A 38-Year-Old Kidney Transplant Recipient with Productive Cough and Deteriorating Mental Status,

Y. Abu El-Sameed, MBBS, A. Al Mubarak, MD

Author address: 

Abu Dhabi/AE

Abstract: 

Introduction: Infection remains a leading cause of morbidity and mortality after kidney transplant with the overall level of immunosuppression and its duration being the major risk. Case: A 38-year-old man presented with headache, chills and weight loss of two months duration. He also admitted to intermittent productive cough of similar duration. His medical history was significant for a live-related kidney transplant in February 2007. There was no history of smoking or IV drug use. His medications included Azathioprine 100 mg daily, Prednisolone 5 mg daily, and Tacrolimus 2 mg twice daily. The patient was alert and oriented. His temperature was 100.5 °F, with normal BP and heart rate. The oxyhemoglobin saturation was 98% using 2 LPM oxygen via nasal cannula. His neurological examination showed no focal deficit. His cardiovascular examination was normal. The chest auscultation revealed scattered crackles on the left side. The WBC count was 6,120 cells/µL with normal differential count. Hemoglobin was 11.4 g/dL, and platelet count was 299,000 cells/µL. Kidney and liver function tests were normal. Cultures from the blood, urine and sputum were negative. Chest XR confirmed by CT scan showed a left upper lobe nodualr airspace opacity with cavity formation. Brain MRI showed multiloculated ring enhancing lesions in the right parietal lobe. An echocardiogram was normal with no valvular vegetations. The patient underwent bronchoscopy and bronchoalveolar lavage (BAL). This revealed Ziehl-Neelsen-positive acid fast bacilli. Subsequently he started having deterioration of his mental status for which he underwent a brain biopsy. This showed a cerebral abscess consisting of numerous multinucleated giant cells with large areas of necrosis. Grocott’s Methanamine Silver stain revealed abundant septate hyphae with 45-degree branching, consistent with Aspergillus. His final diagnosis was cavitory pulmonary tuberculosis (TB) and multiple aspergillus brain abscesses. Discussion: The Incidence of TB in kidney transplant recipients patients varies from 1% to 15% being higher in developing countries. The clinical manifestations are frequently atypical making early investigation a high necessity to avoid the high mortality. Central nervous system (CNS) infections can complicate the course of transplant recipients. Listeria, Cryptococcus and Aspergillus account for 90% of the non-viral CNS infection. Aspergillus is the leading cause of brain abscesses. The coexistence of tuberculus and Aspergillus infections in kidney transplant recipients is rarely described. This report stresses the fact that co-infection should always be borne in mind in immunocompromised patients, specially when the patient's clinical condition fails to respond favorably to initial treatment. Am J Respir Crit Care Med 181;2010:A4717
2010

abstract No: 

Poster Board # C7

Full conference title: 

American Thoracic Society International Conference
    • ATS 2010