Disseminated encephalitozoon cuniculi infection in a Mexican kidney transplant recipient

BACKGROUND: No cases of Encephalitozoon cuniculi infection have been reported in transplant patients. METHODS: A 42-year-old man received a renal transplant 8 months earlier because of terminal glomerulonephritis and was admitted with cough, fever, diarrhea, abdominal pain, and colon wall thickening. While under rapamycin (2 g/day), cyclosporine A (4.4 mg/kg/day), and prednisone (100 mg/day) therapy, he developed Banff grade IB graft rejection and was treated with methylprednisolone (1 g/day) for 3 days and oral prednisone (60 mg/d). RESULTS: Microbiologic studies were inconclusive, and biopsy specimens of ileum, colon, liver, and the grafted kidney revealed numerous gram-positive microsporidia spores. Parasitophorous vacuoles containing various developing stages of Encephalitozoon were seen. Immunofluorescence studies identified the etiologic agent as E. cuniculi. Albendazole therapy resulted in clinical improvement but no eradication after 10 months of follow-up. CONCLUSIONS: This report describes what is, to the authors' knowledge, the first case of disseminated E. cuniculi infection in a kidney transplant human immunodeficiency virus-negative patient from Mexico.     

Disseminated histoplasmosis in a liver transplant recipient.

A 61-yr-old liver transplant recipient presented with abdominal cramping and nonbloody diarrhea resulting in orthostasis. Multiple ulcerations throughout the colon were seen during endoscopy, and biopsies from the ulcer edges revealed histoplasmosis. Treatment with a course of itraconazole improved the diarrhea. The patient later presented with pericarditis and symptomatic pleural effusions, the latter of which was confirmed to be a result of disseminated histoplasmosis. Treatment with amphotericin B led to resolution. Histoplasmosis should be considered in liver transplant patients with diarrhea and large ulcers in the colon. The presence of disseminated histoplasmosis should be ruled out once colonic histoplasmosis has been diagnosed.     

Hypertension in the kidney transplant recipient

Elevated arterial blood pressure is common after kidney transplantation and contributes to shortened patient and allograft survivals and increased fatal and nonfatal cardiovascular events. Unfortunately, current evidence indicates that arterial blood pressure remains poorly controlled in kidney transplant recipients. One concern is how best to evaluate treated levels of arterial pressure in transplant recipients as office and clinic measurements often differ from blood pressure readings obtained using ambulatory blood pressure monitoring. Some antihypertensive drugs interact with immunosuppressive medications and adversely affect electrolyte balance and kidney function, which complicates the management of kidney transplant patients. Target blood pressure readings have been suggested by different guidelines, but patient-specific management plan is still lacking. Understanding the basic mechanisms responsible for the persistent hypertension after kidney transplantation is helpful in drafting patient-directed management plan that includes both pharmacologic and nonpharmacologic interventions to achieve target blood pressure control. In this review, we propose a multilayered treatment plan that addresses hypertension in both the early and late posttransplant periods, bearing in mind complications of antihypertensive medications, interactions with immunosuppressive drugs, patient comorbidities, and patient-specific cardiovascular risk factors in the posttransplant period.     

Disseminated Cladophialophora bantiana infection in a heart transplant recipient.

Cerebral phaeohyphomycosis caused by Cladophialophora bantiana, a dematiaceous fungus, is a rare disease. The majority of cases have been reported among immunocompetent patients; only 4 cases have been published that describe transplantation patients. The overall prognosis is poor. Surgical therapy in combination with chemotherapy with itraconazole is recommended. We report the case of a heart transplant recipient with cutaneous, cerebral, and lung manifestation of Cladophialophora bantiana who died despite surgical and systemic, high-dosage itraconazole treatment.     

Disseminated microsporidiosis with Encephalitozoon species in a renal transplant recipient

To our knowledge, 5 cases of disseminated microsporidiosis with Encephalitozoon species have been reported worldwide in transplant recipients. George et al. present the first such case in Australia, to be reported and treated with good clinical recovery.     

Nocardia carnea infection in a kidney transplant recipient

We report an unusual case of Nocardia carnea brain and lung abscesses in a 54-year-old kidney transplant recipient. Our case was confirmed by molecular detection despite negative cultures. The patient recovered using prolonged cotrimoxazole treatment.     

