Disseminated Mycobacterium genavense with pulmonary nodules in a kidney transplant recipient: case report and review of the literature

J.S. Doggett, L. Strasfeld. Disseminated Mycobacterium genavense with pulmonary nodules in a kidney transplant recipient: case report and review of the literature.
Transpl Infect Dis 2011: 13: 38–43. All rights reserved Abstract: We report a case of disseminated Mycobacterium genavense with pulmonary nodules in a kidney transplant recipient and review the associated literature. Disease caused by M. genavense has been recognized in acquired immunodeficiency syndrome (AIDS) patients since 1990, with subsequent case reports in other immunocompromised host populations. In AIDS patients, pulmonary lesions are an uncommon finding. This is the first report to our knowledge of a human immunodeficiency virus (HIV)‐negative patient with pulmonary nodules as a feature of disseminated M. genavense. Diagnosis of M. genavense is often challenging and frequently requires nucleic acid‐based identification techniques. Because of limitations in culture and drug susceptibility testing, treatment regimens rely on reported clinical experience. This case report and literature review illustrates a successful approach to the diagnosis and treatment of disseminated M. genavense and summarizes the reports of M. genavense infection in HIV‐negative patients.     

Disseminated Mycobacterium kansasii infection with hepatic abscesses in a renal transplant recipient

P. Kaur, J.A. Fishman, J. Misdraji, M.C. Varma, C.N. Kotton. Disseminated Mycobacterium kansasii infection with hepatic abscesses in a renal transplant recipient
Transpl Infect Dis 2011: 13: 531–535. All rights reserved Abstract: Mycobacterium kansasii is the second most frequent cause of non‐tuberculous mycobacterial disease in the United States after Mycobacterium avium complex. While primarily it is a pulmonary disease, extrapulmonary manifestations are common. This case report describes a recent renal transplant recipient with disseminated M. kansasii infection presenting with hepatic abscesses, with discussion of clinical management issues and strategies, and a review of the literature.     

Tuberculous hepatic abscess appearing after liver transplantation in a patient with human immunodeficiency virus and hepatitis B and C virus co‐infection

M. Rodríguez‐Framil, A. Antela, A. Prieto, E. Otero, E. Molina, E. Varo. Tuberculous hepatic abscess appearing after liver transplantation in a patient with human immunodeficiency virus and hepatitis B and C virus co‐infection.
Transpl Infect Dis 2011: 13: 515–519. All rights reserved Abstract: Tuberculosis infection occurs relatively frequently in solid organ transplant recipients, although the occurrence of tuberculous hepatic abscesses is uncommon. Anti‐tuberculous therapy has several concerns in transplant recipients, including an increased risk of cellular rejection and potential hepatotoxicity. We present the case of a human immunodeficiency virus‐infected liver transplant patient who developed multiple tuberculous liver abscesses. Treatment with isoniazid, ethambutol, pyrazinamide, and moxifloxacin was efficacious, well tolerated, and safe.     

Protothecal bursitis after simultaneous kidney/liver transplantation: a case report and review

Solid organ transplantation is an accepted therapy for end‐stage diseases of the kidneys, liver, heart, and lungs. Unfortunately, transplantation is associated with infectious complications. Here, we present a case report of Prototheca wickerhamii olecranon bursitis and review all of the cases in solid organ transplant (SOT) recipients published in the literature to date. In our patient, the infection resolved with surgical therapy and limited antifungal therapy, and no symptoms have recurred over 24 months of follow‐up. A review of the literature suggests that 50% of SOT recipients with Prototheca infection present with disseminated infection, and the overall mortality is 75%. More studies are required to determine the optimal management of protothecosis in this population.     

Nocardia infection in kidney transplant recipients: case report and analysis of 66 published cases

X. Yu, F. Han, J. Wu, Q. He, W. Peng, Y. Wang, H. Huang, H. Li, R. Wang, J. Chen. Nocardia infection in kidney transplant recipients: case report and analysis of 66 published cases.
Transpl Infect Dis 2011: 13: 385–391. All rights reserved Abstract: Nocardiosis is a rare but life‐threatening opportunistic infection, especially in immune compromised patients, including kidney transplant recipients. Primary pulmonary infection is the most common clinical pattern, and can easily result in disseminated Nocardia infection if treatment therapy is not adequate at the beginning. In this article, we report a new case of disseminated nocardiosis (lungs, skin, and pericardium) after renal allograft transplantation. We also review the English literature published from 1980 to 2010 and analyze the clinical characteristics of nocardiosis in kidney transplant recipients.     

