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.     

Penicillium marneffei infection in a lung transplant recipient

Penicillium marneffei is a thermally dimorphic fungus that can cause severe opportunistic infections in endemic regions of Southeast Asia, particularly in individuals infected with human immunodeficiency virus‐1, but has rarely been reported in solid organ transplant recipients. Herein, we report the first case, to our knowledge, of P. marneffei infection in a lung transplant recipient, occurring in a 41‐year‐old woman 28 months post lung transplantation, after recent travel to Vietnam. We have reviewed the literature to derive some management principles for this rare infection in this clinical context. The number of P. marneffei infections in transplant recipients may increase, as a result of increasing rates of transplantation and travel to endemic areas.     

Late primary cytomegalovirus infection presenting with acute inflammatory demyelinating polyneuropathy in a heart transplant recipient: a case report and review of the literature

Cytomegalovirus (CMV) infection is well recognized as a cause of morbidity and mortality in heart transplant recipients. Primary CMV infection can occur early post transplant in at‐risk recipients with donor‐derived infection, or any time after transplantation in community‐acquired infection. We describe a unique case of primary CMV infection occurring 14 years after cardiac transplantation. In addition to end‐organ CMV disease, this patient developed a post‐infectious neurologic phenomenon, acute inflammatory demyelinating polyneuropathy. This entity has rarely been reported in the solid organ transplant population.     

Investigation and control of aspergillosis and other filamentous fungal infections in solid organ transplant recipients

Filamentous fungal infections are associated with high morbidity and mortality in solid organ transplant patients, and prevention is warranted whenever possible. An increase in invasive aspergillosis was detected among solid organ transplant recipients in our institution during 1991–92. Rates of Aspergillus infection (18.2%) and infection or colonization (42%) were particularly high among lung transplant recipients. Epidemiologic investigation revealed cases to be both nosocomial and community‐acquired, and preventative efforts were directed at both sources. Environmental controls were implemented in the hospital, and itraconazole prophylaxis was given in the early period after lung transplantation. The rate of Aspergillus infection in solid organ transplant recipients decreased from 9.4% to 1.5%, and mortality associated with this disease decreased from 8.2% to 1.8%. The rate of Aspergillus infection or colonization among lung transplant recipients decreased from 42% to 22.5%; nosocomial Aspergillus infection decreased from 9% to 3.2%. Cases of aspergillosis in lung transplant recipients were more likely to be early infections in the pre‐intervention period. Early mortality in lung transplant recipients decreased from 15% to 3.2%. Two cases of dematiaceous fungal infection were detected, and no further cases occurred after environmental controls. The use of environmental measures that resulted in a decrease in airborne fungal spores, as well as antifungal prophylaxis, was associated with a decrease in aspergillosis and associated mortality in these patients. Ongoing surveillance and continuing intervention is needed for prevention of infection in high‐risk solid organ transplant patients.     

Fatal Fusarium infection manifesting as osteomyelitis following previous treatment with amphotericin B in a multi‐visceral transplant: Case report and review of Fusarium infections in solid organ transplantation

Invasive fusariosis in solid organ transplant is uncommon and usually presents as localized infection with favorable outcomes compared to hematologic malignancies or bone marrow transplants. We report the first case of Fusarium osteomyelitis in a patient following multi‐visceral transplant and review Fusarium in organ transplant recipients and Fusarium bone and joint infections. Our case underscores the importance of early recognition and multidisciplinary approach to treatment and highlights potential failure to eradicate with amphotericin B monotherapy.     

Tick‐borne illness after transplantation: Case and review

Tick‐borne infections in solid organ transplant recipients are an infrequent and difficult diagnostic challenge owing to multiple routes of acquisition and unusual presentations. A 67‐year‐old male recipient of a combined liver and kidney transplant presented with recurrent fevers following surgery. Standard microbiologic workup was non‐diagnostic. Shortness of breath, confusion, lethargy, and hypotension developed along with progressive anemia, requiring multiple blood transfusions. Workup suggested hemolysis and review of the peripheral smear was diagnostic for Babesia microti infection. Tick transmission, transmission via blood products, and/or the transplanted organ were all considered. More extensive questioning revealed a history of intermittent fevers for several months before transplantation. Testing of pre‐transplant blood was positive for B. microti antibodies, suggesting infection prior to transplantation. The delayed diagnosis of babesiosis in this patient highlights the need for a detailed exposure history prior to transplantation, as well as considering the potential for atypical presentations of tick‐borne infections in immune suppressed solid organ recipients. Furthermore, this case illustrates the importance of early Infectious Disease consultation to meet the challenges exhibited by febrile transplant patients. Infectious Diseases physicians are trained to consider, diagnose, and treat tick‐borne infections, contributing to improved clinical outcome.     

