Hemophagocytic syndrome as an unusual form of presentation of tuberculosis in a hemodialysis patient: case report and review of the literature

We present an unusual manifestation of tuberculosis in a patient on hemodialysis. A 73-year-old woman was admitted to our hospital with a picture of fever, dyspnea and weight loss. She had chronic renal failure and had started periodic hemodialysis 5 years before. Fifteen days after admission, she began with pancytopenia, abnormal liver function and coagulopathy. A bone marrow aspiration was made 1 week later showing macrophage elements with phagocytic activity. Eight weeks later, bone marrow culture in Lowenstein media confirmed the presence of tuberculosis. After the beginning of antituberculosis therapy, the laboratory disturbances disappeared and the clinical situation improved. We think that fever of unknown origin and pancytopenia in patients on maintenance hemodialysis must lead to an early bone marrow biopsy or aspiration since after the diagnosis a specific therapy can cure the disease.     

A case of fulminant hepatitis after reexposure to halothane six years later

We reported a case of halothane-induced fulminant hepatitis with acute renal failure which developed 6 days after reexposure to halothane. The patient was a 58-year-old female. She had a history of liver dysfunction after exposure to halothane 6 years previously. She had surgical treatment of clubfoot under halothane anesthesia in other hospital. Preoperative physical examination and laboratory data were normal. On the 6th post-operative day she abruptly developed high fever and general fatigue. Next day, she was transferred to our hospital. At admission, fulminant hepatitis complicated with acute renal failure was diagnosed with severe liver and renal damage. She was immediately treated with plasma exchange, glucose-insulin therapy, and hemodialysis. Serum transaminase level returned to normal value within a week. However, despite repeated hemodialysis, renal function did not improve, and she died of P. aeruginosa sepsis on 28th day after the operation. It may be suggested that in this patient hypersensitivity to halothane has persisted during the six years.     

A rare cause of anemia due to intestinal tuberculosis in a renal transplant recipient

A renal transplant recipient with stable allograft function presented with massive hemorrhagic diarrhea and severe anemia. No microbial infection could be found in stool cultures. Early colonoscopy showed severe colitis with ulceration. Histological samples confirmed granulomatous inflammation with acid-resistant Ziehl-Neelson-positive microorganisms of mycobacterial type. Polymerase chain reaction (PCR) analysis of native mucosal biopsies specified the infectious organism as Mycobacterium tuberculosis complex. The patient responded well to antimycobacterial therapy and was still asymptomatic after 6 months with a stable graft function. Our case shows that tuberculosis can be a severe clinical problem in transplant recipients. Most of the patients with intestinal tuberculosis, reported to literature, were diagnosed post mortem or after explorative laparotomy and bowel resection. Thus, intestinal tuberculosis should be considered when a transplant recipient shows abdominal symptoms with no clear evidence of another infection. Proper diagnosis and treatment resulted in a beneficial outcome in our patient.     

Tuberculosis of the breast in a patient undergoing hemodialysis

A 61-year-old female patient with diabetes undergoing maintenance hemodialysis presented with fever and swelling of her right breast. She had been unresponsive to nonspecific antimicrobial therapies. Breast tuberculosis and tuberculous lymphadenitis were diagnosed by excision biopsy and tissue culture. A combination antituberculous treatment including isoniazid, rifampin, ethambutol, and pyrazinamide was started and resulted in the remission of the lesions by the end of the first month of therapy.     

Gastrointestinal tuberculosis. A case report

We report a case of gastrointestinal manifestation of tuberculosis (TB). A 52 year-old female patient was admitted into another hospital with unspecified gastrointestinal complaints. A computer tomography (CT) and a coloscopy showed a mild stenosis in the ileocecal region. The routine pulmonary X-ray showed a nodule, the cytology of the sputum was positive for tuberculosis. The patient was therefore transferred to our hospital. Following the anti-tuberculostastic treatment, the patient's abdominal condition improved but the symptoms reappeared weeks later. A sonography showed biliary calculus. Three days after endoscopic cholecystectomy the patient was discharged to home care and medical therapy. Four days later, she was admitted again with signs of subileus. Oral gastrografin solved the problem. The patient refused another coloscopy. Another 13 days later the patient was admitted once more with signs of an acute ileus. An emergency laparotomy with resection of the ileocoecal region was performed because of a complete stenosis. The histology showed a gastrointestinal tuberculosis. The patient had a smooth postoperative recovery and was released on the tenth day. She was on anti-TB therapy for 12 months without any complaints. In July 1999 the tuberculostatic treatment was stopped. It has been pointed out in numerous scientific publications that the clinical picture can be untypical and uncharacteristic, so that only the principal integration of TB in the differential diagnosis can allow the correct diagnosis. Surgical therapy should only be performed in emergency cases. In normal cases, medical therapy is the adequate treatment for tuberculosis.     

