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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 17  |  Issue : 1  |  Page : 45-47

Three different opportunistic infections in the same renal allograft recipient at the same time: Unusual case report


Department of Nephrology and Transplantation, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India

Date of Web Publication7-Apr-2014

Correspondence Address:
Rohit Rungta
Department of Nephrology, Rabindranath Tagore International Institute of Cardiac Sciences (RTIICS), 124 Mukundapur, EM Bypass, Kolkata 700 099
India
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DOI: 10.4103/1119-0388.130185

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  Abstract 

Infection affects all kidney transplant recipients in one form or another. Over 50% of the transplant patients have at least one infection in the first year following transplantation; and for those individuals lucky enough to make it through the first year without an infectious complication, they will be indirectly affected too, as they must take prophylactic medications. With high rates of mortality and graft loss owing to infections, it is imperative to render early diagnosis and treatment to immunosuppressed patients. We present here an unusual case, one year post transplant, who had three different opportunistic infections, all at the same time, and who finally succumbed to them.

Keywords: Fungal infections, infections, recipients, renal transplant


How to cite this article:
Rungta R, Ray DS, Das P, Gupta S. Three different opportunistic infections in the same renal allograft recipient at the same time: Unusual case report. Trop J Med Res 2014;17:45-7

How to cite this URL:
Rungta R, Ray DS, Das P, Gupta S. Three different opportunistic infections in the same renal allograft recipient at the same time: Unusual case report. Trop J Med Res [serial online] 2014 [cited 2019 Jun 25];17:45-7. Available from: http://www.tjmrjournal.org/text.asp?2014/17/1/45/130185


  Introduction Top


The major types of infections observed can be categorized according to the time period post transplant, during which they occur: Postsurgical bacterial infection in the first month after transplantation; opportunistic infection, with Cytomegalovirus playing a major role; transplant pyelonephritis, one to four months post transplant; and a mixture of conventional and opportunistic infections in the late post-transplant period. Conventional infection in this late period occurs primarily in patients with good renal function, who are receiving minimal immunosuppressive therapy; opportunistic infection occurs primarily in patients with poor renal function, who are receiving higher levels of immunosuppression.

Our patient, a renal allograft recipient, one year post transplant was suffering from aspergillosis, Pneumocystis jiroveci pneumonia, and systemic Cytomegalovirus virus (CMV) infections all at the same time, which made the diagnosis difficult, and more so to start the appropriate treatment at the right time.


  Case Report Top


A 29-year-old male, a renal allograft recipient, of one-year duration, came to the Emergency Room (ER) with complaint of shortness of breath and dry cough since last 7-10 days. The patient was on three immunosuppressive drugs regimen and was meticulously compliant with his medicines. He was hemodynamically stable and was conscious and oriented.

General examination of the patient was unremarkable, except for a wart-like fungating mass on his left toe [Figure 1]. Systemic examination revealed mild crepitations in the left inframammary and infrascapular regions. We came to the conclusion that the patient might be having lower respiratory tract infection (LRTI)/Pneumocystis carinii pneumonia (PCP) pneumonia. Relevant investigations were sent for and he was started on antibiotics and Trimethoprim (TMP)/sulfamethoxazole (SMX). Serum creatinine was around 3.5 mg/dl, which usually kept between 0.9 and 1.2 mg/dl, consequently the Calcineurin inhibitor level was asked for, contemplating graft dysfunction/tacrolimus toxicity. The tacrolimus dose was reduced as the calcineurin inhibitor level was around 8.8.
Figure 1: Left foot of patient showing warty lesion

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However, his dyspnea continued to increase despite all efforts and we decided to step up the antibiotics and add on an antifungal medication. Fiberoptic bronchoscopy with lavage was planned. Meanwhile, it was decided to take a wedge biopsy from his toe lesion, as it was turning out to be suspicious by now. The patient, however, failed to show any signs of improvement and in fact his chest X-ray (CXR) posterior-anterior view (PA) worsened [Figure 2]. He was promptly shifted to the intensive therapy unit (ITU) and started on non-mechanical ventilation because of his respiratory distress and persistent desaturation.

