Mystery Lung Mass in a Kidney Transplant Recipient
- Transplantation: Clinical - I
November 02, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
- 2102 Transplantation: Clinical
- Leong, Russell, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Grantham, Connor J., Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Richardson, Trey Howard, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Concepcion, Beatrice P., Vanderbilt University Medical Center, Nashville, Tennessee, United States
The differential for lung masses in solid organ transplant recipients is broad. It includes infections particularly fungal and mycobacterial infections, malignancy, and recurrence of underlying systemic disease (e.g.GPA). The overlapping clinical and radiographic findings make diagnosis challenging.
This is a 64-year-old female with ESKD due to hypertension who underwent a deceased donor kidney transplant with Alemtuzumab and methylprednisolone induction. She received sulfamethoxazole-trimethoprim for Pneumocystis prophylaxis. She was maintained on tacrolimus, mycophenolate mofetil, and prednisone. She had no prior episodes of rejection. She presented one-year post-transplant with 20-lb weight loss, fevers, generalized weakness, and productive cough. CT chest revealed a large right lung mass. Sputum and BAL cultures grew Nocardia nova. Transbronchial needle aspiration of the mass was negative for malignancy. She was treated with imipenem/cilastin and trimethoprim-sulfamethoxazole. Her mycophenolate mofetil was held. She subsequently improved clinically with marked improvement of radiographic findings.
Nocardia is a low virulence organism found in soil and water. It is a rare life-threatening opportunistic infection that affects the lung, brain, and skin. It is more common in solid organ transplants recipients and usually presents 1-2 years post-transplant. Pulmonary nocardia presents with non-specific clinical symptoms. Imaging typically shows cavitary lesions. The risk of nocardiosis increases with net immunosuppression, rejection episodes, and time since transplantation. Prophylaxis with trimethoprim-sulfamethoxazole covers nocardia. This case demonstrates the importance of high index of suspicion for nocardia and a low threshold to send testing for sputum AFB/culture and to pursue early bronchoscopy/BAL. Timely diagnosis and initiation of treatment allow for a good clinical outcome such as what was achieved in this case.