A multicenter study of histoplasmosis and blastomycosis after solid organ transplantation

S.A. Grim, L. Proia, R. Miller, M. Alhyraba, A. Costas‐Chavarri, J. Oberholzer, N.M. Clark. A multicenter study of histoplasmosis and blastomycosis after solid organ transplantation.
Transpl Infect Dis 2011. All rights reserved Aim. A review of the clinical presentation, diagnosis, treatment and outcomes of 30 solid organ transplant recipients (SOTRs) with histoplasmosis or blastomycosis from 3 Midwestern academic medical centers. Background. The endemic fungal pathogens, Histoplasma capsulatum and Blastomyces dermatitidis, may cause severe infection in SOTRs. In this report, we describe the clinical presentation, diagnosis, treatment, and outcomes of these endemic fungal infections (EFIs) among SOTRs at 3 academic transplant centers. Methods. A retrospective review was conducted of SOTRs with histoplasmosis or blastomycosis from 3 Midwestern medical centers in the United States. Data collected included demographics, immunosuppression, clinical presentation, method of diagnosis, antifungal treatment, response to therapy, and patient and graft survival. Results. Between 1996 and 2008, 30 transplant recipients with histoplasmosis or blastomycosis were identified, giving a cumulative incidence of infection of 0.50% (30/5989); 73% of the study patients were renal transplant recipients, and the median time to disease onset after transplantation was 10.5 months. The lungs were the most common site of infection (83%), and 60% had disseminated disease. Urine antigen testing was positive in all patients in whom it was performed (23/23). Initial antifungal therapy consisted of amphotericin B in 70%, and 87% received azoles, typically itraconazole (83%). Two patients developed relapsed infection and 7 patients had graft failure after EFI. Overall mortality was 30%, with an attributable mortality of 13%. Conclusions. As in several previous single‐center studies, the incidence of post‐transplant histoplasmosis and blastomycosis was <1%, but often resulted in disseminated infection. In this cohort, EFI was associated with a high rate of allograft loss and overall mortality.     

Bartonella henselae‐mediated disease in solid organ transplant recipients: two pediatric cases and a literature review

Bartonella henselae, the etiologic agent of cat‐scratch disease, causes a well‐defined, self‐limited syndrome of fever and regional lymphadenopathy in immunocompetent hosts. In immunocompromised hosts, however, B. henselae can cause severe disseminated disease and pathologic vasoproliferation known as bacillary angiomatosis (BA) or bacillary peliosis. BA was first recognized in patients infected with human immunodeficiency virus. It has become more frequently recognized in solid organ transplant (SOT) recipients, but reports of pediatric cases remain rare. Our review of the literature revealed only one previously reported case of BA in a pediatric SOT recipient. We herein present 2 pediatric cases, one of which is the first reported case of BA in a pediatric cardiac transplant recipient, to our knowledge. In addition, we review and summarize the literature pertaining to all cases of B. henselae‐mediated disease in SOT recipients.     

Human granulocytic ehrlichiosis in a renal allograft recipient: review of the clinical spectrum of disease in solid organ transplant patients

Background. Ehrlichiosis is a recently described zoonotic infection with two major expressions: human granulocytic ehrlichiosis (HGE) and human monocytic ehrlichiosis (HME). The organisms associated with HGE and HME have been detected in a tick vector in several regions of United States and cases of ehrlichiosis have been reported in the general population. Methods. We report a case of HGE in a renal allograft recipient and review the clinical spectrum of disease in solid organ transplant recipients and the epidemiological basis for risk. Results. Our patient demonstrated the typical epidemiological, clinical and laboratory features of human granulocytic ehrlichiosis and responded to treatment with doxycycline. Conclusions. Human ehrlichiosis should be considered in the differential diagnosis of patients with solid organ transplants, who present with fever and thrombocytopenia. The incidence of ehrlichiosis in the solid organ transplant population is similar to that in the United States general population. As reported in immunocompetent patients, prompt diagnosis and treatment results in the rapid resolution of symptoms in transplanted individuals.     

