Sirolimus-Induced Drug Fever in a Renal Transplant Patient: A Case Report

Herein we have described the case of a male renal transplant recipient who developed drug fever apparently related to sirolimus. He had been stable under an immunosuppressive regimen of tacrolimus and mycophenolate mofetil, but developed acute cellular rejection at 5 years after transplantation due to noncompliance. Renal biopsy showed marked interstitial fibrosis, and immunosuppression was switched from mycophenolate to sirolimus, maintaining low tacrolimus levels. One month later he was admitted to our hospital for investigation of intermittently high fever, fatigue, myalgias, and diarrhea. Physical examination was unremarkable and drug levels were not increased. Lactic dehydrogenase and C-reactive protein were increased. The blood cell count and chest radiographic findings were normal. After extensive cultures, he was started on broad-spectrum antibiotics. Inflammatory markers and fever worsened, but diarrhea resolved. All serologic and imaging tests excluded infection, immune-mediated diseases, and malignancy. After 12 days antibiotics were stopped as no clinical improvement was achieved. Drug fever was suspected; sirolimus was replaced by mycophenolate mofetil. Fever and other symptoms disappeared after 24 hours; inflammatory markers normalized in a few days. After 1 month the patient was in good health with stable renal function. Although infrequent, the recognition of drug fever as a potential side effect of sirolimus may avoid unnecessary invasive diagnostic procedures. Nevertheless, exclusion of other common causes of fever is essential.     

Mucormycosis Presented with Facial Pain in a Renal Transplant Patient: A Case Report

IntroductionMucormycosis is a severe infection in renal transplant recipients. Here, we report a case of maxillary sinus mucormycosis in a patient who presented with a facial pain complaint.CaseA 51-year-old female patient with renal transplantation due to autosomal dominant, polycystic kidney disease and diabetic nephropathy was admitted to our hospital with facial pain and minimal edema of the left half of her face on the 8th month of transplantation. On physical examination, there was only tenderness and slight edema on the left half of the face. On the paranasal computed tomography, extensive soft tissue densities involving septations, filling the left maxillary sinus, extending to the nasal cavity, and obliterating the left osteometeal unit were observed. Because facial pain was not relieved by antibiotics and several, potent analgesic drugs on the second day, mucormycosis infection with bone involvement was suspected. A left maxillary sinus excision was performed. Microscopic examination of the debridement specimen revealed necrotic bone interspersed with fungal hyphae, and culture isolated Rhizopus oryzae. Liposomal amphotericin B was started. The patient was on tacrolimus, prednisolone, and mycophenolate mofetil. Tacrolimus was switched to cyclosporine to regulate serum glucose levels. The left maxillary sinus was washed with liposomal amphoterin B daily and curetted with intervals. The patient started dialysis because of severe renal function loss. The patient was discharged on the 96th day of liposomal amphotericin B.ConclusionIt should be kept in mind that mucormycosis may be present in the sinuses even if there is no evidence for nasal, oral, and dental examination in renal transplant patients with facial pain.     

A Rare Manifestation of Herpes Zoster: A Case Report

Herpes zoster has an incidence of 350,000 cases per year in the United States. The involvement of the foot and ankle is rare. Most surgeons are not aware of this disease as a cause of extremity pain, its manifestation, and the treatment options. Post-herpetic neuralgia is a common sequela of herpes zoster and can be prevented with prompt treatment. In this article, we present a case of a 53-year-old female with right heel pain secondary to herpes zoster.     

Atypical Presentation of Escherichia coli Monomicrobial Necrotizing Fasciitis in a Renal Transplant Patient: A Case Report

Skin and soft tissue infections (SSTIs) are one of most frequent infectious causes for referral to the emergency department and one of the most frequent infectious causes of hospital admissions. Escherichia coli, the most commonly occurring gram-negative pathogen involved in these infections, contributes to about 7% of all SSTIs cases where gram-positive organisms reign dominant. Patients are more susceptible to these gram-negative SSTIs if they are neutropenic, have hematologic malignancies, have undergone solid organ or hematopoietic transplantation, or have cirrhotic liver disease. Due to their immunocompromised state, the prognosis is very poor and not well understood. We report a case of an atypical presentation of an E coli monomicrobial necrotizing fasciitis in a renal transplant patient. Our findings support improved mortality with rapid aggressive interventions, such as amputation, in immunocompromised patients.     

