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
Top Related