Disseminated Mycobacterium gordonae infection in a child with cystic fibrosis

A 4-year-old girl with cystic fibrosis (CF) presented with unrelenting pyrexia commencing shortly after flushing of the central venous catheter (CVC). Mycobacterium gordonae was subsequently isolated from bronchoalveolar lavage, gastric washings, and lung biopsy. While this case most likely represents central line infection by a non-tuberculous mycobacterial (NTM) species, it is difficult to state this definitively in the absence of positive cultures from the CVC. We suggest that infection with NTM should always be considered in CF patients with indwelling devices and unexplained fever.     

Incidence and clinical significance of non-tuberculous mycobacteria isolated from clinical specimens during a 2-y nationwide survey

A 2-y nationwide survey of patients in Denmark with non-tuberculous mycobacteria (NTM) cultures was undertaken. Patients were identified by means of records held at the International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Denmark. The objectives were to identify isolated NTM to species level, to describe the incidence of the various species and to evaluate the clinical significance of pulmonary NTM isolates other than M. avium complex (MAC) and M. gordonae. Identification was performed by means of hybridization or sequencing of 16S rDNA. The clinical significance of pulmonary NTM isolates was evaluated by means of questionnaires concerning patients (was sent to the clinicians!) patients who had NTM isolated for the first time using bacteriologic, radiographic and clinical criteria. A total of 1110 specimens (2.1%) from 525 patients grew NTM. After MAC (n = 198) and M. gordonae (n = 168), most patients had M. abscessus (n = 21), M. malmoense (n = 20) and M. xenopi (n = 17) isolated. Of the pulmonary patients, 50.6% met bacteriologic criteria, 75.3% radiographic criteria and 53.4% clinical criteria for significant infection. Almost half of the pulmonary patients met all the criteria for significant NTM infection that could be evaluated. Clinically significant infection was associated with underlying disease in most patients.     

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.     

Evaluation of 120 mycobacterial strains isolated from clinical specimens to the species level by polymerase chain reaction-restriction enzyme analysis

In this study, a total of 120 mycobacterial strains isolated from clinical specimens in Hacettepe University Hospital Clinical Pathology Laboratories were evaluated by polymerase chain reaction-restriction enzyme analysis (PRA), which analyses the common mycobacterial heat shock protein gene (hsp65). 95 of 120 strains (79.1%) were identified as Mycobacterium tuberculosis and 25 (20.8%) were identified as non-tuberculous mycobacteria (NTM). M. gordonae I and IV were the most common NTM species (3.3% each) followed by M. chelonae (2.5%). Other NTM species isolated were M. gordonae III, M. avium, M. peregrinum (1.6%), M. fortuitum, M. flavescens, M. malmoense and M. mucogenicum (0.8%). Four isolates had PRA patterns that did not match any patterns previously described. The patients who had NTM had underlying diseases; the most frequent clinical diagnosis among these was chronic obstructive pulmonary disease (COPD) and chronic renal failure. AIDS and pulmonary carcinoma were the other underlying diseases detected.     

Nontuberculous atypical mycobacterial infection with progressive pancytopenia in a patient with myelodysplastic syndrome

We describe a patient with myelodysplastic syndrome (MDS) who developed disseminated infection due to nontuberculous mycobacteria (NTM). A 64-year-old man was admitted because of persistent fever that had been unresponsive to antibiotics. Bone marrow aspiration specimens showed myelodysplasia (RA), but the origin of the fever was unclear. Cytopenia worsened to a level that required transfusion of red blood cells and platelets. Repeated bone marrow examination revealed hypoplasia with hemophagocytosis. Several weeks later, photochromogenic NTM was isolated from bone marrow specimens, sputum and broncho-alveolar lavage (BAL) fluid which had been obtained on admission. Antituberculosis treatment with clarithromycin markedly improved the patient's general condition and hematological abnormalities. Three months after resolution of the NTM infection, the peripheral blood monocyte count increased, the fever recurred, and the patient suddenly died of myocardial infarction. Disseminated infection with NTM has gained attention as a frequent complication of AIDS, and NTM can also be one of the pathogens causing disseminated infection in patients with MDS. In the present case, infection with mycobacteria that normally would have been digested by macrophages and would not have caused disseminated infection in a healthy individual, was probably related to the clinical features including high fever, severe pancytopenia and hemophagocytosis.     

