POS-695 INTESTINAL OBSTRUCTION COMPLICATING CAMPYLOBATER COLI ENTERITIS IN RENAL TRASNPLANTATION PATIENT

Abstract

A 30 year old male, with cadaveric renal transplantation 2 years ago , his primary disease was anti-GBM disease diagnosed one year prior to transplantation and treated with 14 sessions of plasma exchange, steroids and cyclophosphamide shortly after that he was initiated on hemodialysis followed by renal transplantation. Two months post renal transplantation his course was complicated by biopsy proven mixed rejection (T-Cell mediated rejection type IA) and active Antibody medicated rejection , however ,C4d negative. The patient received pulsed steroids, 3 sessions Plasma-exchange and IVIG 2g/kg. He completed 2 doses of Rituximab and his serum creatinine was stable at 200-220 micromole/L. The patient was admitted after 3 weeks with persistent vomiting and abdominal pain and abdominal distention, his serum creatinine 304 micromole/L, abdominal x-ray showed multiple air fluid levels with dilatation of small bowel loops. CT scan with oral contrast showed multiple dilated small bowel loops down to the terminal ileum with caliber of 3.5 mm with multiple air-fluid levels and fecal loading in distal ileum loop with collapsed colon. The contrast media reached into the small bowel in left mid abdomen at mid jejunal loop. Stool culture grew campylobacter coli, BK PCR was positive of 371,000 copies. Other infectious causes of diarrhea were excluded. The patient completed 7 days of ciprofloxacin and treated with intravenous immunoglobulins (IVIG) . His mycophenolic acid was stopped, and he was maintained on dual immunosuppression therapy in form of tacrolimus and steroids. The patient was booked for upper endoscopy and colonoscopy in outpatient setting. View Large Image Figure ViewerDownload Hi-res image Download (PPT) Diarrhea is a common symptom in renal transplant patient population. The main causes of diarrhea after transplantation include infections, immunosuppressive drugs, antibiotics, and other drugs. Viral causes of diarrhea are the most frequently reported and usually last up to 3 days. Patients have tendency to develop Clostridium difficile after antibiotics. Other enteric bacteria responsible for diarrhea are Shigella, Salmonella typhi, Salmonella typhimurium and Campylobacter. CMV can cause enterocolitis, with or without fever, gastrointestinal bleeding, perforation, and toxic megacolon are possible complications. Incidence of diarrhea with mycophenolate mofetil dose of 2 g/day was higher than in other immunosuppressants like azathioprine. Campylobacter infection has prominent features like terminal ileitis, cecitis and mesenteric adenitis. Proton pump inhibitors are main risk factor for campylobacter enteritis as it lowers the gastric juice acidity allowing for pathogen survival. Campylobacter was detected in stool culture of a 31-year-old male patient diagnosed with immunoproliferative small intestinal disease (IPSID) and it was positive in tissue biopsy samples. Antibiotics treatment is enough to eradicate campylobacter and reduce the risk of IPSID. Diarrhea is a common symptom post renal transplantation, Campylobacter coli can be one of the main causes of ileocecal enteritis and may cause small bowel obstruction, treatment is usually conservative with antibiotics.