HHV-6 infection in a pediatric kidney transplant patient

Human herpesvirus 6 (HHV-6) infection can induce unusual complications in transplant patients, such as interstitial pneumonitis, encephalitis and marrow aplasia. We describe the clinical course of HHV-6 infection in a girl with renal transplantation. She presented with diarrhea and poor feeding on day 36 post-transplantation (Tx), after a 5-day steroid pulse for clinical signs of acute rejection. A week later she developed fever and had elevated plasma creatinine and lactic dehydrogenase levels, but a physical examination did not reveal any anomalies with respect to suggest rash, pneumonitis, encephalitis or lymphadenopathy. Two weeks later, the patient developed anemia and leucopenia. HHV-6 was the only pathogen detected by the PCR assay of the serum and marrow aspiration. The patient had a successful recovery without specific treatment. This case report highlights the wide spectrum of complications resulting from HHV-6 infection in immunosuppressed patients.     

Ulcus vulvae acutum in a 13-year-old girl after influenza A infection

A 13-year-old otherwise healthy premenarchal girl presented with acute onset of painful vulvar ulcerations. One day before developing vulvar ulcerations, she experienced flu-like symptoms, including a low-grade fever, cough, sore throat, and myalgia. Results of a throat swab were positive for influenza A infection (polymerase chain reaction [PCR] assay), and the patient was treated with oseltamivir. The patient's constitutional symptoms improved slightly, but within 2 days after her initial presentation, she returned to her primary care provider and described 24 hours of dysuria and vulvar swelling. She had a history of herpes labialis (cold sores) and rare episodes of minor oral aphthae (canker sores) that occurred less than twice a year. The patient denied a history of sexual activity, sexual abuse, or physical trauma. Physical examination showed ulceration and swelling of the labia minora, and the patient received an empiric dose of acyclovir (200 mg 4 times daily) for presumed autoinoculated herpes simplex virus (HSV) infection. An ulcer swab was performed, and urinalysis revealed no evidence of infection. Two days later, the patient presented to the emergency department with increasing vulvar pain and vaginal discharge. The previous ulcer swab findings were negative for HSV (PCR assay), and consequently, acyclovir was discontinued after 1 day of therapy. She received topical viscous lidocaine and an empiric dose of oral fluconazole. The lidocaine provided temporary symptomatic relief. Results of DNA amplification studies were negative for Chlamydia trachomatis and Neisseria gonorrhoeae. A potassium hydroxide preparation was negative for fungi, and an ulcer swab for bacterial culture revealed usual flora. Of note, the PCR assay for Epstein-Barr virus was not performed on ulcer cells. The patient was referred to the department of dermatology, and results of a physical examination showed copious white mucoid discharge and a 2-cm ulceration of the left labia minora (Figure, panel A). Two smaller pinpoint ulcerations and swelling of the left labia minora were also noted. The lesions were clinically indistinguishable from the genital aphthous ulcers of patients with complex aphthosis (recurrent, severe aphthous ulcers on oral or genital mucosa). A diagnosis of ulcus vulvae acutum was made, and treatment was started with clobetasol 0.05% ointment (4 times daily) and lidocaine gel as needed. Four days later, the patient reported marked symptomatic improvement. Physical examination showed near resolution of the large vulvar ulceration (Figure, panel B). The patient tapered use of clobetasol ointment over the next several days until the ulcerations healed completely. Two months after her initial episode, the patient again had 3 small vulvar erosions after symptoms that included low-grade fever, malaise, and vomiting. She did not receive oseltamivir for this illness; clobetasol ointment was applied 4 times daily, and the vulvar erosions ameliorated within a few days. Her constitutional symptoms resolved without treatment. The patient has not experienced any further episodes of vulvar ulcerations in the 18 months after the most recent treatment.     

