the right foot by filamentous test and some loss in the left foot. Punch skin biopsies from his right arm and right chest lesion revealed abundant acid-fast bacilli (AFB). Histopathologic examination revealed perivascular, interstitial and perineural granulomatous inflammation and a large number of AFB organisms within histiocytes. Culture of the skin biopsy specimen was negative for Mycobacterium tuberculosis or atypical mycobacterium. Polymerase chain reaction (PCR) performed for Mycobacterium leprae was positive. The patient was treated with a modified regimen consisting of dapsone 100 mg qd, ethionamide 250 mg qd, and minocycline 100 mg qd. His skin rash and neurological symptoms have resolved .     

Recurrent Hepatitis B and D Virus Infection in a Liver Transplant Recipient

Hepatitis B virus (HBV) and hepatitis delta virus (HDV) co-infections progress rapidly and lead to cirrhosis. In Japan, the prevalence of HBV and HDV co-infected patients is low. Therefore, there are few reports of patients with HBV and HDV co-infection having undergone liver transplantation. Herein, we report a rare case of recurrence of HBV and HDV in a 41-year-old man who underwent living donor liver transplantation 4 years prior.     

A Novel Mutation of the Ornithine Transcarbamylase Gene Leading to Fatal Hyperammonemia in a Liver Transplant Recipient

Ornithine transcarbamylase (OTC) deficiency (OTCD) is an X‐linked urea cycle disorder. Being an X‐linked disease, the onset and severity of the disease may vary among female carriers. Some of them start to develop the disease early in life, whereas others remain asymptomatic throughout their lives. Our patient was a 42‐year‐old man who developed severe hyperammonemia and fatal brain edema after receiving a right lobe graft from an asymptomatic female living donor with unrecognized OTCD. The donor developed hyperammonemia and disturbed level of consciousness that was managed successfully by hemodialysis. Molecular testing of the OTC gene in the donor revealed a heterozygous nonsense mutation (c.429T > A) in exon 5.     

Preemptive Therapy for Systemic and Pulmonary Human Cytomegalovirus Infection in Lung Transplant Recipients

The incidence and treatment of both systemic and pulmonary human cytomegalovirus (HCMV) infection as well as HCMV-specific T-cell immune responses were investigated in 57 consecutive lung transplant recipients (LTR) by using as cutoffs for preemptive therapy: 300 000 DNA copies/mL whole blood for systemic infections and 100 000 DNA copies/mL bronchoalveolar lavage fluid for lung infections. Results showed that out of 29/57 LTR (50.9%) needing preemptive antiviral therapy, 15 (51.7%) reached the blood cutoff, 8 (27.6%) the pulmonary cutoff and 6 (20.7%) both the blood and the lung cutoff (3 simultaneously and 3 subsequently). Recovery of HCMV-specific T-cell immune responses was achieved much earlier for CD8⁺ than CD4⁺ T cells. However, protection from HCMV reactivation was conferred by the presence of both arms of the T-cell response. In two LTR reaching the pulmonary cutoff and not preemptively treated, a full HCMV-specific CD4⁺ and CD8⁺ T-cell response was associated with resolution of lung infection. Antirejection steroid therapy suppressed T-cell immune responses, thus facilitating HCMV reactivation. In conclusion, in LTR, monitoring HCMV infection in both blood and lungs, may improve preemptive therapy efficacy. In addition, monitoring the HCMV-specific T-cell immune response appears useful for predicting control of HCMV infection in the posttransplant period.     

Influenza Virus Infection in Adult Solid Organ Transplant Recipients

BACKGROUND: Solid organ transplant (SOT) recipients have been reported to be more susceptible to influenza virus. However, little is known about the clinical epidemiology and the implications of influenza viral infection among SOT recipients. METHODS: Cohort study of influenza viral infection in SOT recipients at the University of Pittsburgh Medical Center. RESULTS: Between November 1990 and April 2000, 30 cases of influenza were diagnosed in SOT recipients at our center, including influenza A (n = 22) and influenza B (n = 8). These included recipients of lung (n = 19), liver (n = 5) and kidney (n = 6) transplants. The incidence of influenza viral infection was 41.8 cases/1,000 person years (PYs), 2.8 cases/1000 PYs and 4.3 cases/ 1,000 PYs among lung, liver and renal transplant patients, respectively (p <0.0001). Symptoms were reported in all patients and included malaise, myalgia/ arthralgia, fever, cough, and shortness of breath. Secondary bacterial pneumonia occurred in five patients (17%). Other complications were seen in three SOT recipients (2 liver and 1 kidney) and included: myocarditis, myositis, and bronchiolitis obliterans. Biopsy of the transplanted organ was performed in 21 SOT recipients (18 lung, 1 liver and 2 kidney) at the time of influenza viral infection. Overall, 62% (13/21) showed variable degrees of acute allograft rejection, and included 61% (11/18) of lung, and 100% (2/2) of kidney transplant recipients. CONCLUSIONS: Influenza infection is associated with significant morbidity in different groups of SOT recipients. Studies are needed to determine if yearly chemoprophylaxis with antiviral drugs might benefit this patient population.     

Infectious Aortitis in a Liver Transplant Recipient

The development of an abdominal aortic aneurysm secondary to infectious aortitis following solid organ transplantation is a rare event that in the absence of surgical intervention, can lead to uncontrolled sepsis, catastrophic hemorrhage and death. Arterial allografts have been a viable surgical option for the past 30 years, although operative modalities have undergone a paradigm shift in recent years. We describe the first case in the literature of a liver transplant recipient who developed an infrarenal aortic aneurysm secondary to Salmonella bacteraemia, which was treated successfully with aortic allograft transplantation.