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Abstract: SA-PO854

Malakoplakia of the Kidney Allograft

Session Information

Category: Transplantation

  • 2002 Transplantation: Clinical

Authors

  • Triozzi, Jefferson Lorenzo, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Velagapudi, Ramya Krishna, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Fallahzadeh Abarghouei, Mohammad Kazem, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Fogo, Agnes B., Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Concepcion, Beatrice P., Vanderbilt University Medical Center, Nashville, Tennessee, United States
Introduction

Malakoplakia is a rare granulomatous disease associated with infection, usually of the genitourinary tract. Solid organ transplant recipients and other immunocompromised individuals are at increased risk of malakoplakia. This case raises important considerations for the diagnosis and management of malakoplakia in kidney transplant recipients.

Case Description

A 40-year-old woman with end-stage kidney disease secondary to atypical hemolytic uremic syndrome, with a first kidney transplant nine years prior, a second kidney transplant four months prior, and a hospitalization for sepsis due to E Coli urinary tract infection one month prior, was hospitalized with worsening acute kidney injury despite resolution of sepsis. On presentation, she had normal vital signs and physical exam findings, and a serologic work-up and hemolysis studies were negative. A kidney biopsy demonstrated diffuse interstitial infiltrate with tubulitis and rare yeast-like forms for which she was empirically treated with fluconazole. Her kidney function continued to worsen, however, requiring hemodialysis. A second kidney biopsy demonstrated findings diagnostic of malakoplakia with foci of Michaelis-Gutmann bodies with targetoid appearance. Her kidney function improved with reduction of immunosuppression and a thirty-day course of ciprofloxacin.

Discussion

Malakoplakia is an inflammatory response to infection, often secondary to E coli or gram-negative bacteria in the genitourinary tract. Malakoplakia results from impaired phagolysosomal killing and elimination of bacteria by macrophages, resulting in Michaelis-Gutmann bodies (intracytoplasmic basophilic targetoid lesions of enlarged macrophages). Malakoplakia of the kidney allograft raises considerations for kidney transplant recipients. Firstly, urinary tract infections may herald the development of malakoplakia in predisposed individuals. Secondly, reduction of immunosuppression may improve antimicrobial treatment response. Thirdly, the diagnosis of malakoplakia requires collaboration with renal pathology to evaluate for other fungal or bacterial infectious etiologies that could present similarly. In sum, malakoplakia is a rare finding in the kidney transplant that can be treated with reduction of immunosuppression and appropriate antimicrobial therapy.