The patient had to be electively intubated and started on mechanical ventilation because of his worsening mental status and hemodynamic instability. Fiberoptic bronchoscopy was finally performed and the lavage was send to the laboratory for examination. To add to the woes, his total leukocyte count started decreasing and was around 3100/cmm. Suspecting a viral infection we asked for a CMV DNA Polymerase Chain Reaction (PCR) assay. It was situation of saving the patient or salvaging the graft, and finally, after discussing all the pros and cons with his family members, we withheld all his immunosuppressive medications. The patient, however, had a cardiac arrest the next morning and succumbed to it.

His CMV titer was very high (4000 copies/ml); the biopsy of a warty lesion on the toe revealed aspergillosis and bronchoalveolar lavage with methamine silver showed pneumocystitis [Figure 3] all at the same time.
Figure 2: CXR PA of patient on the eighth day

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Figure 3: PCP in BAL stained with Giemsa stain

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  Discussion Top


The incidence of infection in the renal transplant patient is directly related to the net immunosuppressive effect achieved and the duration of time over which this therapy has been administered. [1] A second major factor in the causation of infections in this population are the nosocomial hazards to which these patients are exposed to, ranging from invasive instrumentation to environmental contamination with the Aspergillus species, Legionella pneumophila, Pseudomonas aeruginosa, and other microbial pathogens. Careful surveillance is necessary to identify and eliminate such nosocomial sources of infection.

In the first month, the patients are at risk for postoperative pneumonias, intravenous line-related infections or those due to a faulty catheter. Occasionally there is a re-emergence of a non-eradicated infection that the recipient carried or an infection that was transmitted with the transplanted kidney. In the one-to-six month time period, immunomodulating viruses are most problematic. The Cytomegalovirus (CMV) is a prime example of such a virus. [2] If the patient's graft has been working well for more than six months post transplant, and he or she has not required additional immunosuppression to combat rejection, he or she is primarily at risk for infections encountered by the general population, such as, pneumonias and urinary tract infections. A small group of patients may experience persistent viral infections such as CMV, Epstein-Barr virus (EBV) and hepatitis during this time period. Another small set of patients, who have received additional immunosuppression are at risk for opportunistic infections like cryptococcus, pneumocystis, listeria, and nocardia. [3]

Transplant infectious disease has increasingly become a field characterized by preventative approaches and early therapies, based on sensitive molecular diagnostic tests. [4] The prevention of CMV, other herpes viruses, and pneumocystis have been important advances in transplantation. Infection is often preventable with correction of technical problems (e.g., drainage of fluid collections before infection). [5]

The key to effective treatment of infection is invoking strategies for the prevention and early identification of new infections. An important part of nursing care, for recipients, is identifying the pre-transplant serological status of the recipients and the serologies of the donor to identify those patients at higher risk for opportunistic infections and educate patients regarding their particular risk factors. This includes the types of infections they are at risk for, during each post-transplant phase. It is important to stress the need for compliance with prophylaxis. Understanding the rationale for the drug regimen may increase their adherence to it. Patients need to be educated on how to identify signs and symptoms of infection and when to call the transplant team. As many recipients return to the community for general health maintenance, it is important that they are taught to call the transplant team prior to starting any new medication. Many antibiotics are nephrotoxic or alter immunosuppression levels and should be avoided. [6]

 
  References Top

1.Chong AS, Alegre ML. The impact of infection and tissue damage in solid-organ transplantation. Nat Rev Immunol 2012;12:459-71.  Back to cited text no. 1
    
2.Issa NC, Fishman JA. Infectious complications of antilymphocyte therapies in solid organ transplantation. Clin Infect Dis 2009;48:772-86.  Back to cited text no. 2
    
3.Kalil AC, Levitsky J, Lyden E, Stoner J, Freifeld AG. Meta-analysis: The efficacy of strategies to prevent organ disease by cytomegalovirus in solid organ transplant recipients. Ann Intern Med 2005;143:870-80.  Back to cited text no. 3
    
4.Fishman JA, Strong DM, Kuehnert MJ. Organ and tissue safety workshop 2007: Advances and challenges. Cell Tissue Bank 2009;10:271-80.  Back to cited text no. 4
    
5.Grossi PA, Fishman JA. AST Infectious Disease Community of Practice. Donor-derived infections in solid organ transplant recipients. Am J Transplant 2009;9 Suppl 4:S19-26.  Back to cited text no. 5
    
6.Fishman JA. Opportunistic infections-coming to the limits of immunosuppression? Cold Spring Harb Perspect Med 2013;3:a015669.  Back to cited text no. 6
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