Visceral leishmaniasis after orthotopic liver transplantation: a rare cause of infection

Visceral leishmaniasis (VL) was known as an opportunistic infection associated with immunosuppression, particularly related to human immunodeficiency virus infection and rarely to solid organ transplant recipients. We report a case of VL, 6 months after liver transplantation, in a patient who presented with febrile pancytopenia. The diagnosis was made by demonstration of amastigotes in smears from bone marrow. VL is a very rare infection in patients who undergo liver transplantation and, to our knowledge, this is the first case diagnosed in Portugal.     

Visceral leishmaniasis after renal transplantation: report of 4 cases in northeastern Brazil

Abstract: Visceral leishmaniasis (VL) is a well recognized opportunistic infection in immunosuppressed patients, which may cause febrile illness. We describe 4 renal transplant patients with VL in an endemic area in Brazil and their response to therapy. In 3 cases the diagnosis was confirmed by bone marrow aspirate that revealed the presence of Leishmania. In 1 case the bone marrow aspirate was inconclusive and the diagnosis was made through spleen biopsy that showed the presence of the parasite. VL needs to be considered as a cause of febrile illness in transplanted patients living in endemic areas.     

Acute pulmonary involvement by paracoccidiodomycosis disease immediately after kidney transplantation: Case report and literature review

Paracoccidioides brasiliensis is the cause of paracoccidioidomycosis, one of the most important systemic mycoses in Latin America. Human disease has been observed in a limited geographic and ecological niche, and it is attributed to exposure to the fungus in soil. Most primary infections are subclinical, as the infection is contained by the host mainly through cell‐mediated immune response. However, as the fungus has the ability to survive in a dormant state for long periods, an impairment of the immune response may lead to reactivation and clinical disease. Surprisingly, paracoccidioidomycosis has rarely been reported in transplanted patients. The aim of this communication is to report a case occurring in a kidney recipient in an acute clinical form immediately after transplantation, and to review the available information on previously reported cases.     

Anthropometrically derived dosing and drug costing calculations for treating visceral leishmaniasis in Bihar, India

Objective and method  To estimate drug costs of treating visceral leishmaniasis (VL) based on data on the VL population structure from the high-burden, antimony-resistant area of Northern Bihar, India.
Results  Paromomycin is the cheapest option ($7450 to treat 1000 patients). Treating 1000 patients with oral miltefosine would cost $119 250 at the current private market price or $64 383–$75 129 at preferential public sector price depending on the size of the order. With AmBisome^® it would be $163 600 or $229 500 depending on the dose (10 or 15 mg/kg total). These costs are without considering other direct costs (daily intramuscular injections for 3 weeks for paromomycin; intravenous devices and hospitalization for AmBisome^®; directly observed treatment if applied for miltefosine) and indirect costs.
Conclusion  These calculations provide useful basic information for projections.     

Canine visceral leishmaniasis: performance of a rapid diagnostic test (Kalazar Detect) in dogs with and without signs of the disease

Current visceral leishmaniasis (VL) control programs in Brazil include the infected dog elimination but, despite this strategy, the incidence of human VL is still increasing. One of the reasons is the long delay between sample collection, analysis, control implementation and the low sensitivity of diagnostic tests. Due to the high prevalence of asymptomatic dogs, the diagnosis of these animals is important considering their vector infection capacity. Hence, a rapid and accurate diagnosis of canine visceral leishmaniasis is essential for an efficient surveillance program. In this study we evaluated the performance of rK39 antigen in an immunochromatographic format to detect symptomatic and asymptomatic Leishmania chagasi infection in dogs and compared the results with those using a crude antigen ELISA. The sensitivity of rK39 dipstick and ELISA were 83% vs. 95%, respectively, while the specificity was both 100%. Our results also demonstrated that the dipstick test was able to detect infected dogs presenting different clinical forms.     

Early post‐transplant diagnosis of cytomegalovirus esophagitis in an ABO‐incompatible kidney transplant recipients: A case report

Cytomegalovirus (CMV) is a common infectious pathogen in kidney transplant patients. Here, we present a case of CMV esophagitis with antigenemia, that developed within 3 days of kidney transplantation, a timeline generally considered to be too early for development of a CMV infection. Intense immunosuppressive therapy for desensitization in ABO‐incompatibility or in the presence of donor‐specific antibody can increase the risk for significant opportunistic infection immediately after or even before transplantation.     