Nontuberculous mycobacterial pulmonary infection in renal transplant recipients

T.A. Ho, M. Rommelaere, E. Coche, J.‐C. Yombi, N. Kanaan. Nontuberculous mycobacterial pulmonary infection in renal transplant recipients.
Transpl Infect Dis 2010: 12: 138–142. All rights reserved Abstract: The most common presentations of nontuberculous mycobacterial infections in kidney transplant recipients (KTR) are cutaneous and disseminated diseases. Pleuropulmonary infection not associated with disseminated disease is rare. Its diagnosis can be difficult, requiring a combination of clinical, radiological, and bacteriological criteria. We report on a Mycobacterium avium complex pulmonary infection in a KTR with underlying chronic obstructive pulmonary disease. Chest computed tomography showed an excavated lesion of the right upper lobe, similar to a typical lesion of pulmonary tuberculosis. Evolution was favorable with multiple‐drug therapy including rifampicin, ethambutol, and clarithromycin, along with a slight reduction in immunosuppression. We review the literature and discuss the epidemiology, diagnosis, management, and follow‐up of this uncommon post‐transplant complication.     

Cryptococcal disease presenting as necrotizing cellulitis in transplant recipients

Abstract: Disseminated cryptococcosis uncommonly presents with skin lesions in immunocompromised hosts. Necrotizing fasciitis, necrotizing vasculitis, myositis, or necrotizing soft tissue infection are even more rare presentations. We report 3 cases of cryptococcal necrotizing soft tissue infection, 2 in renal transplant patients, and 1 in a heart transplant patient, and discuss similar cases from the literature. Cryptococcus neoformans should be considered in the differential diagnosis of cellulitis or necrotizing soft tissue infections in immunocompromised patients.     

Two case reports: fatal Absidia corymbifera pulmonary tract infection in the first postoperative phase of a lung transplant patient receiving voriconazole prophylaxis, and transient bronchial Absidia corymbifera colonization in a lung transplant patient

Absidia corymbifera is a rare cause of pulmonary tract infection. There exist only 5 case reports predominantly diagnosed in bone marrow transplant patients. Lung transplant patients are at high risk for invasive fungal infections. Due to A. corymbifera as pathogen, known to be voriconazole resistant, a fatal invasive pulmonary mycosis occurred. In the present case voriconazole prophylaxis failed. A second patient showed a transient colonization of the bronchi. To prevent airborne transmitted invasive pulmonary mycosis in the first postoperative period of lung transplantation the patient should be situated in a room ventilated by HEPA-filtered air. The specific treatment should start very early when first suspicion arises. A review of the literature on pulmonary tract infections induced by Absidia corymbifera is provided.     

Disseminated Acanthamoeba infection in a heart transplant recipient treated successfully with a miltefosine‐containing regimen: Case report and review of the literature

Disseminated acanthamoebiasis is a rare, often fatal, infection most commonly affecting immunocompromised patients. We report a case involving sinuses, skin, and bone in a 60‐year‐old woman 5 months after heart transplantation. She improved with a combination of flucytosine, fluconazole, miltefosine, and decreased immunosuppression. To our knowledge, this is the first case of successfully treated disseminated acanthamoebiasis in a heart transplant recipient and only the second successful use of miltefosine for this infection among solid organ transplant recipients. Acanthamoeba infection should be considered in transplant recipients with evidence of skin, central nervous system, and sinus infections that are unresponsive to antibiotics. Miltefosine may represent an effective component of a multidrug therapeutic regimen for the treatment of this amoebic infection.     

Crusted scabies in a renal transplant recipient treated with daily ivermectin: A case report and literature review

Crusted scabies is a rare disease variant associated with T‐cell dysregulation. Transplant patients are at risk of developing crusted scabies as a consequence of their immunosuppressive regimens. We report a case of crusted scabies presenting with recurrent septicemia in a 65‐year‐old renal transplant recipient, treated with daily ivermectin for 7 days after initial failure of weekly ivermectin dosing. A literature review of crusted scabies in transplant recipients consisting of 19 cases reports was summarized. Pruritus was common, and initial misdiagnosis was frequent. Most were treated with topical therapy, with one‐third receiving ivermectin. Three of seven cases presenting with a concomitant infection died. Crusted scabies is commonly misdiagnosed in transplant recipients owing to its rarity, varied appearance, and different skin distributions. It should be considered in the differential diagnosis of transplant recipients presenting with rash and pruritus, given its association with secondary infection and subsequent mortality.     

