Abstract: SA-PO1159
Oral Immunoglobulin in a Kidney Transplant Recipient with Dengue-Norovirus Coinfection Causing Sepsis and Acute Graft Dysfunction
Session Information
- Transplantation: Clinical - Infectious Diseases
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Author
- Gude, Anirudh Shanmukh, Dr.D.Y.Patil Medical College, Hospital and Research Institute, Pune, Maharashtra, India
Introduction
Renal transplant recipients are highly vulnerable to opportunistic infections because of chronic immunosuppression. Norovirus infection in this population can cause prolonged diarrhea, dehydration, tacrolimus malabsorption, and acute graft dysfunction, while dengue contributes thrombocytopenia and capillary leak. Co-infection with dengue and norovirus is uncommon and may rapidly progress to sepsis and graft injury.
Case Description
A 32-year-old male with hypertension and CKD secondary to biopsy-proven ANCA-associated vasculitis progressed to ESKD and underwent live-related renal transplantation in May 2024. He was maintained on tacrolimus, mycophenolate mofetil, and steroids, with baseline creatinine of 1.1 mg/dL.
In November 2025, he presented with profuse diarrhea, abdominal pain, fever, and breathlessness. He was hypotensive and tachycardic, requiring oxygen support. Investigations revealed severe pancytopenia (Hb 6.6 g/dL, platelets 16,000/µL), acute graft dysfunction (creatinine 3.94 mg/dL), elevated procalcitonin (14.1 ng/mL), electrolyte abnormalities, and subtherapeutic tacrolimus levels (<2 ng/mL). HRCT chest showed bilateral ground-glass opacities with pleural effusion. Dengue NS1 antigen was positive, while stool BioFire PCR detected norovirus. Blood and urine cultures were sterile.
The patient received broad-spectrum antibiotics, intravenous fluids, electrolyte correction, blood transfusion, tacrolimus optimization, and supportive care. Oral immunoglobulin (POIG) was initiated as adjunctive therapy for norovirus. Following treatment, diarrhea subsided with marked clinical and biochemical recovery. By discharge, creatinine improved to 1.3 mg/dL, procalcitonin reduced to 0.5 ng/mL, tacrolimus levels normalized, and blood counts recovered significantly.
Discussion
Norovirus infection in renal transplant recipients may follow an aggressive course due to impaired viral clearance and prolonged gastrointestinal involvement. Persistent diarrhea can result in dehydration, tacrolimus malabsorption, electrolyte imbalance, and acute graft dysfunction. Coexisting dengue further amplified disease severity through thrombocytopenia and systemic inflammation. POIG was used as a mucosally targeted therapy delivering neutralizing IgG directly to the intestinal lumen and was associated with rapid recovery and excellent graft outcome.
Acknowledgment
I sincerely thank the faculty and staff of the Department of Nephrology, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Pimpri, Pune, for their guidance and support in the management of this case.