Necrotizing Microascus tracheobronchitis in a bilateral lung transplant recipient

Invasive fungal infections are a major cause of mortality among solid organ transplant recipients. Scopulariopsis species and their teleomorph Microascus are molds found in soil and decaying organic matter. We report here the case of a woman who underwent bilateral lung transplantation for severe emphysema. On day 25 after transplantation, endobronchial green‐black lesions were detected during routine endoscopy. Endobronchial swabs, biopsies, and bronchoalveolar lavage samples were positive for Microascus cirrosus. This fungal infection developed despite voriconazole given for previous persistent invasive aspergillosis. Treatment consisted of a combination of antifungal medication (voriconazole, terbinafine, amphotericin B, and caspofungin) and endoscopic resection of necrosed bronchial mucosa. A favorable clinical outcome was achieved after 7 weeks of treatment. Seven cases of Scopulariopsis/Microascus infection have been previously described in solid organ transplant recipients. Only two survived after treatment with an antifungal combination therapy including echinocandins, posaconazole, and terbinafine. In immunocompromised patients, infection by Microascus species is a rare but life‐threatening event because of innate resistance to most common antifungal drugs. Our patient was successfully cured by combined therapy including intravenous voriconazole and caspofungin, oral terbinafine, and inhaled voriconazole and amphotericin B administered for 7 weeks in association with iterative endoscopic debridement to reduce fungal inoculum.     

Legionnaires' disease in transplant recipients: A 15‐year retrospective study in a tertiary referral center

Legionnaires' disease (LD) can be fatal among high‐risk transplant recipients. To understand the epidemiology of LD, we reviewed 15‐year longitudinal data from a center in Seattle, Washington that cares for both solid organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients. We identified all laboratory‐confirmed LD and extracted data on species, diagnostic modalities, clinical presentation, management, and outcomes from medical records. Among 32 patients with LD, transplant recipients made up the majority of diagnoses (22, 69%; SOT 10, HCT 12). Approximately 0.8% of transplant recipients who underwent Legionella‐specific testing were positive. Non‐pneumophila Legionella species (LNLP), which are not detected by urinary antigen test, accounted for half the cases, led by Legionella micdadei (32%). The severity and outcome between Legionella pneumophila and LNLP infections were similar (attributed mortality, 36% vs 27%); all LNLP deaths occurred in transplant recipients with L. micdadei. The clinical and radiological features mimicked other opportunistic pathogens; 32% (n=7) were not on empiric treatment at the time of diagnosis. These data add to the emerging literature describing the importance of LD and highlight the need for both routine Legionella testing on transplant recipients with pulmonary findings and empiric Legionella‐active antibiotic therapy.     

Successful treatment with isavuconazole of subcutaneous phaeohyphomycosis in a kidney transplant recipient

Phaeohyphomycosis is a diverse group of uncommon mycotic infections caused by dematiaceous fungi which appears to be increasing in incidence, particularly in transplant recipients. Alternaria is the most frequent isolated genus. Subcutaneous, pulmonary and disseminated disease are the most common sites of Alternaria infection in solid organ transplant recipients. We report the first case, to our knowledge, of a kidney transplant recipient with Alternaria alternata subcutaneous infection who was successfully treated with isavuconazole.     

Acute prostatitis caused by Raoultella planticola in a renal transplant recipient: a novel case

We present a unique case of acute bacterial prostatitis caused by a very rare human pathogen, Raoultella planticola, in a renal allograft recipient 3.5 months post transplantation. Only a few cases of human infection by this pathogen have been reported worldwide. The present study reports the case of a 67‐year‐old man who was admitted to our transplant unit 3.5 months post transplantation with fever, dysuria, suprapubic pain, symptoms and signs of acute prostatitis, and elevated markers of inflammation and prostate‐specific antigen. R. planticola was isolated in the urine culture. The patient was treated with ciprofloxacin (based on the antibiogram) and had a full recovery, with satisfactory renal function. To the best of our knowledge, this is not only the first reported case of R. planticola prostatitis, but also the first report of such an infection in a solid organ transplant recipient or in a patient on immunosuppressive medication.     

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.     

