| Abstract|| |
Patients with End-stage Renal Disease being immunocompromised; are prone to a variety of infections, sometimes, rare ones, more than the general population. This fact should alert the physicians to be more vigilant and have a broader scope when considering the etiology of infections in such patients. We report the case of a 65-year-old man who had a very stormy hospital stay secondary to cerebral nocardiosis with multiple brain abscesses, prolonged unconsciousness and neurological deficits. However, the patient was treated successfully, surgically and chemotherapeutically. He was discharged home in a good condition.
Keywords: End stage renal disease, Hemodialysis, Nocardiosis, Immunocompromised, Infection, Biocompatible Membrane.
|How to cite this article:|
Ghalib MB, Hassan IS. Prolonged Unconsciousness in a Patient with End-Stage Renal Disease. Saudi J Kidney Dis Transpl 2006;17:273-7
|How to cite this URL:|
Ghalib MB, Hassan IS. Prolonged Unconsciousness in a Patient with End-Stage Renal Disease. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2019 Jul 15];17:273-7. Available from: http://www.sjkdt.org/text.asp?2006/17/2/273/35802
| Introduction|| |
Infections remain a serious complication in patients on regular hemodialysis. , They are the second commonest cause of death in such patients. ,, Pathogenetically, regular hemodialysis is associated with profound immunologic defects that compound the immune dysfunction that is inherent to the "uremic state". ,, These defects are thought to be "hemodialysis- membrane" induced and affect both the innate and acquired immune responses as well as the humoral and cellular arms of the immune response. , Hemodialysis with biocompatible membranes is less immunosuppressive and in fact switching from bioincompatible to biocompatible membrane dialysis is shown to improve both the lymphocyte counts and Natural Killer cell function. ,
The commonest infections in hemodialysis patients are vascular-access related but systemic opportunistic and non-opportunitic infections are also recognized. ,
In this case report we describe the case of a middle-aged man on hemodilaysis who developed cerebral Nocardiaosis as well as non-nocardial respiratory and peritoneal infections. We highlight his presentation, his dramatic and long course in hospital, how the diagnosis was reached and his response to treatment.
| Case Presentation|| |
A 65 years old Saudi male From Almadinah was referred to our hospital via Medivac on July 2004 with a Computerised Tomographic head scan diagnosis of a brain abscess. His chief complaints on admission were fever, headache, altered mental status and left sided weakness of one week duration. He was known to suffer from hypertension and chronic kidney disease stage V. He had no history of diabetes mellitus. He was initially on hemodialysis starting March 2003 but was switched to CYCLER automated peritoneal dialysis 5 months later. He had previously completed his renal transplant workup at our centre.
On examination, he was found to be confused and febrile (39.7 0 C). He was hemodynamically stable. There were bilateral basal coarse crepitations on examining his chest. Abdominal examination revealed a clean exit site of his Tenckhoff catheter and it was non-tender with no palpable or ballottable mass. Shifting dullness was positive (peritoneal dialysis fluid). Neurologically he had long tract signs with grade 4/5 weakness of both left upper and lower limbs and bilateral papilloedema.
| Initial Investigations|| |
Computerised Tomographic Scan and Magnetic Resonance Imaging of the brain confirmed the presence of multiple parieto-occipital abscesses, surrounding edema with mass effect and midline shift [Figure - 1].
Peritoneal fluid was turbid but biochemical, cytological and microbiological investigation were all negative for infection. Chemistry and haematology results are shown on [Table - 1].
| Immediate Management|| |
The patient was started on empirical antibiotics to cover both Gram positive as well as Gram negatives (vancomycin, gentamicin, imipenem) by the infectious diseases team.
The neurosurgeon was consulted; who reviewed the patient and decided to take him immediately to theatre. Through a right occipital bur hole, 10 mls of pus were drained and sent to the laboratory. However, the patient continued to deteriorate, got shifted to the intensive care unit where he was started on intravenous steroids for his brain edema. He was intubated and ventilated because of aspiration pneumonia and respiratory distress. A repeat peritoneal aspirate smelled of faeces. The patient had a surgical laparatomy and his Tenckhoff catheter was then removed. He was restarted on hemodialysis again but needed Continuous Veno-Venous Hemodiafiltration briefly because of hemodynamic instability.
A Gram stain of the pus that was drained from the cerebral abscess showed a Gram positive branching rod which was later identified on culture as Nocardia species [Figure - 2].
| Later Course|| |
The patient was started on high dose intravenous Co-trimoxazole and Amikacin along with Vancomycin and Ceftriaxone. He gradually improved (clinically, mentally and hemodynamically) and was shifted back to hemodialysis.
On regular physiotherapy he started mobilising independently. By early October 2004 he was well enough to be discharged home on renal replacement therapy after staying in hospital for 91 days, 62 of which he was either comatose or confused [Figure - 3].
| Discussion|| |
Nocardia is a delicate, partially acid fast filamentous Gram positive branching rod that may be associated with acute, subacute or chronic infection. , Microbiologic culture may take 2-3 weeks. It has got the unusual tendency to relapse or even progress despite appropriate therapy. Virtually all organ-systems may be involved - pulmonary, central nervous system, bone, retina, heart, joints, kidneys, and skin. Cell-mediated immune responses whether innate (gamma-delta cells) or specific are crucial in protection against Nocardial infection. , However, its ability to evade the immune response by inhibiting phagosomelysosomal fusion in macrophages and by producing L-forms contributes to its persistence and relapse properties.  Additionally, Nocardial superoxide dismutase and catalase activities have also been shown to inhibit the microbicidal activities of human polymorphonuclear neutrophils.  Nocardial infections are more frequently seen in the immunocompromised host but infections in the immunocompetent are also seen. , Dysfunctional cell-mediated immune responses, lymphopenia, impaired natural killer cell and phagocytic function in hemodialysis patients predispose these patients to many infections including Nocardiosis. ,,,,, One of the various means to improve or lessen the immune-dysfunction in patients on hemodialysis is changing the dialysis membrane. ,, Furthermore, effective hemodialysis may indirectly improve the immune-dysfunction by removing the uremic toxins. ,, Prophylactic antibiotics is another measure to combat opportunistic infections in this population of patients e.g. isoniazid prophylaxis in tuberculin-positive patients. Prophylaxis against Nocardiosis is not recommended in view of the rarity of this infection in our patient population. Our patient developed multiple Nocardial brain abscesses that were successfully treated with the combination of co-trimoxazole and amikacin, the recommended treatment for this complication. The plan was to keep him on treatment for at least twelve months. Treatment with a sulphonamidecontaining regimen is standard of care. , Resistance testing is recommended as the organism is occasionally drug resistant, alternative antibiotics may be needed if sulphadrugs are to be discontinued due to adverse reactions, and the potential for sulphonamide nephrotoxicity in transplant recipients on cyclosporine. , Recently, Linezolid, an oxazolidinone, with bacteriostatic activity against almost all Gram-positive bacteria was shown to be an effective therapy for Nocardiosis.  The primary lesson from this case is to always consider Nocardiosis whenever multiple abscess are seen anywhere in the body especially in the immunocompromised patient.  The laboratory should specifically be alerted to culture for Nocardia and to keep the culture for four weeks before considering the test as negative. Alternatively, diagnosis may be reached faster using the polymerase chain reaction. 
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Mohamed B Ghalib
Department of Medicine 1443, King Abdulaziz Medical City, King Fahad National Guard Hospital, PO Box 22490, Riyadh 11426
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1]