Spinal gout in a renal transplant patient: a case report and literature review

BACKGROUND: Gout in the axial spine is rare. We present a case report on a renal transplant patient who developed fever and acute back pain at the L5 through S1 level secondary to sodium urate deposits. We review the literature on this rare disease and propose a management algorithm based on a resulting analysis. CASE DESCRIPTION: A 37-year-old man with a history of gout and a renal transplant for IgA nephropathy presented with acute back pain and fever without evidence of neurological deficits. Magnetic resonance imaging revealed a uniformly contrast-enhancing infiltrative process involving the right pedicle, lamina, and inferior facet of the L5 vertebra. Computed tomography-guided needle biopsy revealed a friable white tissue consistent with sodium urate crystals. Conservative treatment with steroids and narcotics was used with good symptomatic relief. CONCLUSION: Although few cases of gout involving the spine have been reported, its prevalence is likely grossly underestimated. Most patients have a history of gout and have elevated levels of serum urate level on presentation. The disease most commonly involves the lumbar spine. Patients usually have neurological deficits on presentation, and surgical decompression produces favorable outcomes. However, conservative medical management is appropriate for those with back pain only. Aggressive control of hyperuricemia is essential regardless of the method of treatment.     

Cerebellar abscess due to Rhodococcus equi in an immunocompetent patient: case report and literature review

Rhodococcus equi (R. equi) is a facultative, intracellular, nonmotile, non-spore-forming, gram-positive coccobacillus, primarily causes zoonotic infections that affect grazing animals, mainly horses and foals and is a rare opportunistic pathogen found in severely compromised patients, and most commonly in recent years, in human immunodeficiency virus (HIV)-infected persons. Early cases, most in patients receiving immunosuppressant therapy, were more likely to be successfully treated with antimicrobial agents than cases in AIDS patients, it is emerging as an important pathogen in patients with cellular immune deficiency. We report a case of an immunocompetent 37 year-old patient with cerebellar abscess location that seems to be the only thin to today described in the literature. R. equi is a facultative, intracellular, nonmotile, non-spore-forming, gram-positive coccobacillus, primarily causes zoonotic infections that affect grazing animals, mainly horses and foals and is a rare opportunistic pathogen found in severely compromised patients, and most commonly in recent years, in human immunodeficiency virus (HIV)-infected persons. Early cases, most in patients receiving immunosuppressant therapy, were more likely to be successfully treated with antimicrobial agents than cases in AIDS patients, it is emerging as an important pathogen in patients with cellular immune deficiency. We report a case of an immunocompetent 37 year-old patient with cerebellar abscess location that seems to be the only thin to today described in the literature.     

Rhodococcus equi pneumonia in a renal transplant patient: a case report and review of literature

Immunocompromised patients are susceptible to many pathogens, including those that are predominantly problems in veterinary medicine. We report a case of a 42-yr-old white male who presented 19 months post-cadaveric renal transplant (for IgA nephropathy) with a 5 d history of nausea, vomiting, abdominal cramping and diarrhea. Admission chest X-ray revealed a suspicious mass lesion in the left lower lobe. Computed tomography (CT) guided biopsy of the lesion showed a large zone of CD68 +ve histiocytes in a non-caseating granuloma. Gram stain revealed multiple gram-positive rods within the histiocytes, which were eventually identified as R. equi. After 4 months of therapy with fluoroquinolones (Avelox) and Azithromycin a repeat CT showed complete resolution of the lesion. We reviewed the literature with special focus on the clinical features, challenges in diagnosis, and treatment of this rare infection (especially in the transplant patients who are also on immunosuppressive therapy).     

Extracorporeal shock wave lithotripsy in the renal transplant patient: a case report and review of literature

Renal allograft lithiasis is a rare complication of renal transplantation, which in the past has required various invasive procedures for adequate stone fragmentation and dissolution. Noninvasive techniques such as extracorporeal shock wave lithotripsy (ESWL) can now be extended to the renal transplant patient. Five cases have been previously reported in which ESWL was used effectively for dissolution of renal allograft calculi. We now report a 6th case in which a calculus, initially identified 2 weeks after renal transplantation, was effectively fragmented 3 years later using ESWL. Based on our experience and the reviewed composite experience in the literature, ESWL is a safe therapy for renal allograft calculi.     

