Abstract: PUB240
Disseminated Nocardia vinacea Infection in a Kidney Transplant Recipient After Alemtuzumab Induction
Session Information
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Maturostrakul, Boonyanuth N., Baystate Medical Center, Springfield, Massachusetts, United States
- Agarwal, Krishna A., Baystate Medical Center, Springfield, Massachusetts, United States
Introduction
Nocardia infection is a rare but serious opportunistic infection complication in kidney transplant recipients, particularly in the setting of T cell depleting induction agent. Disseminated disease carries high morbidity and mortality.
Case Description
A 78 year old male with end stage kidney disease due to hypertension underwent deceased donor kidney transplantation with alemtuzumab induction. He had immediate graft function and was maintained on tacrolimus monotherapy. Low dose prednisone was added in attempt to lower his tacrolimus goal due to side effects. Pneumocystis prophylaxis was changed from Trimethoprim-sulfamethoxazole (TMP-SMX) to atovaquone early post transplant due to persistent transaminitis.
Five months post transplant, he developed productive cough and right calf pain. Ultrasound showed an 8.4 cm complex right calf fluid collection and chest CT showed a 5.7 cm mass like consolidation in the right lower lung lobe. He was initially treated for bacterial pneumonia with IV piperacillin/tazobactam and was subsequently discharged on amoxicillin/clavulanate potassium.
Repeat chest CT done 6 weeks after prior CT demonstrated evolving necrotizing cavitary pneumonia. Culture of the calf fluid collection grew Nocardia vinacea. Bronchoalveolar lavage cultures also grew the same bacteria. Brain MRI revealed multiple small rim enhancing lesions suspicious of intracranial abscesses.
He was diagnosed with disseminated nocardiosis involving lungs, soft tissue, skin, and brain. Due to Norcardia vinacia antibiotic susceptibility, patient was treated with intravenous ceftriaxone and high dose TMP-SMX which led to partial radiographic resolution of pulmonary and CNS lesions at 6 weeks of treatment initiation. Ceftriaxone was discontinued, and he remains on prolonged TMP-SMX therapy for at least 1 year from diagnosis of infection. His serum creatinine remains stable at around 2.2 mg/dL.
Discussion
Disseminated Nocardia infection is life threatening in kidney transplant recipients. In this case, early discontinuation of TMP-SMX and transition to atovaquone may have contributed, as TMP-SMX provides prophylaxis against Nocardia. Caution should be exercised before discontinuing TMP-SMX early post transplant. Early diagnosis and appropriate antimicrobial therapy are critical for favorable outcomes.