Adenoviral nephritis in a renal transplant recipient: Case report and literature review

Adenovirus (AdV) infections in transplant recipients may cause invasive disease. We present a case of granulomatous interstitial nephritis secondary to AdV infection in a renal transplant recipient that was initially interpreted as acute graft rejection on histopathology. Specific testing based on clinical suspicion, however, aided in making an accurate diagnosis. We present a retrospective review of all cases of AdV infection in renal transplant recipients to date, and analyze outcomes based on different treatment modalities for this disease.     

Endovascular Mycobacterium abscessus infection in a heart transplant recipient: a case report and review of the literature

Nontuberculous mycobacteria are ubiquitous in the environment. Although rarely a cause of infection in immunocompetent individuals, increased risk and severity of infection are seen in patients who are immunocompromised, such as those with solid organ transplants. In this report, we describe the first case of disseminated endovascular Mycobacterium abscessus in a heart transplant recipient. A review of the literature regarding this infection in heart transplant recipients and its therapeutic options and concerns are summarized.     

Cutaneous bacillary angiomatosis in renal transplant recipients: report of three new cases and literature review

Bacillary angiomatosis (BA) is a rare vasculoproliferative disorder due to Bartonella henselae (BH) or Bartonella quintana. It can involve many organs, including the skin, and has been mainly reported in patients with acquired immunodeficiency syndrome. In organ transplant recipients (OTR), this disorder remains misdiagnosed and therapeutic guidelines are nonexistent. We report 3 cases of BA with skin involvement in OTR and review similar cases from the literature. BA manifests on the skin with violaceous lesions mimicking Kaposi sarcoma, and is associated with fever, lymphadenopathy, and liver, spleen, or lung nodules. Bartonellosis infections in OTR are due to BH, the agent causing cat‐scratch disease (CSD), but BA comprises histologically a prominent vascular proliferation, which is usually lacking in CSD. Cultures and serologic tests are poorly reliable for the diagnosis, which relies on demonstration of BH within the lesions. A history of cat exposure exists in most cases and pediatric OTR are at higher risk. Prevention consists of regular use of a flea‐control product in cats and prompt cleaning of scratches. Our cases highlight several original features of this rare condition, which could potentially improve the management of BA in OTR.     

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.     

Disseminated microsporidiosis in a renal transplant recipient: case report and review of the literature

Microsporidia are opportunistic pathogens that usually cause a limited disease in the gastrointestinal tract. Occasionally, they can cause disseminated disease. In solid organ transplant recipients, disseminated disease has been reported only rarely. We describe a 68‐year‐old woman who presented with fever, cough, and acute kidney injury 6 months after kidney transplantation. Dissemination was confirmed by identification of microsporidial spores in urine and bronchoalveolar lavage fluid. Polymerase chain reaction analysis identified the species as Encephalitozoon cuniculi.     

Leprosy in a renal transplant recipient: review of the literature

Abstract: A 52‐year‐old male underwent living‐related renal transplantation. He received prednisolone, azathioprine, and cyclosporine as immunosuppression protocol. Eleven years after transplantation, he developed pyrexia with multiple nodular lesions on his limbs, trunk, and face. Skin biopsy and smears showed the presence of numerous acid‐fast bacilli with 5% sulfuric acid indicative of Mycobacterium leprae. He was initiated on multidrug therapy (MDT) including dapsone, clofazimine, and rifampicin. After 2 years of MDT, he developed new multiple erythematous, tender subcutaneous nodules in crops over his face and upper limbs. Skin biopsies and histopathological examination confirmed the diagnosis of type 2 lepra reaction or erythema nodosa leprosum. He was managed with an increase in the dose of prednisolone and thalidomide. He was continued on MDT.     