A case of Mycobacterium mucogenicum infection in a liver transplant recipient and a review of the literature

Bacterial, viral, and fungal infections can be devastating in a postoperative liver transplant recipient on multidrug immunosuppressive therapy. Various atypical (nontuberculous mycobacteria [NTM]) mycobacterial infections have been reported in the solid organ transplant population, but to our knowledge, no cases of Mycobacterium mucogenicum infections have been reported. Here, we report a case of a patient with end‐stage liver disease secondary to primary biliary cirrhosis, model for end‐stage liver disease score of 29, who underwent deceased‐donor orthotopic liver transplantation, with her postoperative course complicated by multiple pleural effusions and peritonitis. Despite numerous courses of antibiotics, her condition did not improve. Acid‐fast bacilli cultures grew M. mucogenicum, which was then treated with appropriate antimicrobical therapy. M. mucogenicum, a rapidly growing NTM that can be present in water contamination, should be recognized as a potential source of infection, especially in the immunocompromised population.     

A case of Q fever after liver transplantation

Coxiella burnetii, the causative agent of Q fever, is a zoonosis that causes both acute and chronic disease in humans. Few cases have been reported in solid organ transplant recipients, and this case highlights the need to include Q fever in the differential diagnosis for fever of unknown origin in solid organ transplant hosts.     

Very early‐onset of Cryptococcus neoformans disease following liver transplantation: Report of two cases and a review of the literature

Cryptococcosis is the third most common invasive fungal infection following solid organ transplantation, and mortality is high. Most cases occur late and are due to reactivation of latent infection; however, very early reactivation and donor‐derived transmission can occur. Routine screening pre‐transplant and antifungal prophylaxis for cryptococcosis post‐transplant in solid organ transplantation are not standard practice. We present two cases of very early‐onset Cryptococcus neoformans disease following liver transplantation to highlight the need to consider individualized pre‐transplant screening and be aware that reactivation of Cryptococcosis neoformans can occur in the immediate post‐transplant period.     

Cerebral trypanosomiasis in a renal transplant recipient

Chagas disease is a lifelong, systemic, parasitic infection caused by the protozoan Trypanosoma cruzi. The main form of disease transmission is vector borne, but vertical transmission, such as by organ transplantation from a chronically infected donor, is also possible. The brain tumor‐like form can occur years after infection and has been described in patients with acquired immunodeficiency syndrome, and in a very few cases in transplant recipients. We describe the case of a kidney transplant patient who was human immunodeficiency virus negative and infected with T. cruzi, and developed cerebral trypanosomiasis that was successfully treated with benznidazole at 7 mg/kg/day for 60 days. The risk of Chagas disease transmission should not be underestimated in renal transplant patients, even in non‐endemic areas. Chagas disease can present as a tumor‐like brain lesion, very difficult to differentiate from other opportunistic infectious or neoplastic processes. Frequent monitoring for T. cruzi infection is essential to promptly implement treatment, which, in our patient, proved to be effective and safe.     

Early listeriosis after liver transplantation: Report of two cases

Listeria monocytogenes is a rare cause of potentially lethal infection and sepsis in transplant recipients. Listeriosis is usually described after kidney or bone marrow transplant, and has been less frequently reported after liver transplantation. Here, the authors present two cases of severe Listeria infection occurring within 4 months after complicated liver transplantation in patients still recovering on the ward. The patients were successfully treated by intravenous ampicillin. These cases should remind transplant physicians that listeriosis may develop in liver transplant recipients, that food safety advice should be provided, and that intravenous ampicillin might be an effective treatment for systemic listeriosis in solid organ recipients. It is likely that trimethoprim‐sulfamethoxazole prophylaxis might help prevent early listeriosis after solid organ transplantation.     

Mycobacterium kansasii pericarditis in a kidney transplant recipient: a case report and comprehensive review of the literature

Mycobacterium kansasii is the second most common non‐tuberculous mycobacteria in kidney transplant recipients (KTRs) and has been reported to cause disseminated infection in KTRs. We report the first case to our knowledge of M. kansasii pericarditis after kidney transplantation in a 54‐year‐old man. The patient was admitted with a 2‐month history of intermittent fever and myalgia, treated with oral prednisolone and mycophenolate mofetil prior to admission. Chest computed tomography showed enlarged mediastinal lymph node and small amount of pericardial effusion. Mediastinoscopic biopsy of mediastinal lymph node revealed reactive hyperplasia, without evidence of granuloma, but acid‐fast bacilli stain of pericardial fluid reported positive finding and pericardial fluid culture identified M. kansasii. The patient has been treated successfully with rifabutin‐based combination therapy. All available cases of M. kansasii infection in kidney transplant patients and M. kansasii pericarditis in human immunodeficiency virus‐infected patients are comprehensively reviewed.