Diagnosis and treatment of tuberculosis in hemodialysis and renal transplant patients

BACKGROUND: The incidence of Mycobacterium tuberculosis in hemodialysis (HD) and renal transplant (RT) patients in developing countries is high. With the resurgence of tuberculosis in the US, insights gained in the diagnosis and treatment of this infection in HD and RT patients in developing countries should be valuable to physicians in the West. METHODS: A retrospective study of 40 cases of tuberculosis, 24 in HD patients (24/177, 13.6%) and 16 in RT patients (16/109, 14.7%) diagnosed over a period of 21 months in one center. RESULTS: The clinical features, diagnostic procedures, and management dilemmas of this group of patients are described in this report. Diabetes mellitus was the most common associated disease in both groups of patients. Fever, the most common presenting sign, was persistent low grade in 66.6% of HD patients and high intermittent in 56.2% of RT patients. Fever of unknown origin was only seen in RT patients. Pulmonary involvement was most common in both groups, presenting either as infiltrates or effusions. Tuberculous peritonitis was seen only in HD patients (33.3%). Eight HD patients were treated for tuberculosis for variable periods prior to transplantation, 4 of whom had less than 6 months of therapy. None had a recurrence of tuberculosis after transplantation. Because of the known cyclosporin-lowering effect of rifampicin resulting in an increased cost of immunosuppressive therapy, 13 patients were treated successfully with rifampicin-sparing therapy. CONCLUSION: Tuberculosis should be included in the differential diagnosis of fever in HD and RT patients, especially if fever is of unknown origin in the RT patient. M. tuberculosis in the renal transplant patient can present with high intermittent fever. Partial treatment of tuberculosis is sufficient prior to renal transplantation but treatment should be continued to completion after transplantation. If the cost of immunosuppressive therapy is prohibitive because of rifampicin, rifampicin-sparing antituberculosis therapy can be successfully employed in RT patients.     

Successful percutaneous drainage for infected cysts in polycystic kidney disease in a case of chronic hemodialysis

A 60-year-old woman, who had been receiving chronic hemodialysis for chronic renal failure due to polycystic disease for 7 years, was admitted to our hospital with the chief complaints of right flank pain and high-grade fever on February 3, 1986. She had a family history of polycystic kidney disease and her elder sister has been undergoing chronic hemodialysis. The patient has had repeated episodes of urinary tract infection. The right markedly distended kidney was palpated with severe tenderness, and the performance status was poor. Computerized tomography showed the right kidney enlarging beyond the median line, but localization of the infected cysts was not clear. The 7-day intensive antibiotic therapy had no beneficial effect. On the 8th hospital day, percutaneous drainage, which was carried out for a large cyst with low-level echoes using ultrasonic guidance, yielded 600 ml of hemopurulent fluid. Bacterial culture of the aspirated fluid was positive for Escherichia coli. As the clinical symptoms did not improve after the 8th day, 10 Fr. catheter placement, percutaneous drainage and catheter placement were added for other cysts containing hemopurulent fluid. Although hematopyuria persisted, the patient became afebrile and the right kidney became smaller and softer. Both catheters were removed on the 30th hospital day. Repeated computerized tomography or ultrasonography revealed a few hyperdense or hyperechoic cysts in the right kidney. However, no recurrence of high-grade fever or right flank pain has been seen for 3 months. Ultrasonic-guided percutaneous drainage has a great potential for patient care of infected cysts in polycystic kidney disease.     

Differential diagnosis of an unusual pelvic mass in a renal transplant recipient: multidrug-resistant abdominopelvic tuberculosis

Renal transplant patients are more prone to tuberculosis infection due to the underlying intense immunosuppression, with an incidence 20-74 times higher than that in the general population. It is associated with graft dysfunction and increased mortality rates. It can be frequently pulmonary but extra-pulmonary involvement is not rare, and in the latter case, it may be misinterpreted as genital malignancies. In this case report, we discuss a renal transplant patient with pelvic pain and fever, who was later diagnosed as having abdominopelvic tuberculosis.     

Bridge to transplantation with a left ventricular assist device

A 61-year-old female patient was diagnosed with dilated cardiomyopathy with severe left ventricle dysfunction. Two days after admission, continuous renal replacement therapy was performed due to oliguria and lactic acidosis. On the fifth day, an intra-aortic balloon pump was inserted due to low cardiac output syndrome. Beginning 4 days after admission, she was supported for 15 days thereafter with an extracorporeal left ventricular assist device (LVAD) because of heart failure with multi-organ failure. A heart transplant was performed while the patient was stabilized with the LVAD. She developed several complications after the surgery, such as cytomegalovirus pneumonia, pulmonary tuberculosis, wound dehiscence, and H1N1 infection. On postoperative day 19, she was discharged from the hospital with close follow-up and treatment for infection. She received follow-up care for 10 months without any immune rejection reaction.     