Disseminated Sporotrichosis in a Liver Transplant Patient: A Case Report

Sporotrichosis is an infection caused by the fungus of the Sporothrix schenckii complex and can be particularly harmful in immunocompromised patients. We report the case of a 26-year-old male patient with a previous history of pulmonary infection who underwent a liver transplant for Budd-Chiari syndrome. After the procedure, he presented with persistent fever and leukocytosis. On the 13th post-operative day, he was diagnosed with thrombosis of the hepatic artery and underwent a second liver transplant 15 days after the first procedure. After the retransplant, he presented daily episodes of fever, even after the use of several antimicrobial, antiviral, and antifungal agents. A number of negative cultures from different sites were obtained. After an acute episode of mental confusion, the growth of S schenckii was observed in cultures from cerebrospinal fluid and ascites obtained from a diagnostic paracentesis. Treatment with amphotericin B was started but the patient died on the fourth day of antifungal treatment, from a massive gastrointestinal hemorrhage. We found no previous report in the literature of spontaneous dissemination of S schenckii to the abdominal cavity causing peritonitis.     

Non-Hodgkin Lymphoma in a Kidney Transplant Patient: A Case Report

Post-transplant lymphoproliferative disorders are a possible complication of kidney transplant due to chronic immunosuppressive therapy, and they can elevate the mortality rate. Furthermore, the type of clinical appearance has a wide range. We describe a case of a 38-year-old male recipient who developed post-transplant lymphoproliferative disorders and received successful treatment. The recipient had received a kidney with 1 HLA-B and 1 HLA-DR match, and the deceased donor allotransplant was performed successfully on December 9, 2012. The cause of kidney failure was membranoproliferative-glomerulonephritis proved by biopsy results. The induction therapy was antithymocyte globulin; the basic immunosuppressive therapy consisted of tacrolimus, steroid, and mycophenolate mofetil. After 2 months the patient had elevated serum creatinine level, and biopsy results revealed cellular rejection (Banff grade I). We applied steroid bolus therapy. After that the graft worked properly for 5 years, and the patient had no symptoms or complaints; then he had right lower abdomen pain. After urgent procedures (laboratory diagnostics, abdominal ultrasonography, computed tomography), we operated on the patient in a short time, and after a few weeks the fluorescence in situ hybridization confirmed the translocation of region C-myc; the diagnosis was diffuse large B-cell lymphoma. With the assistance of hematologists, the patient received adequate therapy. He was asymptomatic half a year after the rituximab with cyclophosphamide, vincristine, doxorubicin, methotrexate/ifosfamide, etoposide, and high-dose cytarabine protocol therapy; the lymphoma is in remission. Our case is worth presenting because immunosuppressive drugs can modify the clinical picture, complicating the diagnosis and delaying treatment.     

Case Report: Spontaneous Hemorrhage of a Rare Renal Tumor in the Native Kidney of a Renal Transplant Recipient

Renal cancers are some of the most common solid organ malignancies found during follow-up of patients who have undergone renal transplantation (RT). In this case report, we describe a life-threatening spontaneous hemorrhage of a rare subtype of renal cell carcinoma in the native kidney of a 27-year-old man, 4 years after RT. After fluid resuscitation and stabilization, the patient underwent emergent open radical nephrectomy with the final histopathology reporting T1bN0Mx mucinous tubular and spindle cell (MTSC) carcinoma. This case report highlights the need to consider an underlying malignancy in patients who presents with spontaneous hemorrhage of native kidneys after RT.     

Trichoblastoma Cutis in a Renal Transplant Recipient: A Case Report

Trichoblastoma is rare, benign skin neoplasm that may be difficult to distinguish from malignant baso-cellular skin cancer. Renal transplant recipients are at increased risk for development of skin malignancies. Resection and histopathological evaluation of a suspicious lesion is mandatory to determine malignant skin changes. We present the first reported case of trichoblastoma in a renal transplant recipient. Proper diagnosis enables less aggressive resection and maintenance of the same immunosuppressive protocol.     