Cryptococcus neoformans pericarditis in a lung transplant recipient: Case report,literature review and pearls

A 68‐year‐old man presented for outpatient evaluation of dyspnea and new‐onset atrial fibrillation 9 months after undergoing bilateral lung transplantation. Echocardiography prior to cardioversion raised concern for tamponade. Therapeutic pericardiocentesis returned fluid containing 1875 wbc/mcl (68% pmn) and yielded Cryptococcus neoformans in culture. Cryptococcal antigen was detected in serum at a titer of 1:20. Cerebrospinal (CSF) fluid was without evidence of inflammation and without detectable cryptococcal antigen. There was no radiographic evidence of pulmonary cryptococcosis. Cultures of blood and CSF were without growth. Liposomal amphotericin B (3 mg/kg/day) was administered for 15 days. Oral fluconazole was added on day seven of amphotericin, and the patient was discharged to home 3 days later. Daily dosages of prednisone (10 mg), mycophenolate (500 mg), and tacrolimus (3 mg) at discharge were the same as at hospital admission. He was readmitted 12 days later with dyspnea and with re‐accumulation and loculation of pericardial fluid. A pericardial window was created. Pericardial fluid contained 722 wbc/mcl (35% pmn); Cryptococcus was not identified on direct examinations or cultures of pericardial fluid or tissue. Cryptococcus antigen was present in serum at 1:160. Liposomal amphotericin B was resumed and continued for 2 weeks followed by resumption of fluconazole. Mycophenolate was stopped. Prednisone and tacrolimus were continued. Restrictive pericarditis was evident 3 weeks after window creation. Colchicine was initiated, prednisone increased to 15 mg daily and pericardiectomy planned. We aim to raise awareness to Cryptococcus as a potential etiology for pericarditis in solid organ transplant recipients.     

Multifocal spinal and extra-spinal Mycobacterium chelonae osteomyelitis in a renal transplant recipient

Only localized cases of Mycobacterium chelonae osteomyelitis have been reported. In this article, a 55-year-old immunosuppressed man with M. chelonae osteomyelitis and multiple spinal and extra-spinal involvement is presented. The patient had nodule-pustular skin lesions, spondylodiscitis at multiple levels, and osteolytic lesions at extra-spinal locations. Biopsy and cultures of the osseous lesions showed M. chelonae osteomyelitis. The patient started antimycobacterial chemotherapy with ciprofloxacin and clarithromycin. Progressive cervical kyphosis associated with anterior wedged deformity of the C5 vertebra and posterior C5-C6 spondylolisthesis resulted in compression of the spinal cord and neurological impairment. The patient underwent anterior decompression and C4-C6 arthrodesis using a titanium mesh cage and cervical plate. About 15 months after the initiation of chemotherapy and 5 months after surgery, the patient was pain free, with significant improvement of his neurological function. In the presence of immunosuppression, the physician should be alert for unusual or opportunistic pathogens of osteomyelitis. Long-term antimicrobial chemotherapy and surgical intervention is the cornerstone of successful treatment of multifocal bone M. chelonae infection.     

Unusual presentation of Ramsay Hunt syndrome in renal transplant patients: case report and literature review

Abstract: Ramsay Hunt syndrome (RHS) is a rare manifestation of varicella zoster virus (VZV) infection that accounts for around 12% of all cases of facial paralysis. Although it is more common in immunosuppressed individuals, it has not been yet reported in kidney transplant recipients. We describe the case of a 41-year-old man with a history of renal transplant for whom the diagnosis and treatment of RHS were delayed owing to an unusual presentation. We also review the literature on VZV infection in renal transplant patients.     

Severe acute Q fever pneumonia complicated by presumed persistent localized Q fever endocarditis in a renal transplant recipient: A case report and review of the literature

Q fever in solid organ transplant (SOT) recipients is rarely described in the medical literature. We present a case of severe acute Q fever pneumonia that evolved into persistent localized Q fever endocarditis in a renal transplant recipient.     

Phaeohyphomycosis due to Exophiala infections in solid organ transplant recipients: Case report and literature review

This case report and literature review underscores the cutaneous presentations of phaeohyphomycosis in the solid organ transplant population. Increased cognizance with prompt identification is critical. The therapy and clinical outcomes of phaeohyphomycosis, caused by the Exophiala genus, in the solid organ transplant population, is analyzed to examine optimal care. This review highlights the inherent difficulties in providing the appropriate duration of antifungal therapy to avoid relapsing infections in immunosuppressed patients.     