Confirmed microsporidial graft infection in a HIV‐negative renal transplant recipient: A case report and review of the literature

Microsporidia are intracellular organisms most commonly known to cause opportunistic infection in patients with human immunodeficiency virus (HIV). There have been several case reports of infection in solid organ and bone marrow transplant recipients. Here, we report a case of a non‐HIV–infected renal transplant patient with microsporidiosis of the renal tract associated with acute graft dysfunction. We also review the literature of 12 previously reported cases of microsporidiosis in patients with renal transplants who had described graft involvement. We review the pattern of illness as well as the common renal biopsy features when microsporidial infection is associated with renal graft infection.     

West Nile virus encephalitis acquired via liver transplantation and clinical response to intravenous immunoglobulin: case report and review of the literature

C. Rhee, E.F. Eaton, W. Concepcion, B.G. Blackburn. West Nile virus encephalitis acquired via liver transplantation and clinical response to intravenous immunoglobulin: case report and review of the literature.
Transpl Infect Dis 2011: 13: 312–317. All rights reserved Abstract: A patient developed West Nile virus (WNV) encephalitis 2 weeks after receiving a liver transplant and recovered fully, following treatment with intravenous immunoglobulin (IVIg). Laboratory testing documented transmission from the organ donor. Clinicians should be suspicious for organ‐transmitted WNV in any post‐transplant patient who develops fever and neurological symptoms. We review previous cases of organ‐transmitted WNV, the use of IVIg for WNV encephalitis, and the issue of organ donor screening.     

Disseminated nocardiosis masking an atypical zygomycosis presentation in a kidney transplant recipient

E. Colón‐Santos, M. González‐Ramos, J. Bertrán‐Pasarell, G. Rodríguez‐Vega, M. Almira‐Suarez, R. Vélez‐Rosario. Disseminated nocardiosis masking an atypical zygomycosis presentation in a kidney transplant recipient.
Transpl Infect Dis 2011: 13: 380–384. All rights reserved Abstract: Immunosuppressive agents increase the vulnerability of solid organ transplant patients to opportunistic infections. An atypical clinical presentation of a bacterial and fungal co‐infection makes diagnosis and treatment even more challenging in this population. A 54‐year‐old hypertensive woman underwent a cadaveric kidney transplant after years on hemodialysis. Her treatment included mycophenolate, tacrolimus, and prednisone. By post‐transplant week 8, she had pneumonia followed by progressive visual changes and seizures. Diagnostic work‐up, consisting of magnetic resonance imaging of the brain and chest x‐ray, showed several cerebral ring‐enhancing lesions, and a pulmonary cavitary lesion. Disseminated nocardiosis was suspected and therapy was started. Skin biopsy was taken from a nodular lesion and culture confirmed Nocardia species infection. During hospitalization, neurological deficit persisted with worsening of brain lesions. She underwent excision of a brain abscess and the final pathologic report showed mucormycosis, revealing the patient's co‐infection by 2 different pathogens. After therapy with liposomal amphotericin B and posaconazole, she has remained stable for more than 1 year. Disseminated nocardiosis masked and delayed the diagnosis and treatment of a more aggressive and worrisome organism. Mucormycosis, as a non‐fatal isolated brain abscess without rhinal involvement, is an atypical presentation, and only a few cases have been reported.     

Resolution of insulin-requiring diabetes in a liver transplant recipient after treatment of a pheochromocytoma: case report and review of literature

The aim of this paper was to report the case of type 2 diabetes and significant insulin resistance that improved dramatically after removal of a pheochromocytoma in a liver transplant recipient , and to provide a review of the relevant literature. We describe the clinical presentation, diagnostic results and management of the patient. In addition, we performed a PubMed search for related English language articles, to provide an overview of the pertinent literature. A 53 year old woman with a history of an orthotopic liver transplantation and insulin-requiring type 2 diabetes was admitted to the hospital with fever, diaphoresis, tachycardia and hypertension. A pheochromocytoma was diagnosed and removed. The patient subsequently developed hypoglycemia and required no further insulin therapy. Pheochromocytomas have been described to lead to hyperglycemia and diabetes, due to the suppression of insulin release and increased insulin resistance. Furthermore, a review of the literature revealed only 3 other reported cases of pheochromocytomas in organ transplant recipients. None of these pheochromocytomas were believed to have occurred de novo after transplantation. This is the first report of a pheochromocytoma in a liver transplant recipient and possibly the first case of a de novo pheochromocytoma in any organ transplant recipient. Moreover, this case showcases pheochromocytomas as a rare cause of diabetes mellitus.     