Blastomyces dermatitidis in a Renal Transplant Recipient: A Case Report

Fungal infections have an important role in organ transplant recipients, and in some cases can be lethal. Blastomycosis is rare in kidney transplantation. We present a case of cutaneous blastomycosis in a kidney transplant recipient in Tunisia, a country outside the known endemic countries. This case, with the very uncommon and unexpected diagnosis of blastomycosis, demonstrates the diversity of infections in transplant recipients and reflects the importance of histologic and serologic tests in the immunocompromised patient.     

Tuberculous Sacroiliitis in a Renal Transplant Recipient: A Case Report

Although Mycobacterium tuberculosis (TB) is the predominant infectious disease after solid organ transplantation worldwide, extrapulmonary involvement in the sacroiliac (SI) joint has never been reported in renal transplant patients. Herein we have described a 59-year-old man who presented with left hip pain and fever at 1 year after renal transplantation. He had a positive Patrick's test on the left hip, elevated serum C-reactive protein, and widening of left SI joint on pelvic radiograph. Although the initial workup including blood culture, acid-fast stain, and tumor markers was nonrevealing, whole body bone scan and magnetic resonance imaging were suggestive of left sacroiliitis. Surgical debridement with biopsy confirmed mycobacterium TB infection. After a complete course of anti-TB treatment, his symptoms significantly resolved. Given the inconspicuous and protean symptoms of extrapulmonary TB, a high index of suspicion for TB sacroiliitis in renal transplant recipients with unexplained hip pain is warranted for early diagnosis and prompt treatment.     

Urinary Bladder Injury During Inguinal Herniorrhaphy in a Renal Transplant Patient: Report of a Case

(Received for publication on Sept. 17, 1998; accepted on July 13, 1999)     

A Case of Multidrug-Resistant Monoarticular Joint Tuberculosis in a Renal Transplant Recipient

Tuberculosis (TB) is a common opportunistic infection after renal transplantation. The risk of TB in renal transplant recipients is reported to be 20 to 74 times higher than in the general population. Although extrapulmonary TB occurs frequently, isolated ankle joint TB is a rare form of extrapulmonary TB infection. It is often difficult to diagnose because of its atypical presentation; management is complex, especially with multidrug-resistant TB, the need for a prolonged course of therapy, and the risks of drug interactions and drug toxicity. We report herein a case of a 60-year-old female renal allograft recipient who developed multidrug-resistant ankle joint TB 11 months after her deceased donor renal transplantation. She presented to the emergency department with escalating pain and swelling of the left ankle, difficulty in ambulation, and a low-grade fever. An x-ray of the ankle revealed an effusion and soft tissue swelling. A synovial fluid culture was performed which tested positive for acid fast bacilli which grew a multidrug-resistant form of Mycobacterium tuberculosis. She was initially treated with isoniazid, rifampin, ethambutol, and pyrazinamide; then therapy was tailored secondary to the resistant nature of the organism. She received a combination of extensive debridement of the joint and institution of second-line anti-TB therapy with pyrazinamide, ethambutol, moxifloxacin, and ethionamide. To our knowledge, no other cases of multidrug-resistant TB have been reported in the literature after renal transplantation. This case shows both an atypical presentation of TB and the difficulties in managing a transplant patient with this disease.     

Successful Treatment of Cutaneous Blastomycosis in a Renal Transplant Patient With BK Virus Infection: A Case Report

This is the first case report from Turkey to describe a renal transplant complicated by subcutaneous blastomycosis and BK infection. The cutaneous lesions were successfully treated with amphotericin B and fluconazole. The presence of BK infection led to graft failure. Infections with uncommonly seen organisms should be kept in mind due to the impaired T-cell immunity in transplantation.     

Antibody-Mediated Rejection in a Multiple Lung Transplant Patient: A Case Report

Lung transplant is an effective way to treat many end-stage lung diseases. However, one of the main barriers of allograft organ transplant is still the immunologic rejection of transplanted tissue, which is a response of the HLA molecules. Rejection is a complex process involving both T-cell–mediated delayed-type hypersensitivity reactions and antibody-mediated hypersensitivity reactions to histocompatibility molecules on foreign grafts. We report the case of a 25-year-old female patient with cystic fibrosis who underwent 2 lung transplants because of her initial diagnosis and appearance of bronchiolitis obliterans syndrome after the first transplant. Only 13 months after the second transplant, despite the therapies applied, a new rejection occurred associated with high mean fluorescent intensity donor-specific antibody levels, which resulted later in the death of the patient. The present case draws attention to the importance of matching HLA molecules between donor and recipient in addition to immunosuppressive therapy.     

