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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2016  |  Volume : 27  |  Issue : 4  |  Page : 830-831
Perigraft abscess with gas forming organism


Department of Radiology, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre - Dr. H.L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India

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Date of Web Publication5-Jul-2016
 

How to cite this article:
Pandya V, Sutariya H. Perigraft abscess with gas forming organism. Saudi J Kidney Dis Transpl 2016;27:830-1

How to cite this URL:
Pandya V, Sutariya H. Perigraft abscess with gas forming organism. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2020 Feb 25];27:830-1. Available from: http://www.sjkdt.org/text.asp?2016/27/4/830/185285
To the Editor,

Perigraft abscess may be caused by pyelonephritis, bacterial seeding of a lymphocele, hematoma, urinoma, or introduction of gas producing bacteria from exterior. It represents high risk to the survival of graft. A 38-year-old nondiabetic female with chronic kidney disease underwent deceased renal transplantation in our institute. After 15 days of transplantation, the patient complained of abdominal pain, vomiting, diarrhea, and fever. Ultrasound showed multiple echogenic foci with posterior dirty shadowing suggestive of presence of air in perigraft region. Computed tomography (CT) scan showed a large fluid collection with internal pockets of air in graft bed [Figure 1]a extending to medial and lateral sides of graft and pelvis, indenting right the lateral wall of the bladder [Figure 1]b. Inflammation also extended to iliacus muscle, muscles of lower lateral abdominal wall, and subcutaneous tissue. Emergency surgical exploration was performed and the graft was preserved. Pus showed heavy growth of Klebsiella aerogenes in culture, which responded to cefoperazone and sulbactam; metronidazole and levofloxacin were added to them. Repeat ultrasound and CT-scan showed no residual abnormality. She was discharged with normal serum creatinine and was normal in follow-up.
Figure 1:

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Infections of surgical site are common in renal transplant patients as a consequence of the immunosuppressive agents. Approximately, 20-51% transplant patients show the evidence of perigraft fluid collection and approximately 2-31% cases of total aspirated fluid show the presence of infection. [1],[2] Perigraft abscesses may be caused by pyelonephritis, bacterial seeding of lymphocele, hematoma, urinoma, or introduction of gas producing bacteria from the exterior. Surgical site infections following kidney transplant are also not uncommon. [3] These infections become evident two to three weeks after transplantation or even appear later, especially when deep infections of soft tissue are involved.

An average age of presentation varies from 40 to 60 years. Females are twice more commonly affected than males. Symptom duration seems to be 11 days before the diagnosis is made and only 35% of cases are diagnosed correctly on time. [4]

Multiple causative agents are identified including Gram-negative bacteria, Esp Escherichia coli (52%), Staphylococcus aureus (29%), and anaerobic bacteria (17%). [1],[5] K. aerogenes are responsible for 28% of the cases of perigraft abscesses. Our patient's presentation was consistent with an immunocompromised host since she was relatively asymptomatic despite of a large abscess. K. aerogenes was found to be the causative factor for perigraft abscess in our patient. Currently, imaging studies including CT scan and magnetic resonance imaging have high sensitivity for diagnosis. Management includes wide spectrum antibiotics and additional percutaneous drainage should be considered for abscess larger than 3 cm. Open drainage is considered the treatment of choice for abscesses larger than 5 cm in size.


   Conflict of Interest Top


The authors declared no conflicts of interest with respect to the authorship and publication of this article.

 
   References Top

1.
Edelstein HE, McCabe RE, Lieberman E. Perinephric abscess in renal transplant recipients: Report of seven cases and review. Rev Infect Dis 1989;11:569-77.  Back to cited text no. 1
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2.
Ali A, LaRocco A, Mooney ML, et al. Pasteurella multocida perinephric abscess after renal transplantation. Infect Dis Clin Pract 2007;15:196-8.  Back to cited text no. 2
    
3.
Rao PS, Ravindran A, Elsamaloty H, Modi KS. Emphysematous urinoma in a renal transplant patient. Am J Kidney Dis 2001;38: E29.  Back to cited text no. 3
[PUBMED]    
4.
Klein FA, Smith MJ, Vick CW 3rd, Schneider V. Emphysematous pyelonephritis: Diagnosis and treatment. South Med J 1986;79:41-6.  Back to cited text no. 4
    
5.
Kalra OP, Malik N, Minz M, Gupta KL, Sakhuja V, Chugh KS. Emphysematous pyelonephritis and cystitis in a renal transplant recipient - computed tomographic appearance. Int J Artif Organs 1993;16:41-4.  Back to cited text no. 5
[PUBMED]    

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Correspondence Address:
Dr. Vaidehi Pandya
Department of Radiology, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre - Dr. H.L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat
India
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DOI: 10.4103/1319-2442.185285

PMID: 27424712

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