Peripheral blood cells chimerism after unrelated cord blood transplantation in children: kinetics,predictive factors and impact on post‐transplant outcome

This study aimed to describe kinetics of complete donor chimerism occurrence (cDC, >99·9% donor) after unrelated cord blood transplantation (UCBT), to identify its predictive factors and its impact on post‐transplant outcome. Ninety‐four children who received single UCBT after a myeloablative conditioning regimen had blood chimerism evaluation at predefined post‐transplant dates, using a real‐time polymerase chain reaction method with 0·1% sensitivity. Cumulative incidence of cDC at 1 year post‐transplantation was 61·8%. Three predictive factors were identified in multivariate analysis: history of malignant disease (P = 0·03), older age (above 2·16 years, the first quartile of age, P = 0·0055) and higher level of cord/recipient human leucocyte antigen mismatch (4/6 vs. 5‐6/6, P < 0·001) increased the probability of post‐transplant cDC. Although graft cell dose had a strong impact on haematological recovery, it did not apparently influence cDC occurrence. Early cDC (i.e. more than 99·9% donor chimerism on days 15–30 post‐transplant) appeared useful to predict engraftment (P = 0·003) as well as acute and chronic graft‐versus‐host disease (GvHD). Severe acute or chronic GvHD never occurred in patients with DC ≤99·9%, suggesting than even minimal residual host haematopoiesis is associated with a very low risk of GvHD after UCBT.     

Successful treatment of monomorphic primary central nervous system post‐transplantation lymphoproliferative disorder 5 years after kidney transplantation

A 31‐year‐old man underwent living‐related kidney transplantation in 2004 as a consequence of primary focal segmental glomerulosclerosis (FSGS). Four years after the transplantation, we confirmed nephrotic syndrome caused by recurrent FSGS. We performed plasmapheresis and low‐density lipoprotein adsorption. We also combined steroid therapy with a reduction in the dose of tacrolimus and an increased dose of mycophenolate mofetil. The nephrotic syndrome improved dramatically with this combined therapeutic approach. However, 10 months after these treatments, he revisited our hospital because of altered consciousness. We detected multiple tumor masses in his brain that were ring enhanced on contrast magnetic resonance imaging. Consequently, we suspected primary central nervous system post‐transplantation lymphoproliferative disorder (CNS‐PTLD). We performed a craniotomy to biopsy the brain tumors. The biopsy specimen showed Epstein–Barr virus‐associated diffuse large B‐cell lymphoma. There is no definitive treatment for CNS‐PTLD. Therefore, we treated the primary CNS‐PTLD successfully with whole‐brain radiation and discontinuation of immunosuppression therapy.     

Visceral leishmaniasis in a patient with systemic lupus erythematosus: Dilemma in diagnosis and management

Patients with systemic lupus erythemasus (SLE) have an increased risk of bacterial, viral, fungal or parasitic infections, especially if they are receiving immunosuppressive therapy. Leishmaniasis is a group of diseases caused by intracellular flagellate protozoan parasites belonging to the genus Leishmania. We present a 48-year-old female patient, diagnosed with SLE many years ago, who presented with high fever and pancytopenia. We thought that the patient's hematologic findings were related to SLE hematologic involvement. However, we investigated other possible causes when there was no response to drugs for the treatment of SLE. A second bone marrow biopsy showed Leishmania amastigotes and the patient was diagnosed with leishmaniasis. The patient was treated with liposomal amphotericin-B (treatment completed at 40 days). She showed rapid clinical improvement and showed no signs of disease after 4 months.     

Presentation and management of mycotic pseudoaneurysm after kidney transplantation

Pseudoaneurysms (PAs) developing at the site of vascular anastomosis after organ transplantation are a rare but serious complication. We report a series of 3 cases of PA observed in a single center over a period of 18 years. The mode of presentation was acute bleeding in 2 cases. In the third patient, who underwent combined kidney and pancreas transplantation, the PA on the renal graft was discovered by chance. Graft removal associated with iliac artery ligation and extra‐anatomic femoro‐femoral bypass represents the standard treatment. However, interposition of a venous homograft may allow preservation of inferior limb perfusion and possibly graft salvage.     

Remission of Epstein‐Barr virus‐positive post‐transplant lymphoproliferative disorder by conversion to everolimus in a kidney transplant recipient

Post‐transplant lymphoproliferative disorder (PTLD) is a fatal complication of transplantation. There is no clear consensus on the treatment of PTLD. In most cases, the pathogenetic mechanism of PTLD involves the Epstein‐Barr virus (EBV). We report the case of an elderly kidney transplant recipient who developed EBV‐positive monomorphic T‐cell PTLD 14 years after transplantation. Conversion from conventional immunosuppressants to everolimus induced complete remission of PTLD accompanied by a decrease in blood EBV‐DNA level without chemotherapy.     

