Exciting Cases in Transplant Infectious Diseases

Wanessa ClementeDigestive Transplant Service

University of Minas Gerais - Brazil

Outline

• Case Presentation

• Question

• Literature information

Case Presentation Time of transplantation

• 31 yo female, DM since age 17 y• Hemodialysis (9 mo before transplantation)• Kidney-pancreas transplant (Enteric drainage)• IS regimen: Steroid + FK + MMF• Hematoma (reopperated), Urinary fistula + UTI (clinical

approach) E. coli MS• Length of stay: 1 month• Prophylaxis:

– GCV, trimethoprim-sulfamethoxazole, ivermectin +albendazole

~ 18 months after transplantation: Persistent diarrhea + vomiting of 2 weeks duration.

Sore throat: 4 weeks before hospital admission.

Distended and diffused painful abdomen.

No cutaneous lesions.

During hospitalization: Fever Cefepime

Admission Laboratory

Findings:

Case Presentation

CMV antigenemia Negative

Clostridium toxin Negative

Acid-staining test (Cryptosporidium and Isospora)

Negative

Blood cultures Negative

Urine culture >100,000 UFCK pneumoniae

Stool Negative, including Baermann-Moraes method

Blood exam Hemoglobin 11.8g/dL; WBC 6630/mm3

Eosinophilia 21%/1390/mm3 Platelets 376,000/ mm3

Upper intestinal obstruction

Esophagogastroduodenoscopy

Normal esophagus, mild

pangastritis, nonspecific

duodenitis. Diffusely

ulcerated duodenal mucosa.

Duodenal wall thickening with

obstruction of the lumen.

Abdominal CT

Pancreas and kidney grafts with usual appearance. Absence of lymphadenomegaly. Marked thickening of theduodenum and jejunum wall with reduction of the lumen. Significant dilation of the stomach.

Biopsy

Chest radiograph

Follow-up

• Immunosuppresion was reduced

• Ivermectin (200 μg/kg/d for 30 days)

• Control EGD (after 2 wk): GI CMV Gancyclovir

• Hospital discharge: Day 31

On the other hand...

TID, Vilela 2008

Fatal case of SS hyperinfection in 43 yo LT recipient. Two weeks after IS treatment for graft rejection. Cause of death: alveolar hemorrhage + secondary sepsis

Questions

Q1: What is the Ss epidemiology?

Q2: When to suspect?

Q3: Should prophylaxis or empiric treatment be done?

Q4: Which treatment regimen is better?

Epidemiological aspects

Strongyloidiasis is a worldwide infection, but unusually reported in SOT

recipients Schwartz & Mawhorter AJT 2013

SS hyperinfection syndrome is more frequent within 3 mo of transplantation

Classically follows corticosteroid therapy Fardet Journal of Infection 2007

Diagnostic methods lacks in sensitivity and specificity Buonfrate CMI 2015

Mortality can approach 70%

DD Ss infection is rare but recognized transplant complication Le AJT 2014

Geographic Distribution

Plos 2013

Which drug should be chosen?

Preferred: Ivermectin

Alternative: Thiabendazole/ Albendazole (Second-line drugs)

Consider intermittent treatment in high-risk patients

Which regimen?

Daily oral ivermectin 5 - 7d 30 dVeterinary preparationsConsider adjuvant ATM therapy

Fox Curr Opin Infect Dis 2006

• Patients who have lived in an endemic region should be screened before procedure/ IS (stool examination and eosinophilia) or treated without screening (e.g. false negative testing)

• Antibody testing may be useful in non-endemic setting

• DDI has been documented, mainly intestinal and pancreatic transplant recipient

Considerations

Ahead of print Transplantation. Wright et al