Aortic stent-graft explantation in a kidney transplant recipient

AAA repair in renal transplant recipients has generated a variety of methods of managing the allograft. Endovascular techniques have been successfully employed in this patient population. Due to inherent limitations of present endovascular methods, occasional stent-graft excision must be performed. We present a case of aortic stent-graft excision in a renal transplant recipient using a pump-oxygenator to maintain allograft perfusion.     

Extragastrointestinal stromal tumor in a kidney transplant recipient

The occurrence of de novo malignant neoplasms has been shown in post-transplant recipients receiving immunosuppressive treatment. We present a case of a rare extragastrointestinal stromal tumor (EGIST) located in the pelvic cavity of a kidney transplant patient. A 57-year-old female patient was admitted to our department because of non-specific lower abdominal pain 6 months after renal transplantation. An abdominal computed tomography scan showed a 4.5 cm diameter pelvic tumor mass. The tumor was resected en bloc and confirmed as not being connected to the gastrointestinal wall. Microscopically, the tumor consisted of typical spindle cells with 2?3 mitotic figures per 50 high-power fields. Immunohistochemically, the tumor cells were strongly positive for CD117 (c-kit), and negative for CD34, SMA, s-100 protein, and desmin. Genetically, the tumor showed a silent mutation in exon 18 of the PDGFRA gene at codon 824 GTC > GTT (V824V) [rs2228230]. No recurrence was noted 24 months after the operation. This case draws our attention to the importance of considering EGISTs (including GISTs), even though they are extremely uncommon, in the differential diagnosis of mesenchymal neoplasms, especially in transplant patients.     

Blood pressure management in the kidney transplant recipient

Hypertension is extremely common after kidney transplantation. It has been observed in up to 80% to 90% of patients. The etiologies are multifactorial but, in large part, rest with the native kidneys, concomitant immunosuppressant drugs, and behavioral factors that promote the development of higher levels of blood pressure, including obesity, salt intake, smoking, and alcohol consumption. There is a direct relationship between kidney allograft failure and level of systolic blood pressure during follow-up. Patients with a systolic blood pressure greater than 180 mmHg have 2-fold greater risk of loss of graft function compared with patients with systolics of less than 140 mmHg. A similar pattern exists for diastolic blood pressure. Some investigators have also demonstrated that higher levels of blood pressure also correlate with an increased risk of acute graft rejection, particularly in African Americans. What is not known is whether more effective control of arterial pressure in the transplant patient will reduce the likelihood of graft loss and improve survival. No prospective outcome trials have ever been performed. However, it is likely, given the marked success of better control of blood pressure in nontransplant patients in reducing cardiovascular death and the rate of progression of kidney disease, that similar benefits will be appreciated in the transplant patient. Given the greater cardiovascular burden in the kidney transplant recipient because of the presence, in many cases, of diabetes and hypertension, perhaps even more risk reduction may be realized with incremental reductions in blood pressure. Preferred treatment strategies for lowering blood pressure depends on the mechanism of action and medical comorbidity. Drugs that block the renin-angiotensin system should be preferentially considered because they may have similar advantages in delaying progressive loss of allograft function, much in the same way they have proven benefits in protecting native kidney function. Treating blood pressure in the kidney transplant recipient is a complicated process because patients are already on multiple medications and many will need 3 to 5 antihypertensive drugs to achieve optimal control of blood pressure, which should preferably be below 130/80 mmHg.     

Nocardia niigatensis infection in a kidney transplant recipient

This is the first reported case of Nocardia niigatensis infection in an adult kidney transplant recipient. A 57-year-old Asian woman presented with multiple cutaneous abscesses and rapidly growing fungating mass on the left pretibial area for 2 months. She received a cadaveric kidney transplant 4 years previously and was undergoing immunosuppression with prednisolone, cyclosporine and mycophenolate sodium. The microbiological diagnosis was established by isolation of Nocardia from the purulent material expressed from a granule. The strain was identified to the species level by 16S rRNA gene-targeted PCR. The closest match was with N. niigatensis . Antibiotic treatment (trimethotrim–sulfamethoxazole) was continued for 6 months and the skin lesions improved.