Multivisceral Transplant in a Patient With Portopulmonary Hypertension: A Case Report

Portopulmonary hypertension, a type of pulmonary arterial hypertension in the setting of cirrhotic or noncirrhotic portal hypertension, is associated with elevated morbidity and mortality during and after transplantation. Uncontrolled portopulmonary hypertension may prevent or delay listing for transplant candidates, and the prognosis without treatment and ultimately transplant is extremely poor. We present a 29-year-old White woman, who had a post-liver transplant at infancy due to biliary atresia. Later on, she developed extensive portal vein thrombosis and portopulmonary hypertension and underwent a multivisceral transplant (liver, stomach, pancreaticoduodenal complex, and small and large intestine). Preoperative mean pulmonary artery pressure was <30 mm Hg with a pulmonary vascular resistance of <300 dynes^.s/cm⁵ on oral sildenafil and intravenous epoprostenol. Intraoperatively, management required comprehensive transfusion protocols, a careful balance between correcting blood loss and preventing thrombosis. Intravenous epoprostenol, sildenafil, milrinone, and inhaled nitric oxide were used to reduce elevated mean pulmonary artery pressure and right ventricular strain associated with vascular clamping, reperfusion, and massive fluid shifts. Nitric oxide and epoprostenol use unleashed antiplatelet effects on a patient already susceptible to coagulopathy. A multimodal and multidisciplinary approach continued throughout the surgery and in the postoperative period, which led to a successful outcome.     

Positron-emission Tomography Used to Diagnose Tuberculosis in a Renal Transplant Patient

We describe the case of a 22-year-old Portuguese renal transplant patient whose post-transplant course was complicated by prolonged delayed graft function and pyrexia of unknown origin. Conventional imaging techniques were not definitive, but positron-emission tomography (PET) scanning identified abnormalities in the lung and mediastinum that led to a diagnostic biopsy demonstrating mycobacterial infection.     

Primary Lingual Tuberculosis in Immunocompetent Patient: a Case Report

Oral manifestations of tuberculosis are quite rare with an incidence rate of 1.4%. The tongue is the most common site of oral tuberculosis having varied presentations. Lingual tuberculosis is a diagnostic dilemma because of its rarity, particularly in immunocompetent patients. We are reporting a rare case of primary tuberculosis of the tongue in a 38 year old male diagnosed on fine needle aspiration cytology.     

Conversion to Rapamycin in a Renal Transplant Patient With Von Hippel-Lindau Disease: Encouraging Results—A Case Report

von Hippel-Lindau (VHL) disease is a genetic syndrome based on an abnormality of the VHL gene located on the short arm of chromosome 3. Clinically, it presents as multiple tumors at several levels. The VHL gene product (pVHL) acts as a tumor-suppressing protein. In conditions of hypoxia it leads to an increase in several growth factor levels. mTOR inhibitors have proved to have dual properties: immunosuppressive and antitumor effects. Herein we have presented a case in which conversion to sirolimus improved graft function and also caused regression of retinal angioblastomas.     

A Rare Case of Disseminated Tuberculosis and Hematological Malignancy in a Heart Transplant Recipient

A 77-year-old man who underwent a heart transplant 7 years ago presented with multiple bloody bowel movements. Endoscopic and histologic evaluation revealed chronic active ileitis, granulomatous inflammation, multinucleated giant cells, and a rare, equivocal acid-fast bacterium in the terminal ileum. Positive sputum cultures for Mycobacterium tuberculosis and acid-fast bacilli established a diagnosis of intestinal tuberculosis, and RIPE (rifabutin, isoniazid, pyrazinamide, ethambutol) therapy was initiated. Elevated IgG levels on quantitative immunoglobulin testing and a bone marrow biopsy specimen of ≥60% plasma cells confirmed the diagnosis of multiple myeloma that later transformed into its aggressive form, plasma cell leukemia. Induction chemotherapy was initiated; however, the patient experienced retroperitoneal bleeding and pancytopenias, limiting the continuation of chemotherapy, and as a result, the patient was transitioned to palliative care.