De novo membranoproliferative glomerulonephritis III in a renal transplant patient: case report and review of the literature

Idiopathic membranoproliferative glomerulonephritis (MPGN) is a rare cause of renal failure with a cumulative incidence of 0.3% of all ESRD and 4% of all primary glomerulonephritis for types I and II. Membranoproliferative glomerulonephritis type III is more uncommon and idiopathic de novo MPGN III in a renal transplant patient has not been reported. We present the case of a 57-year old white female patient with a diagnosis of lithium toxicity as cause of end stage renal disease (ESRD) who developed MPGN III in her allograft 6 years after a renal transplant. Despite treatment, she progressed to ESRD within four and a half years from the time of diagnosis.     

Angiosarcoma arising in an arteriovenous fistula site in a renal transplant patient: a case report and literature review

Angiosarcoma in the setting of immunosuppressed renal transplant recipients is exceedingly rare. In this report, we describe the occurrence of angiosarcoma arising at an arteriovenous fistula site of a 39-year-old renal transplant recipient that clinically mimicked a thrombosed aneurysm. These tumors are histologically high-grade and clinically aggressive malignancies. They have a predilection for arteriovenous fistula sites. The literature on this uncommon entity is reviewed and possible histogenesis is discussed.     

Acute thrombosis of the renal transplant artery: a case report and review of the literature

Acute thrombosis of the renal transplant artery is a known but unusual complication of renal transplantation usually occurring in the first month. Reported here is a case of acute renal artery thrombosis in a well functioning long-term renal allograft in which there was clear angiographic evidence of a normal renal artery two years earlier.     

Double endocrine neoplasia in a renal transplant recipient: case report and review of the literature

Introduction

The incidence of cancer compared for age groups is 3-4 times higher in transplant recipients than the general population. The increased risk is related to immunosuppressive therapy as well as the use of increasingly older donors and recipients. Although cardiovascular disease with a functioning transplant is the leading cause of death (47%), cancer mortality is significant especially among older patients. However, the most frequent posttransplantation cancers relate to hemolymphopoietic organs and skin, whereas the occurrence of solid tumors elsewhere is rare. Herein we have described a rare case of synchronous double malignancy of endocrine organs (thyroid-adrenal) in a young woman who underwent renal transplantation.

Case Report

A 37-year-old woman with end-stage renal disease for 18 years underwent transplantation when she was 30 years old with a 17-year-old standard cadaveric donor receiving immunosuppressive therapy with mycophenolate mofetil, cyclosporine, and steroids. Follow-up demonstrated good indices of renal function with negative tumor pathology at 79 months when, at an annual ultrasound monitoring, we found a lesion in the right lobe of the thyroid and left adrenal neoplasm of dubious interpretation. The cytology for the thyroid was highly suspicious of papillary carcinoma, whereas the histological examination after surgery diagnosed a thyroid multifocal papillary microcarcinoma (mpT1NxMx) and an oxyphil cell adrenocortical carcinoma (pT2, N0).

Results

Six months after total thyroidectomy with central lymphadenectomy and left kidney and adrenal gland removal the patient showed no evidence of recurrent lesions and stable graft function.

Conclusions

The rare occurrence of solid tumors after transplantation has no known etiopathogenetic relation. Despite the young age of the patient and the double neoplasm that could have produced an unfavorable outcome for the patient and the graft, careful follow-up for tumor pathologies and multidisciplinary management achieved an early diagnosis of both tumors with a surgical eradication without adjuvant therapy, preserving the life of the patient and the function of the graft.     

Epidural abscess: case report and literature review

OBJECTIVE: To report a case of spinal epidural abscess complicating epidural analgesia, and to heighten awareness of the condition and the importance of early recognition and treatment. CASE REPORT: A 72-year-old woman underwent adrenalectomy and groin dissection for recurrent malignant melanoma under combined general and epidural anesthesia. On the fourth postoperative day, she developed signs of localized infection at the epidural site and a band of reduced sensation. Further neurological signs developed before the diagnosis was made by magnetic resonance imaging scan. She subsequently underwent emergency laminectomy and drainage of epidural abscess. CONCLUSION: Delayed diagnosis allowed the development of significant morbidity before neurosurgical intervention and antibiotics were instituted.     

