A case of a lethal febrile illness in a renal transplant patient presenting after a dental visit

Abstract

Division of Nephrology, the Department o Pathologyf , and the Vanderbilt Transplant Center, Nashville, Tennessee, USAA 28-year-old man with type I diabetes mellitus andrenal replacement by a cadaver kidney transplant pre-sented with fever, swelling and pain in the right jawfollowing a tooth extraction.His ill health began at the age o 2f when he presentedwith an episode of diabetic ketoacidosis. After a yearhe was started on insulin therapy. The ensuing 18 yearswere relatively quiescent, save for progressive prolifer-ative diabetic retinopathy requiring surgery. At the ageof 23 he developed rapidly progressive renal failurewithout the usual diabetic prodrome of nephroticsyndrome, which culminated in a renal biopsy.Interestingly the biopsy revealed endocapillary andmesangial proliferation, subendothelial electron-densedeposits positive, immunofluorescence for IgG andcomplement in the same localization, on a backgroundof mild diabetic glomerulopathy. There was reduplica-tion of the basement membrane with tram-tracking.There was no evidence for systemic vasculitis by his-tory, serologies, or other laboratory data. A diagnosisof membranoproliferative glomerulonephritis type IIIwas made and a course of steroids was attempted.After a brief period of haemodialysis, renal functionrecovered either consequent to or in spite of steroidtherapy. During the next 4 years the diabetic diathesismarched briskly along with increasing retinopathy,sensorimotor polyneuropathy, and the onset of prob-able diabetic nephropathy seen on the original biopsyand now the probable cause of renal deterioration withfirst the nephrotic syndrome, fixed hypertension, andthen renal failure. Just prior to the need for renalreplacement by dialysis he received a IB, 1DR matchedcadaver renal allograft which functioned immediately,lowering the serum creatinine to 1.4 mg/dl managedby anti T-cell antibody induction, and sequential quad-ruple immunosuppression. He was discharged to theclinic on cyclosporin, prednisone, and azathioprine.Over the next 15 months renal transplant excretoryfunction remained superb, but gross haematuria, pro-teinuria, with 2.3 g for 24-h excreted despite a glomer-ular filtration rate by isotopic clearance methods of