Treatment of transplant ureteral stricture with Acucise endoureterotomy: case report and literature review

We report a patient who was diagnosed with end-stage renal disease and who received renal transplantation in her right iliac fossa in 2003. After transplantation, right hydronephrosis was noted on abdominal ultrasonography and right lower ureteral stricture was diagnosed by antegrade pyelography. She received ureter internal stent insertion three times, but hydronephrosis and urinary tract infection recurred after the stent was removed. Therefore, Acucise endoureterotomy was used to treat the recurrent ureteral stricture. The patient was discharged on the second postoperative day and abdominal ultrasonography revealed no hydronephrosis during regular follow-up.     

Mycobacterial species diversity at a general hospital on the island of Crete: first detection of Mycobacterium lentiflavum in Greece

The objective of the present study was to investigate the diversity of mycobacterial isolates in a general hospital in Crete, Greece. 48 positive Lowenstein-Jensen cultures over a 3-y period were analysed by means of AccuProbe and GenoType assays. Non-tuberculous mycobacteria (NTM) comprised the majority of the isolates (56.3%, 27/48) vs 33.3% (16/48) of M. tuberculosis; 10.4% of the isolates could not be classified. Among NTM, M. lentiflavum was the predominant species isolated (9/27) followed by M. kansasii, M. gordonae and M. peregrinum, whereas no M. avium complex isolates were detected. This is the first detection of M. lentiflavum in Greece. The susceptibilities of the M. lentiflavum isolates to an extended panel of antibiotics were determined by the proportions method and the medical files of the 9 patients were reviewed. Three isolates were from urine, which is an unusual site. All strains exhibited multidrug resistance. The patients were adults with immunosuppression or predisposing conditions for NTM infection. Diagnosis of true infection was either not pursued or the patients died shortly after isolation.     

Iatrogenic emphysematous pyelonephritis in a renal transplant patient

Abstract: Emphysematous pyelonephritis (EPN) is a rare condition that typically occurs in patients with diabetes mellitus, urinary tract obstruction, or immunosuppression such as solid organ transplant recipients. It has high mortality and frequently requires nephrectomy to achieve cure, although percutaneous drainage has been reported to be successful in some patients. We report a renal transplant recipient with underlying diabetes mellitus who developed iatrogenic EPN. The patient initially presented with dyspnea and was admitted for cardiac evaluation. There was no evidence of urinary tract infection at the time of admission. The patient developed high‐grade fever 3 days after admission. Despite intravenous (IV) antibiotic therapy, the patient developed acute renal failure requiring hemodialysis. Studies revealed Klebsiella bacteremia and EPN. We believe that urinary tract infection was precipitated by urinary bladder catheterization performed on the day of admission. Despite 2 weeks of IV antibiotic therapy, infection persisted with progressive extension of gas into the perinephric space on repeat imaging. The patient underwent a transplant nephrectomy with subsequent clinical recovery. This case illustrates that antibiotics alone are often inadequate to cure and preserve renal function in EPN despite immediate therapy. Furthermore, this patient underscores the risk of serious infection precipitated by urinary bladder catheterization in immunocompromised patients.     

Rapidly growing non‐tuberculous mycobacterial infection in a renal transplant patient after alemtuzumab induction

Renal transplant recipients are at high risk of developing opportunistic infections particularly in the first 6 months after transplantation. Organisms causing such infections include rapidly growing non‐tuberculous mycobacteria (NTM). Lymphocytes have a central role in combating mycobacterial infections. The use of lymphocyte‐depleting agents, such as alemtuzumab, in the renal transplant population has increased in recent years. A case of multifocal osteomyelitis caused by one of the NTM, Mycobacterium chelonae, in a renal transplant recipient, after alemtuzumab induction, is presented.     