Acute epididymo-orchitis with abscess formation due to Pseudomonas aeruginosa: report of 3 cases

We report 3 patients with acute epididymo-orchitis with abscess formation due to Pseudomonas aeruginosa, which is relatively unusual and difficult to treat. All patients presented with swollen testicles, pain and high fever. First, they were treated empirically with several antibiotics. After several weeks of antibiotics therapy, the swelling of scrotum still persisted. In one patient, dark yellow pus drained from a fistula of the scrotum. Finally, an orchiectomy was performed on all patients. During the operation, an abscess was found in each testis. Each culture of the pus yielded P. aeruginosa, which is susceptible to many antibiotics.     

Prostatic abscess: report of a case and review of the literature

Prostatic abscess is an uncommon entity nowadays due to widely use of antibiotics, however, in some patients, because of the seriousness, a quick diagnosis and interventionist treatment is required. We report a case of a 78 year-old male patient who had a torpid evolution and needed an urgent prostatectomy. We review ethiopathogenic factors, clinical findings, diagnosis and treatment of this uncommon entity.     

Thyroid abscess: case report and review of the literature

A thyroid abscess is an infrequently encountered condition with a rarity that is attributable to anatomic and physiologic characteristics of the gland that impart a unique quality of infection resistance. The differential diagnoses for a painful thyroid is limited, with subacute and chronic thyroiditis being the most often-encountered processes. Acute suppurative thyroiditis with abscess formation, although rare, is a formidable clinical scenario with morbid complications. Because the diagnosis of a thyroid abscess is often delayed in lieu of investigating other more common etiologies of thyroiditis, this disease entity may portend to a dismal clinical outcome. The authors report the case of a 53-year-old woman with a thyroid abscess yielding a single microbial isolate believed to be resultant from a urinary tract bacteremia. They also review the literature for discussion of abscess etiologies, presentations, and management strategies.     

Acute renal failure due to leptospirosis in a renal transplant recipient: a brief review of the literature

We present the case of a 43-year-old renal transplant patient who presented with fever, malaise, pruritus, headache, and severe jaundice of 3-week duration following work in a rice field. He was found to have acute renal failure and severe hyperbilirubinemia with a positive serum leptospira antibody titer, making the diagnosis of Weil's disease. The patient responded to reduction in immunosuppressive medications and intravenous penicillin therapy with no need for dialysis. This is the second case of leptospirosis in a kidney transplant patient reported in the English literature.     

Unusual Merkel cell carcinoma in a renal transplant recipient: case report and review of the literature

Merkel cell carcinoma (MCC) is an uncommon and aggressive neuroendocrine primary skin cancer known for its high propensity for local recurrence and distant metastases. There is no consensus regarding the optimal therapeutic approach, and the relative roles of surgery, radiotherapy and chemotherapy are still controversial. MCC generally affects elderly patients in areas of actinically damaged skin. Several studies suggest that a more aggressive course is observed in immunocompromised patients such as organ transplant recipients. Clinically, MCC usually appears as a rapidly growing, dome-shaped and solitary nodule. More than half of these tumours occur in the head and neck, and can become a challenge for the plastic and reconstructive surgeon. An unusual case of this cutaneous malignancy is presented in a renal transplant recipient. The tumour was located in the medial canthus of the eye. Tumour resection was performed and a reverse flow pre-auricular island flap and a forehead flap were used for reconstruction.     

Tacrolimus-associated myositis: a case report in a renal transplant patient

A 55-year-old Caucasian man who had received a second kidney graft in July 1993, was switched from cyclosporine to tacrolimus in June 2000 due to deterioration of renal function. Thereafter, he began to complain of muscle cramps in both quadriceps with an increased CPK and EMG findings of polyneuropathy. A muscle biopsy demonstrated acute myositis. Prednisone was administered with amelioration of the patient's symptoms, but with persistently increased CPK and myoglobin levels. In February 2001, mycophenolate mofetil was introduced and tacrolimus tapered to 3 mg daily to seek a toxic role of this immunosuppressant, since there was no other cause of myositis. A sudden decrease in CPK was observed, but the complete normalization took place only after its withdrawal in September 2002. This case represents a tacrolimus-associated myositis.