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Kidney Week

Abstract: SA-PO374

A Unique Case of Malakoplakia of the Kidney

Session Information

Category: Trainee Case Report

  • 1602 Pathology and Lab Medicine: Clinical

Authors

  • Muttineni, Manognya, Indiana University School of Medicine, Indianapolis, Indiana, United States
  • Sutton, Timothy A., Indiana University School of Medicine, Indianapolis, Indiana, United States
  • Taber-Hight, Elizabeth, Indiana University, Zionsville, Indiana, United States
  • Hellman, Richard N., Indiana University Division of Nephrology, Indianapolis, Indiana, United States
Introduction

Malakoplakia is a rare inflammatory condition that has a gross and microscopic appearance resembling xanthogranulomatous pyelonephritis but with distinctive Michaelis-Gutmann bodies on pathology. Malakoplakia can affect any organ system but genitourinary tract involvement is the most common, particularly in immunocompromised individuals. We are presenting a unique case of malakoplakia presenting with AKI requiring dialysis and our treatment approach.

Case Description

A 40yo Caucasian female presented to a local hospital with altered mental status. She had a history of tobacco, alcohol, and cocaine abuse. There was no history of IV drug abuse or prior urinary tract infections. She was found to be in septic shock due to Escherichia coli bacteremia from a UTI that progressed to multiorgan failure requiring ventilatory support and AKI (SCr=7.2) that required renal replacement therapy. UA demonstrated pyuria and proteinuria. Renal US showed bilaterally enlarged kidneys. Clinical status improved with antibiotic treatment although there was no recovery in kidney function and fevers persisted. Renal biopsy was performed revealing sheets of macrophages, eosinophils and Michaelis Guttman bodies on EM characteristic of malakoplakia. Antibiotics were changed to ciprofloxacin and she was transferred to a tertiary care facility for further care. A multidisciplinary approach involving nephrology, urology, infectious diseases and immunology was initiated. Patient was started on methylprednisolone and consideration of bilateral nephrectomy for source control was discussed. Five weeks into the hospital course daily fevers subsided and evidence of kidney recovery ensued. Ultimately, she was discharged off of dialysis with improving kidney function, prolonged course of antibiotics, and steroid taper. Six months later she is off both antibiotics and steroids with stable kidney function (SCr=1.4).

Discussion

Renal malakoplakia must be kept in mind for patients presenting with AKI and bilaterally enlarged kidneys especially in the setting of E. coli bacteremia from a urinary source. It was a challenging case given her age and nephrectomy as potential treatment options. We learned that in such cases suppressing the inflammatory process as an adjunct to antibiotic therapy can salvage kidney function. A multidisciplinary approach was very useful in avoiding surgery and coming up with treatment plan.