Didactic Lessons from the Serum Lactate Dehydrogenase Posttransplant: A Clinical Vignette

Posttransplant lymphoproliferative disorder (PTLD) is a serious complication after solid organ transplantation. An elevated serum lactate dehydrogenase (LDH) is a marker of PTLD activity. We report the case of a 58-year-old female renal transplant patient with a prior history of extranodal PTLD, which developed 19 years after a second transplant. She was successfully treated with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) and maintained subsequently on sirolimus and prednisone. She presented 3 years later with fever, dyspnea, cough, lung infiltrates and elevated serum LDH concerning for recurrence of PTLD. Bronchoscopy revealed Pneumocystis carinii (jiroveci) pneumonia. The patient was treated with trimethoprim-sulfamethoxazole, but developed nausea and was converted to dapsone. The patient was readmitted 4 weeks later with increasing dyspnea and hypoxemia and found to have a methemoglobin level of 16%. Dapsone was discontinued with resolution of all symptoms. We discuss the diagnostic and clinical challenges in this complex case.     

A case of neuroleptic malignant syndrome with acute renal failure]

Neuroleptic malignant syndrome is a potentially lethal side effect of neuroleptic drugs, characterized by fever, muscle rigidity, autonomic dysfunction, and altered consciousness. A 50-year-old female hospitalized three times in the past for psychiatric treatment was admitted to Umayabashi Hospital for treatment of a relapse of a schizophrenic psychosis. She had received 50 mg of chlorpromazine and one tablet of Vegetamin-A (chlorpromazine 25 mg, promethazine 12.5 mg, phenobarbital 40 mg). Approximately 24-36 hours later, the patient became febrile and lost consciousness, and eight days later, acute renal failure occurred with muscle rigidity. She was transported to Maebashi Red Cross Hospital to receive hemodialysis. On admission, the laboratory studies showed high levels of serum creatine phosphokinase, glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, creatinine and blood urea nitrogen. She underwent hemodialysis for treatment of acute renal failure and recovered from it after 16 sessions of hemodialysis.     

Case of emphysematous pyelonephritis in a renal allograft

Emphysematous pyelonephritis is a rare, but serious complication after renal transplantation. This is a case report of a 49-yr-old female who had a renal transplant for diabetic nephropathy. She presented to ER with about 1 wk history of right lower abdominal pain and fever 15 months after the transplant. She had gross hematuria and mental status changes just prior to presentation. A computed tomography (CT) scan of the abdomen showed extensive retroperitoneal and extraperitoneal air dissecting from the transplanted kidney in the right lower quadrant to the level of the mediastinum. There was air in the urinary bladder. These findings were highly suggestive of extensive emphysematous pyelonephritis. The patient was taken to the operating room emergently and underwent a transplant nephrectomy. Blood culture and urine culture were subsequently positive for Salmonella (serogroup O 6, 8 or C2). Initial blood culture also yielded Enterobacter cloacae. The patient was treated with imipenem, cefepime, flagyl, and diflucan empirically: this was later changed to complete a 6-wk course of ciprofloxacin upon discharge. Her hospital course was complicated by a urinary leak; she was discharged to home on day 21. This is the 12th reported case of emphysematous pyelonephritis occurred in a renal transplant recipient.     

Multiple osseous involvements in a case of disseminated cryptococcosis

Osseous involvement occurs in 5–10% of patients with disseminated cryptococcosis. We are reporting an unusual case of disseminated cryptococcosis involving the sternum and lumbar vertebra with the formation of psoas abscess with pulmonary tuberculosis. The patient presented with fever for 3 months. A diagnosis of pulmonary tuberculosis was made on thoracic contrast-enhanced computerized tomography and she was put on antituberculosis treatment. She was immunocompetent with negative human immunodeficiency virus. She conceived subsequently and had complaints of backache and swelling over the sternum. Magnetic resonance imaging showed destruction of L5 vertebra with psoas abscess. Vertebral cryptococcosis may mimic tuberculosis and malignancy. She had a bad obstetric history and experienced five, first-trimester spontaneous abortions in each successive year since 2001. This pregnancy again resulted in spontaneous abortion. Cryptococcus neoformans was isolated from two different sites: pus-involving the sternum and ultrasound-guided psoas abscess aspirate. Serum latex agglutination test for cryptococcal capsular polysaccharide antigen was positive. The diagnosis of cryptococcosis was delayed because the patient was diagnosed as a case of pulmonary tuberculosis, wherein clinical signs, symptoms and radiological findings in both the conditions are similar. Amphotericin B was started but she developed varicella infection and expired due to cardiac failure.     