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.     

Emphysematous pyelonephritis in renal allograft related to antibody‐mediated rejection: A case report and literature review

Emphysematous pyelonephritis (EPN) is a rare condition which can rapidly progress to sepsis and multiple organ failure with high mortality. We experienced a rare case of EPN in a renal allograft related to antibody‐mediated rejection (AMR). The patient received a deceased donor kidney transplant due to end‐stage renal disease secondary to diabetes mellitus. Cross‐match test was negative but she had remote history of anti‐HLA‐A2 antibody corresponding with the donor HLA. Surgery concluded without any major events. Anti‐thymoglobulin was given perioperatively for induction. She was compliant with her immunosuppressive medications making urine of 2 L/d with serum creatinine of 1.9 mg/dL at discharge on post‐operative day (POD) 6. She did well until POD 14 when she presented to the clinic with features of sepsis, pain over the transplanted kidney area and decline in urine volume with elevated serum creatinine. CT revealed extensive gas throughout the transplanted kidney. Renal scan revealed non‐functional transplant kidney with no arterial flow. Based on these findings, a decision to perform transplant nephrectomy was made. At laparotomy, the kidney was completely necrotic. Pathology showed non‐viable kidney parenchyma with the tubules lacking neutrophilic casts suggestive of ischemic necrosis. Donor‐specific antibody (DSA) returned positive with high intensity anti‐HLA‐A2 antibody. This is the first case of early EPN in allograft considered to have occurred as a result of thrombotic ischemia secondary to AMR. This case suggests consideration of perioperative anti‐B‐cell and/or anti‐plasma cell therapies for historical DSA and strict post‐operative follow‐up in immunologically high‐risk recipients to detect early signs of rejection and avoid deleterious outcomes.     

Human herpesvirus 6B encephalitis in a liver transplant recipient: A case report and review of the literature

Human herpesvirus 6B (HHV‐6B) encephalitis in a liver transplant recipient is rarely reported. In this report, we presented a case of HHV‐6B encephalitis in a liver transplant recipient and reviewed the relevant literature. A 56‐year‐old man was admitted to the intensive care unit (ICU) with an acute headache and intermittent convulsion 17 days after liver transplantation. Next‐generation sequencing (NGS) of the cerebrospinal fluid (CSF) revealed 30691 sequence reads of HHV‐6B and real‐time polymerase chain reaction (real‐time PCR) of the CSF detected HHV‐6B DNA at 12 000 copies/mL, so the patient was diagnosed with HHV‐6B encephalitis and received ganciclovir treatment promptly. The condition of the patient improved well and returned to the general ward with no neurologic deficits. This case indicated that adequate awareness, early diagnosis, and timely treatment are crucial to a good prognosis of HHV‐6B encephalitis after liver transplantation.     

Small bowel obstruction caused by inflammatory cytomegalovirus tumor in a renal transplant recipient: report of a rare case and review of the literature

Cytomegalovirus (CMV) infection in renal transplant recipients can present as asymptomatic viremia or CMV syndrome or, in more severe cases, as tissue‐invasive disease. CMV enteritis, a common manifestation of CMV invasive disease, usually presents with fever, abdominal pain, anorexia, nausea, and diarrhea, and can be rarely complicated by colon perforation, hemorrhage, or megacolon. CMV infection occurs primarily in the first 6 months post transplantation, when immunosuppression is more intense. We describe the case of a female renal transplant recipient with small bowel obstruction caused by CMV disease 7 years post renal transplantation. The patient presented with diarrhea and abdominal pain. Because of elevated CMV viral load, she was initially treated with antiviral therapy with transient response. Endoscopy and imaging tests showed obstruction of the terminal ileum and, subsequently, the patient underwent exploratory laparotomy when a right hemicolectomy was performed. Biopsy results confirmed the diagnosis of CMV enteritis. Epidemiologic characteristics, clinical presentation, diagnostic workup, therapeutic options, and morbidity–mortality rates of CMV infection/disease, in renal transplant recipients, are reviewed.     

