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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2011  |  Volume : 22  |  Issue : 6  |  Page : 1203-1204
Nocardia infection in a renal transplant recipient


1 Department of Nephrology and Transplantation Medicine, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases & Research Centre (IKDRC) - Dr. H.L. Trivedi Institute of Transplantation Sciences (ITS), Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India
2 Department of Pathology, Lab Medicine, Transfusion Services and Immunohematology, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases & Research Centre (IKDRC) - Dr. H.L. Trivedi Institute of Transplantation Sciences (ITS), Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India

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Date of Web Publication8-Nov-2011
 

   Abstract 

Opportunistic infection occurs in up to 20% renal transplant patients and is associated with a high mortality. We report a 47-year-old diabetic female with 1-year-old deceased donor renal allograft on triple drug immunosuppression. She developed cytomegalovirus retinitis at ten months post-transplant followed by nocardiasis manifested by hemiparesis with comatose state due to lumbar epidural and multiple brain abscesses, in spite of immediately curtailing immunosuppression. She recovered with linezolid and cotrimoxazole and was discharged two weeks later. She is maintaining stable graft function with serum creatinine 1.4 mg/dL on cyclosporin 2.5 mg/kg/day and prednisone10 mg/day with maintenance therapy for nocardiasis.

How to cite this article:
Kaswan K K, Vanikar A V, Feroz A, Patel H V, Gumber M, Trivedi H L. Nocardia infection in a renal transplant recipient. Saudi J Kidney Dis Transpl 2011;22:1203-4

How to cite this URL:
Kaswan K K, Vanikar A V, Feroz A, Patel H V, Gumber M, Trivedi H L. Nocardia infection in a renal transplant recipient. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Nov 17];22:1203-4. Available from: http://www.sjkdt.org/text.asp?2011/22/6/1203/87233

   Introduction Top


Nocardiasis is an uncommon opportunistic infection that affects immunocompromised individuals. It occurs in 0.7% to 3 % of renal transplant patients with cutaneous, subcutaneous, and pulmonary manifestations, or disseminated infection spreading to liver, kidneys, and brain with mortality around 77%. We report a case of nocardiosis in a renal transplant patient who survived the infection with appropriate therapy.


   Case Report Top


A 47-year-old female with endstage renal disease of two years associated with diabetes mellitus of eight years duration underwent deceased donor renal transplantation on October 7, 2007.

She was discharged with stable graft function with serum creatinine (SCr) 1.1 mg/dL on three immunosuppressive agents, including cyclosporin (CsA) 3 mg/kg/day, prednisone 10 mg/day, and azathioprine 100 mg/day. She presented with acute CMV retinitis eight months post-transplant. She was treated with ganciclovir; CsA was reduced to 2.5 mg/kg/day and azathioprine was discontinued.

The patient presented one month later with low backache radiating to lower limbs. Magnetic resonance imaging (MRI) of her lumbosacral spine revealed epidural abscess in the lumbar region. Incidentally, she developed high-grade fever and lower limb weakness. She underwent an emergency L1-L4 laminectomy, and pus was drained and sent for bacteriology and mycology workup. Gram's and acid fast bacilli stain revealed weak positive filamentous organisms with beaded appearance and diagnosed as Nocardia [Figure 1]. Her fever responded to meropenem, however, the lower limb weakness persisted. An MRI of her brain was performed, which suggested multiple brain abscesses. She was treated with linezolid and cotrimoxazole, which resulted in full recovery and was discharged two weeks later.
Figure 1: Acid fast bacilli (AFB) stain, arrow head showing beaded AFB (Nocardia), ×1000.

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On her last follow-up four months later, she had normal lower limb tone and power, stable graft function with SCr 1.4 mg/dL on CyA 2.5 mg/kg/day, and prednisone 10 mg/day. She remained on maintenance therapy of linezolid and co-trimoxazole for nine months.


   Discussion Top


High-dose immunosuppression including steroids, calcineurin inhibitors, and history of CMV infections are high independent risk factors for Nocardia infection in renal transplantation. [1],[2] In the current era of evolving immunosuppressive agents and improving graft survival with minimum drugs, this case indicates that early diagnosis and prompt treatment with judicious use of drugs can prevent opportunistic infections, such as Nocardia.

In conclusion, Nocardia as an opportunistic infection may present in disseminated form in renal transplant patients. Early diagnosis and prompt treatment with bactrim and linezolid along with curtailment of immunosuppression can be effective in full recovery and prevention of mortality.

 
   References Top

1.Nampoory MR, Khan ZU, Johny KV, et al. Nocardiosis in renal transplant recipients in Kuwait. Nephrol Dial Transplant 1996;11:1134-8.  Back to cited text no. 1
    
2.Peleg AY, Husain S, Quereshi ZA, et al. Risk factors, clinical characteristics, and outcome of Nocardia infection in Organ Transplant Recipients: A matched case-control study. Clin Infect Dis 2007;44:1307-14.  Back to cited text no. 2
    

Top
Correspondence Address:
A Feroz
Assistant Professor, Department of Nephrology and Transplantation Medicine, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases & Research Centre (IKDRC) - Dr. H.L. Trivedi Institute of Transplantation Sciences (ITS), Civil Hospital Campus, Asarwa, Ahmedabad 380016, Gujarat
India
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PMID: 22089782

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    Abstract
   Introduction
   Case Report
   Discussion
    References
    Article Figures
 

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