Prolonged norovirus infection after pancreas transplantation: a case report and review of chronic norovirus

Norovirus is a major cause of self‐limited gastroenteritis worldwide. Prevention and treatment are thwarted by rapid viral evolution, and thus supportive care remains the mainstay of therapy. Chronic infection in immunocompromised hosts is increasingly described. We report a case of norovirus infection lasting 2543 days in a pancreas transplant recipient. Serial fecal specimens were obtained, from which a map of genetic relatedness was derived. The clinical course was complicated by renal failure that progressed to end‐stage renal disease. Minimization of immunosuppression was associated with resolution of the infection. Subsequently, the patient experienced a suspected allograft rejection that did not compromise pancreas function. The patient later underwent living‐related renal transplantation without recurrence of enteritis.     

Cellulitis as a manifestation of miliary tuberculosis in a renal transplant recipient

Cutaneous involvement is an unusual presentation of tuberculosis (TB) and is rarely reported in renal transplant recipients. We describe a 37-year-old renal transplant recipient with disseminated Mycobacterium tuberculosis infection that presented as cellulitis. The organism was isolated from tissue and blood cultures. The patient was treated with quadruple anti-TB therapy for 12 months. Anti-TB therapy led to a complete resolution of TB lesions. We also provide a review of the literature on cutaneous TB in renal transplant recipients. Skin TB in renal transplant recipients usually occurs with nontuberculous mycobacteria. The spectrum of the skin lesions can be quite different and can mimic bacterial infections. Mycobacteriosis should always be included in the differential diagnosis of a skin lesion in renal transplant recipients.     

Disseminated infection with Mycobacterium gordonae: report of a case and critical review of the literature.

Mycobacterium gordonae is only rarely a cause of infection despite its ubiquity in the environment. We describe an 11-year-old girl with disseminated infection due to M. gordonae whose course was complicated by renal failure requiring hemodialysis but who recovered after 15 months of chemotherapy. In a literature search we identified 23 additional cases of infection attributed to M. gordonae, with involvement of the lungs (eight), soft tissue (seven), the peritoneal cavity (three), the cornea (one), and with disseminated disease (five patients, including ours). Two patients were infected with human immunodeficiency virus. We assessed the patterns of infection characteristic of each site and the antibiotic sensitivities of the isolates. Adequate documentation of M. gordonae infection (e.g., amount of growth per culture, detection of specific biochemical characteristics, and confirmation of the organism's identity by a reference center) was lacking in many reports. M. gordonae should not automatically be dismissed as a contaminant when isolated from clinical material. Additional studies are required to establish the extent of this organism's pathogenic role.     

High rates of infection and colonization by nontuberculous mycobacteria after allogeneic hematopoietic stem cell transplantation

Nontuberculous mycobacteria (NTM) are essentially ubiquitous and can infect both immunocompetent and immunocompromised hosts. However, NTM infection is surprisingly uncommon in reports from allogeneic hematopoietic stem cell transplant (alloSCT) centers that do not routinely perform allograft T-cell depletion. We reviewed medical records for all adult patients who underwent alloSCT at our center between January 1993 and December 2001. American Thoracic Society and Centers for Disease Control and Prevention guidelines Were used to define definite, probable, and possible NTM infection. Of 571 patients, 36 of 372 (9.7%) T-cell depleted and 14 of 199 (7.0%) conventional alloSCT recipients (P=0.26) had a positive culture for NTM after alloSCT. Of the 50 patients with NTM infection, 16 had definite infection and 34 had probable or possible infection. Rates of NTM infection were 5 to 20-fold higher than rates reported by other centers. Of the 16 definite infections, nine were caused by Mycobacterium haemophilum. Two patients had disseminated M. avium complex (MAC) infection and one had a vascular catheter infected by MAC. Three patients died from complications of NTM infection. Patients with probable or possible NTM infection had markedly different epidemiology, risk factors, site and species of NTM infection, and prognosis than patients with definite NTM infection.     