Recovery from Talaromyces marneffei involving the kidney in a renal transplant recipient: A case report and literature review

Talaromyces marneffei is an emerging opportunistic infection among immunocompromised patients. We observe the first native case of disseminated T. marneffei involving the kidney in a renal transplant recipient in mainland China. We describe the comprehensive clinical course, and ultrasound imaging of renal transplant biopsy, pathologic images, and electron microscopy observation of the biopsy specimen, highlighting the relevance of biopsy findings and the blood culture. We also focus on the treatment and good outcome of the patient. Then we review the literature and show the additional 10 reported cases of T. marneffei in renal transplant recipients. In addition, we discuss the new methods of rapid diagnosis of T. marneffei. In brief, timely diagnosis and proper treatment of T. marneffei infection is important in renal transplant recipients.     

Infective endocarditis in the setting of renal transplantation: Case report and review of the literature

The potent immunosuppressive drugs used by transplant recipients place them at risk of infections. Data on infective endocarditis (IE) in the setting of renal transplantation (RT) are sparse. We describe a 36‐year‐old woman referred to a tertiary medical center for evaluation of elevated creatinine levels 1 month after a second RT. Work‐up revealed the presence of all four of Duke's criteria: fever, persistent bacteremia, new‐onset tricuspid regurgitation, and masses suspected to be vegetation attached to the tricuspid annulus. Symptoms resolved with antibiotic treatment and fluids. Fluorodeoxyglucose‐positron emission tomography/computed tomography (FDG‐PET/CT) revealed hypermetabolic absorption in the femoral vascular graft that had been used for hemodialysis prior to transplantation. The graft was removed by open surgery, and the patient was discharged home in good condition with continued antibiotic treatment. Review of the literature yielded 73 previously reported cases of IE in renal transplant recipients. Several differences were noted from IE in the general population: lower male predominance, younger age (<60 years), absence in most cases of a preexisting structural cardiac anomaly, and more variable causative pathogens. Our case also highlights the importance of FDG‐PET/CT for detecting the source of IE and alerts clinicians to the sometimes unexpected course of the disease in renal transplant recipients.     

Leprosy in transplant recipients: report of a case after liver transplantation and review of the literature

M.A.B. Trindade, M. de Lourdes Palermo, C. Pagliari, N. Valente, B. Naafs, P.C.B. Massarollo, L.A.C. D'Albuquerque, G. Benard. Leprosy in transplant recipients: report of a case after liver transplantation and review of the literature.
Transpl Infect Dis 2011: 13: 63–69. All rights reserved Abstract: Leprosy still is an important public health problem in several parts of the world including Brazil. Unlike the diseases caused by other mycobacteria, the incidence and clinical presentation of leprosy seems little affected in immunosuppressed patients. We report the first case, to our knowledge, of a liver transplant patient who developed multi‐bacillary leprosy. The patient presented with papules and infiltrated plaques with loss of sensation suggestive of leprosy 3.5 years after living‐related liver transplantation for autoimmune hepatitis. A skin biopsy showing non‐caseating macrophagic granulomas, neuritis, and intact acid‐fast bacilli on Fite‐Faraco stain, confirmed the diagnosis of borderline lepromatous leprosy. The donor of the liver did not show any evidence of leprosy. During follow‐up, the patient presented 2 episodes of upgrading leprosy type I reactions, 1 mild before leprosy treatment, and 1 moderate 3 months after receiving standard multi‐drug treatment (rifampicin, clofazimine, and dapsone). These reactions were accompanied by increase in liver function tests, especially of canalicular enzymes. This reaction occurred despite the patient's triple immunosuppression regimen. The moderate reaction was successfully treated with further immunosuppression (prednisone, 0.5 mg/kg). Currently, the patient is asymptomatic, off leprosy medication, with routine liver transplant follow‐up. The dilemmas in diagnosis and management of such a case are discussed and the literature on leprosy in transplant recipients is reviewed.