Vancomycin‐resistant enterococcal meningitis in an autologous stem cell transplant recipient cured with linezolid

Enterococci are an unusual cause of meningitis, with most cases reported in the literature preceded by neurosurgical procedures. Spread to the meninges from an enterococcal bloodstream infection is even more rare, with few cases reported in the literature. We report the first documented case, to our knowledge, of successful treatment of vancomycin‐resistant enterococcal (VRE) meningitis with linezolid therapy in an immunosuppressed hematopoietic stem cell transplant recipient. Our case highlights the success of monotherapy with linezolid for VRE meningitis. A literature review is provided, which reveals that there is little evidenced‐based data on the optimal therapy for VRE meningitis.     

Disseminated Mycobacterium haemophilum skeletal disease in a patient with interferon‐gamma deficiency

Disseminated non‐tuberculous mycobacterial (NTM) infection is rare in immunocompetent adults. Anti‐interferon‐gamma (IFN‐γ) autoantibodies have recently been associated with NTM infections, particularly in patients of Asian ethnicity. We describe a case of disseminated Mycobacterium haemophilum skeletal infection due to anti IFN‐γ autoantibodies in a 71‐year‐old Cambodian man. He responded to a combination of anti‐mycobacterial antibiotics without requirement for immunomodulator therapy. Testing for acquired IFN‐γ deficiency due to IFN‐γ autoantibodies should be considered when standard tests for immunodeficiency are negative in patients with unusual or severe opportunistic infections, including NTM.     

Prosthetic joint infection with Mycobacterium avium complex in a solid organ transplant recipient

Abstract: Prosthetic joint infection (PJI) occurs with significant morbidity and health care expenditure. Transplant recipients on immunosuppressive medications are at increased risk for infections caused by less common organisms at unusual sites. Here we report a case of isolated PJI with Mycobacterium avium complex (MAC) in an immunosuppressed failed kidney transplant recipient and review the literature on this unique infection. We discuss the likely pathogenesis of PJI with MAC including the role of biofilm formation by non‐tuberculous mycobacteria. The possible role of cytokine milieu alteration by immunosuppressive therapy, particularly the reduction in interferon‐gamma levels, as a predisposing factor for non‐tuberculous mycobacterial infections in transplant recipients is explored. Lastly, we review the role of immune cell function assay in predicting the susceptibility to infection in our patient specifically and in solid organ transplant recipients in general.     

Spinal tuberculosis in post‐liver transplantation patients: case reports

X.F. Lou, R.H. Wu, S.Z. Xu, X.J. Lin. Spinal tuberculosis in post‐liver transplantation patients: case reports.
Transpl Infect Dis 2010: 12: 132–137. All rights reserved Abstract: Recipients of solid organ transplantation are, because of immunosuppressive therapy, disposed to opportunistic infections including tuberculosis (TB). Spinal TB is a rare complication after transplantation but it is serious with high mortality. We report 3 cases of spinal TB in Chinese recipients of orthotopic liver transplant whose first complaint was back pain. These 3 cases were diagnosed by magnetic resonance imaging and percutaneous biopsy. After treatment with isoniazid, rifampicin, streptomycin, and ethambutol for >1 year, symptoms of 2 patients improved noticeably, but 1 patient died of liver failure and severe mixed pulmonary infection. Diagnosis and treatment regimens of spinal TB are discussed.     

Mycobacterium avium‐intracellulare‐associated acute interstitial nephritis: a rare cause of renal allograft dysfunction

Abstract: Nontuberculous mycobacterium (NTM) infections are unusual in the renal transplant population. We present a case of disseminated Mycobacterium avium‐intracellulare in a renal transplant recipient who was negative for human immunodeficiency virus infection. Our patient developed renal allograft dysfunction in the setting of disseminated disease and reduced immunosuppression. Transplant biopsy showed acute interstitial nephritis with granulomas and acid‐fast bacilli. Acute renal failure resolved completely with further reductions in immunosuppression and anti‐mycobacterial therapy. Our patient demonstrates the challenges in diagnosis and treatment of this rare infectious complication.     

Late aspergilloma of a renal allograft without need for operative management: a case report and review of the literature

Aspergillus infection localized to the renal allograft is a rare and potentially life‐threatening infection and typically requires a combination of operative and medical management. We report the case of a renal allograft aspergilloma in a renal transplant patient presenting 2 years post transplant, successfully managed non‐surgically. To our knowledge, this is the first report of a patient presenting with an allograft aspergilloma so long after transplantation and being successfully managed with antifungal therapy alone.