Acute renal failure due to adenovirus-associated obstructive uropathy and necrotizing tubulointerstitial nephritis in a bone marrow transplant recipient

Management of post-transplant complications caused by severe adenoviral infection remains a major therapeutic challenge. A 17-year-old male who had undergone bone marrow transplantation for the treatment of acute lymphoblastic leukemia developed complete anuria following hemorrhagic cystitis 34 days after the transplant procedure. The computed tomogram scan revealed bilateral hydronephrosis, indicating acute renal failure because of obstructive uropathy. The emergency procedure of percutaneous nephrostomy caused massive bleeding in the left kidney, which eventually required a nephrectomy. Adenovirus-positive severe necrotizing tubulointerstitial nephritis was the histopathological diagnosis. Post-transplant acute renal failure because of hydronephrosis, which could be complicated by adenovirus-induced renal parenchymal disease, is of great concern and may cause significant problems with interventional treatment.     

Donor‐transmitted parvovirus infection in a kidney transplant recipient presenting as pancytopenia and allograft dysfunction

Abstract: Parvovirus B19 is a nonenveloped single‐stranded DNA virus that commonly causes a benign childhood infection typically manifesting as a ‘slapped‐cheek’ rash. In immunodeficient hosts, this infection can cause persistent anemia and occasionally pancytopenia. Recently, direct renal involvement has been reported in renal transplant recipients leading to various forms of glomerulopathy and allograft dysfunction. Most cases are primary infections and are donor transmitted through the transplanted organ. Clinical and virological response to intravenous immunoglobulin (Ig) is usually excellent. We describe a case of donor‐transmitted parvovirus infection in a 23‐year‐old male who received his first cadaver renal transplant. The patient had an uncomplicated postoperative course with immediate graft function. Eight weeks after transplantation, he presented with fever, polyarthralgia, pancytopenia, and allograft dysfunction. Serological studies revealed elevated IgM titers against parvovirus B19. A renal biopsy was performed, which showed no evidence of acute rejection but with moderate degree of tubular damage. Parvovirus B19 viral DNA was detected in the renal tissue via polymerase chain reaction (PCR). The patient received a 10‐day course of intravenous Ig (400 mg/kg/day) with excellent response. His blood count normalized and the allograft improved to baseline function. The incidence of parvovirus infection in renal transplant patients is probably underestimated, because patients are not routinely screened for it and anemia and/or pancytopenia in these patients are often ascribed to immunosuppressive drugs. Because this infection is treatable, we conclude that parvovirus B19 infection should be actively considered in transplant patients presenting with pancytopenia and allograft dysfunction.     

Mycobacterium avium complex infection in kidney transplant patients

Mycobacterium avium complex (MAC) infections have been reported rarely in renal transplant patients. Consequently the clinical course and optimal treatment of these patients are not well understood. We present 3 patients with MAC infections after receiving a renal transplant (2 with generalized and 1 with localized infection). All patients were treated with combination antibiotic therapy and reduction of immunosuppression. One patient experienced clinical control of disease but a mild cellular rejection that was successfully treated with high-dose corticosteroids. One patient died of disseminated MAC infection. The patient with localized infection died of unrelated causes. In summary, MAC infection, although rare in renal transplant patients, may respond to combination antimicrobial therapy and reduction of immunosuppression.     