Acute Tubular Necrosis Associated with Non-Hemorrhagic Dengue Fever: A Case Report

Dengue fever (DF) is an arthropod-born viral infection affecting humans. Dengue viruses are transmitted through the bites of the mosquito Aedes aegypti. Acute renal failure (ARF) is reported in patients who are affected mainly with Dengue hemorrhagic fever (DHF), which is a severe presentation of the disease. We report the case of a 24-year-old Omani female with no past history of particular medical problems. She was referred to our hospital for the further management of acute renal failure. She had clinical features of DF without DHF. The kidney biopsy showed features of acute tubular necrosis (ATN). She had a complete recovery after 25 days and required three sessions of hemodialysis. We conclude that DF even without DHF may lead to ATN and ARF. Clinicians should be aware of this etiology. Treatment is supportive and may require dialysis. The prognosis could be favorable.     

A Case Report of a Kidney Transplant Recipient With Organizing Pneumonia After Graft Loss

We present a case of a 68-year-old male patient who underwent ABO-incompatible living kidney transplantation from his wife because of immunoglobulin A nephropathy 13 years ago. Over time, the patient showed a gradual decline in graft function and required reinitiation of hemodialysis because of fluid overload, which led to his admission to our hospital. An arteriovenous fistula was created, and subsequently, hemodialysis therapy was started. Because he had chronic cytomegalovirus retinopathy and thrombotic microangiopathy due to immunosuppressive therapy at admission, mycophenolate mofetil and tacrolimus were discontinued during hemodialysis initiation. Only low-dose prednisolone was continued. One week later, the patient had a fever, and chest computed tomography revealed bilateral pneumonia, which was not improved by antibiotics. The patient was diagnosed with organized pneumonia. After ruling out opportunistic infection, including pneumocystis pneumonia, increased doses of prednisolone resulted in the remission of organizing pneumonia.     

Congenital cytomegalovirus infection after recurrent infection in a mother with a renal transplant

A woman with a renal transplant developed a systemic cytomegalovirus infection. She recovered and 3 years later she became pregnant. She had 3 days of fever in the first trimester. She delivered an infant severely affected with congenital cytomegalovirus infection. The incidence of symptomatic congenital cytomegalovirus infection in infants born to immunosuppressed mothers who develop reactivated cytomegalovirus during their pregnancy seems high. Received April 22, 1996; received in revised form September 3, 1996; accepted October 22, 1996     

Visceral Leishmaniasis: A Case Report of a Challenging Diagnosis After Orthotopic Liver Transplantation

Leishmaniasis is a disease caused by a protozoan and transmitted by sandfly species in several emerging countries. Visceral leishmaniasis is a serious complication, especially in immunosuppressed patients, and is uncommon after liver transplantation. We report the case of a 48-year-old female patient who underwent liver transplantation owing to polycystic liver disease. Six months after the procedure, she was hospitalized with diarrhea, acute kidney failure, and leukopenia. She had been off steroids for 3 months and was taking mycophenolate and tacrolimus. She had already been treated for cytomegalovirus, which was negative on admission. During hospitalization, fever, splenomegaly, ascites, and pancytopenia appeared. Serology for Leishmania by indirect immunofluorescence was negative. Then, bone biopsy and molecular testing for Leishmania diagnosed it as visceral leishmaniasis. Amphotericin therapy was initiated with resolution of fever after 4 days of treatment and gradual recovery from pancytopenia. This case highlights the challenge of early diagnosis of visceral leishmaniasis in liver transplant recipients with diarrhea and leukopenia, which can be caused by immunosuppression or more prevalent viral diseases. Late onset of fever, splenomegaly, and a first negative serologic test also made early diagnosis difficult. The aim of the report is to emphasize the suspicion of visceral leishmaniasis in symptomatic patients from emerging countries and to question the benefit of including protozoan screening in liver transplant donors and recipients in endemic areas.     

Thalidomide for Treatment of Bleeding Angiodysplasias during Hemodialysis

Renal transplant patients are more prone to tuberculosis infection due to the underlying intense immunosuppression, with an incidence 20–74 times higher than that in the general population. It is associated with graft dysfunction and increased mortality rates. It can be frequently pulmonary but extra-pulmonary involvement is not rare, and in the latter case, it may be misinterpreted as genital malignancies. In this case report, we discuss a renal transplant patient with pelvic pain and fever, who was later diagnosed as having abdominopelvic tuberculosis.