CAVITARY LUNG LESION AFTER RENAL TRANSPLANT

Abstract

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Opportunistic infections are serious complications that can occur after renal transplant. While potent immunosuppressive therapy has improved graft survival after transplantation, susceptibility to infections remains a significant concern – particularly pulmonary infections. CASE PRESENTATION: A 54-year-old female with a history of lupus nephritis status-post deceased donor kidney transplant 9 months prior presented to clinic with two weeks of fevers, nonproductive cough, and tender subcutaneous nodules on her breast and thigh. Her post-transplant course had been complicated by CMV viremia. She was undergoing evaluation for declining renal function, concerning for graft rejection, and had required adjustment of her tacrolimus for supratherapeutic levels. On evaluation, her chest x-ray showed a right apical infiltrate, and she was admitted to the hospital when chest computed tomography demonstrated a right upper lobe cavitary lesion. She underwent bronchoscopy with bronchoalveolar lavage (BAL) of the right upper lobe and biopsy of her thigh subcutaneous nodule. Within 72 hours, the BAL fluid and wound culture grew Nocardia farcinica, suggesting disseminated Nocardia infection. Magnetic resonance imaging of the brain was performed, which showed no evidence of central nervous system (CNS) involvement. She was treated with intravenous trimethoprim/sulfamethoxazole and imipenem-cilastin. DISCUSSION: Nocardia is a Gram-positive filamentous bacterium that primarily affects hosts with defects in cell-mediated immunity. The incidence of nocardiosis in solid organ transplant recipients varies from 0.7% to 3.5%. Significant risk factors include high-dose corticosteroids, CMV disease in the preceding 6 months, and high levels of calcineurin inhibitors in the preceding 30 days. Pulmonary nocardiosis infection typically occurs from inhalation of contaminated particles in soil, decaying vegetation, or water. Cavitation within the pulmonary nodules occurs in approximately 1/3 of cases. Disseminated disease occurs in about 30% of patients, with the most frequent extra-pulmonary sites being the subcutaneous tissues and the brain. Biopsy of subcutaneous lesions yields a diagnosis in approximately 24% of patients, and BAL in 20%. Initial treatment should include two agents effective against Nocardia and have the ability to penetrate the CNS. Duration of treatment is a minimum of 6 months, and at least 12 months if there is CNS involvement. CONCLUSIONS: Nocardia is a rare opportunistic infection that most frequently occurs in the first 12 months post-transplant. It is a severe disease that confers a mortality rate of approximately 20% in solid organ transplant recipients. Therefore, early recognition and treatment is essential in this population. Reference #1: Coussement J, Lebeaux D, et al. Nocardia Infection in Solid Organ Transplant Recipients: A Multicenter European Case-control Study. Clin Infect Dis 2016;63:338-345. Reference #2: Horl MP, Schmitz M, Ivens K, Grabensee B. Opportunistic infections after renal transplantation. Curr Opin Urol 2002;12(2):115-123. Reference #3: Wilmes D, Coche E, Rodriguez-Villalobos H, Kanaan N. Bacterial pneumonia in kidney transplant recipients. Resp Med 2018;137:89-94. DISCLOSURES: No relevant relationships by Jeannette Collins, source=Web Response No relevant relationships by Nikhil Huprikar, source=Web Response No relevant relationships by Paul Robben, source=Web Response