Occult hepatitis B in renal transplant patients

BACKGROUND: Occult hepatitis B (HB) is characterized by the presence of HBV-DNA in patients who do not have HB surface antigen (HBsAg) detectable in sera, and is frequently described in patients with hepatitis C virus (HCV) infection. These viral liver diseases are common and may have a negative impact on the survival of renal transplant patients, especially if they are both present. In this study we aimed to evaluate the prevalence of occult HB in renal transplant patients either with or without HCV infection. PATIENTS AND METHODS: In a cross-sectional survey 101 HbsAg-negative renal transplant patients were evaluated; 51 were anti-HCV positive. Sera were analyzed for the presence of the S and core genes of the HBV-DNA by a nested polymerase chain reaction technique. Markers of HBV infection and liver function tests were also analyzed. RESULTS: The core gene was identified in 1 HCV-infected patient and 1 anti-HCV-negative patient who also presented the S gene (prevalence: 2% and 1% for each gene, respectively). HCV-infected patients had longer pre-transplant dialysis time (50.8 +/- 34.6 vs. 32.0 +/- 20.9; P < 0.001). Liver function tests were also increased in the HCV-infected group: alanine aminotransferase (P < 0.001), aspartate aminotransferase (P < 0.05), gamma-glutamyl transpeptidase (P<0.02), and alkaline phosphatase (P < 0.04). Multivariate analysis revealed that HCV infection was the only determinant of the altered results of the liver function tests. CONCLUSION: We found that occult HB is a condition present in our population of renal transplant patients and that HCV infection does not seem to be associated with occult HB infection in this setting.     

168例术后伤口龟分枝杆菌感染的治疗与随访观察

目的　总结术后伤口龟分枝杆菌感染的治疗经验。方法　回顾 16 8例非结核分枝杆菌 (NTM)伤口感染患者诊断、治疗及 4年半以来随访情况。根据药敏试验结果 ,抗生素治疗以克拉霉素及丁胺卡那为主 ,疗程 4～ 8个月。其中 10 4例患者在抗生素治疗 1个月后实施根治性病灶切除手术 ,术后继续抗生素治疗 3～ 5个月。结果　抗生素治疗加外科根治性病灶切除 10 4例 ,其中 98例伤口Ⅰ期愈合 ;5 0例用抗生素治疗加伤口换药而治愈 ;8例仅伤口换药 ,未用抗生素治愈 ;5例小儿包皮环切后NTM感染者经抗生素治疗加局部激光治疗而治愈 ;1例疝手术后感染者以丁胺卡那作病灶周围封闭治愈。所有病例经随访 4年半 ,无一例复发。结论　采用敏感抗生素系统治疗加外科根治性病灶切除是NTM伤口感染治疗的重要手段。     

Withdrawal of immunosuppressive agents in the treatment of disseminated coccidioidomycosis

Disseminated coccidioidomycosis is a systemic fungal infection that causes high mortality in the renal transplant patient. Cell-mediated immunity, which appears to be the relevant host defense mechanism, is impaired by the immunosuppressive agents used to prevent allograft rejection. In the case presented, immunosuppressive therapy was stopped as an adjunct to treatment of this infection. The patient has shown evidence of improvement, and his allograft has continued to function nine months after the withdrawal of immunosuppressive therapy and 18 months after the diagnosis. In vitro lymphocyte function studies indicate that the impairment in cell-mediated immunity detected prior to withdrawal of immunosuppressive therapy has persisted, probably accounting for allograft survival. Withdrawal of immunosuppressive therapy may prolong survival in renal transplant patients with disseminated coccidioidomycosis. Additionally, depression in cell-mediated immunity associated with the fungal infection itself may be sufficient to prevent allograft rejection in these patients.     

Tuberculosis isolated to the renal allograft

Immunosuppressed patients after renal transplantation are at increased risk of developing infective complications, including tuberculosis. We describe four renal transplant patients who presented with tuberculosis isolated to the renal allograft. The three patients with adequate follow-up presented with a febrile illness 12–26 months after the transplant. The mycobacterial infection was found in the graft nephrectomy specimen in three patients. One patient with renal allograft dysfunction had a percutaneous biopsy that showed tuberculosis. The latter patient recovered renal allograft function after anti-tuberculous therapy. None of the patients had evidence of tuberculosis elsewhere. We conclude that tuberculosis isolated to the renal allograft, especially in an endemic area, may be the cause of renal dysfunction, and appropriate therapy could lead to salvage of the graft.