Visceral leishmaniasis in southeastern Nepal: a cross-sectional survey on Leishmania donovani infection and its risk factors

OBJECTIVE: To document the frequency of Leishmania donovani infection at community level in a highly endemic region in southeastern Nepal, and to assess socioeconomic and environmental risk factors. METHODS: A random cross-sectional population survey was held in two visceral leishmaniasis (VL) foci in Morang District in April to May 2003, enrolling individuals 2 years or older and residing in the endemic area for at least 12 months. Leishmania infection was defined as a direct agglutination test (DAT) titre equal to or higher than 1:3200. Risk factors were identified by logistic regression. RESULTS: The direct agglutination test was positive in 7.5% (95% CI: 5.1-10.8) and the leishmanin skin test (LST) in 13.2% (95% CI: 9.9-17.2) of the 373 study participants. No case of current kala-azar was found, but 5.1 % (95% CI: 3.1-7.8) reported having suffered from VL. Independent risk factors for Leishmania infection were proximity of the house to ponds [odds ratio (OR) 3.7, 95% CI: 1.6-8.5], family size (OR 4.4, 95% CI: 1.6-12.6), age > or =15 years (OR 5.5, 95% CI: 1.2-25.0) and house constructed in mud (OR 3.0, 95% CI: 1.1-7.6). Bednets, not impregnated and in poor condition, were used by 95.2% (95% CI: 92.3-97.0) of the population, but did not show any protective effect. CONCLUSION: This study shows that there is a serious problem of transmission of VL in this area of Nepal. The risk factors identified are linked with the socioeconomic level and the environment. The population would benefit from a community intervention to improve the environmental and housing conditions in the villages.     

JC virus‐associated nephropathy in a post‐heart and ‐kidney transplantation patient

JC virus‐associated nephropathy is rare in kidney transplant recipients, and even rarer in recipients of other solid organ transplants. We present a case of JC virus‐associated nephropathy in a heart‐kidney transplant recipient, which to our knowledge is the first case reported in the literature. We discuss the findings on renal biopsy for JC virus nephropathy and our management approach to this rare complication.     

Post‐kala‐azar dermal leishmaniasis in visceral leishmaniasis‐endemic communities in Bihar,India

We assessed the prevalence of post‐kala‐azar dermal leishmaniasis (PKDL), a late cutaneous manifestation of visceral leishmaniasis (VL), in 16 VL‐endemic communities in Bihar, India. The prevalence of confirmed PKDL cases was 4.4 per 10 000 individuals and 7.8 if probable cases were also considered. The clinical history and treatment of the post‐kala‐azar dermal leishmaniasis cases are discussed.     

Recurrent leishmaniasis in kidney transplant recipients: report of 2 cases and systematic review of the literature

I. Simon, K.M. Wissing, V. Del Marmol, S. Antinori, M. Remmelink, E. Nilufer Broeders, J.L. Nortier, M. Corbellino, D. Abramowicz, A. Cascio. Recurrent leishmaniasis in kidney transplant recipients: report of 2 cases and systematic review of the literature.
Transpl Infect Dis 2011: 13: 397–406. All rights reserved Abstract: The characteristics of 8 episodes of leishmaniasis with atypical manifestations in 2 Italian kidney transplant recipients are analyzed and contextualized among those of 52 other episodes of leishmaniasis observed in 19 transplant recipients found through a systematic review of the international literature. In all the patients, the initial episode was visceral leishmaniasis, which was associated with mucocutaneous involvement in 2 cases. With the exception of 1 case of post kala‐azar dermal leishmaniasis, 2 episodes of Leishmania endophthalmitis, and 3 episodes of mucocutaneous leishmaniasis, all the recurrences were characterized by visceral involvement. The potential role of polymerase chain reaction in monitoring the infection, the importance of a long follow‐up, the potential benefit of chemoprophylaxis, and the therapeutic challenges are discussed.     

Experience with miltefosine for persistent or relapsing visceral leishmaniasis in solid organ transplant recipients: A case series from Spain

The incidence of visceral leishmaniasis (VL) after solid organ transplantation (SOT) is increasing. The optimal therapy for post‐transplant VL remains unclear, as relapses after liposomal amphotericin B (L‐AmB) are common. Miltefosine has been shown to be effective for treating VL in immunocompetent patients, although data in the specific population of SOT recipients are lacking. In the setting of an outbreak of leishmaniasis occurring in Southwest Madrid, we reviewed our experience in 6 SOT recipients with persistent or relapsing VL who received a 28‐day course of miltefosine (2.5 mg/kg/day) as salvage therapy. All patients had been treated previously with L‐AmB as first‐line therapy. The incident episode of VL occurred at a median of 14 months after transplantation. Two patients experienced persistent infection and the remaining 4 had a relapse after a median interval of 168 days since the completion of the course of L‐AmB. All the patients had an apparent initial clinical improvement with miltefosine. However, VL relapsed in 3 of them (after a median interval of 46 days), which required retreatment with L‐AmB‐based regimens. Miltefosine therapy was followed by a prolonged secondary prophylaxis with L‐AmB in the only 2 cases with sustained clinical response and ongoing immunosuppression. No adverse effects associated with miltefosine were observed. Albeit limited, our experience suggests that miltefosine monotherapy likely has a limited utility to obtain a long‐lasting clinical response in complicated (persistent or relapsing) forms of post‐transplant VL, although its role in association with L‐AmB‐based secondary prophylaxis may merit further investigation.