Primary toxoplasmosis complicated by possible IRIS 15 years after renal transplantation

Abstract

Abstract Background Acute toxoplasmosis in the transplant recipient can be a serious infection and usually represents reactivation of latent infection. Primary toxoplasmosis after transplantation is much rarer and is associated with greater morbidity and mortality. We report a case of primary toxoplasmosis 15 years after kidney transplantation with concomitant Epstein–Barr virus (EBV) reactivation as well as an IRIS-like reaction to anti-toxoplasma treatment. Case report A 26-year-old man, who received a living donor kidney transplant 15 years previously, presented with a 1-week history of fevers, headache, photophobia and dry cough. Immunosuppression was maintained with prednisolone 5 mg daily, mycophenolate mofetil (MMF) 500 mg twice daily and tacrolimus 5 mg twice daily. He was treated empirically for meningitis, although initial investigations were unremarkable. Due to worsening of symptoms, he was transferred to the transplant centre where he was also investigated for suspected post-transplant lymphoproliferative disorder owing to rising titres of EBV DNA. Retrospective serology and PCR supported a diagnosis of primary toxoplasmosis and he started treatment with sulfadiazine and pyrimethamine. After 72 h, he presented with recrudescence of fever and worsening lymphadenopathy. Sulfadiazine was switched to clindamycin with good effect and his symptoms resolved. Unfortunately, his kidney transplant later failed and he re-commenced haemodialysis. Conclusions Primary toxoplasmosis after kidney transplantation is rare, with existing literature limited to case-series and case reports. Since 1966, there have been 20 well described cases. Early presentation post-transplant is associated with worse outcomes. Acute toxoplasmosis may have resulted in concomitant EBV reactivation due to impaired immunosurveillance and specific cell-mediated immunity. There is a lack of consensus regarding toxoplasma screening and chemoprophylaxis in transplant recipients. A high index of suspicion is required to ensure that cases are not missed and transplant recipients should receive counselling to prevent infection.