mycophenolic-acid and Abscess

Nocardiosis is a life-threatening infection in immunocompromised patients. The prevalence of the disease ranges from 2.3% to 5% in renal allograft recipients. Here, we describe a case of BK nephropathy associating with nocardiosis with successful recovery. The 54-year-old male patient had end-stage kidney disease due to diabetic nephropathy associated with diabetic retinopathy, hypertension, and dyslipidemia. He started hemodialysis in October 2017; 2 years later, he underwent a deceased donor kidney transplant with 2 HLA mismatches and high panel reactive antibodies. He received desensitization with intravenous immunoglobulin and rituximab, received thymoglobulin as induction, and was maintained on prednisolone, mycophenolate mofetil, and tacrolimus. His serum creatinine decreased to a nadir of 90 μmol/L. He developed graft dysfunction, which was proven to be due to BK nephropathy. Therefore, mycophenolate mofetil was replaced with leflunomide in addition to intravenous immunoglobulin therapy. Ten months later, he had an accidental fall and sought an orthopedic evaluation. Magnetic resonance imaging of the lumbar spine and pelvis revealed lumbar spondylosis, avascular necrosis of the femoral head, and obturator muscle abscess. He was explored surgically, but the surgeon found no abscess or avascular hip necrosis. The patient's blood grew Nocardia, and he was readmitted and started imipenem and linezolid empirically. Brain and chest computed tomography scans ruled out any central nervous system or pulmonary involvement, but a bone scan revealed osteomyelitis of the right superior pubic ramus and prepubic swelling, which was confirmed by computed tomography to be an abscess in both obturator externus and internus. He continued the same antibiotics for 6 months based on culture and sensitivity. At follow-up, the patient has shown stable graft function (creatinine 155 μmol/L) with improved BK viremia with immunosuppression minimization. In renal transplant recipients, successful management of combined BK nephropathy and nocardiosis was feasible with minimization of immunosuppression and proper antimicrobial therapy.

Topics: Abscess; BK Virus; Creatinine; Graft Rejection; Humans; Immunoglobulins, Intravenous; Immunosuppressive Agents; Kidney Diseases; Kidney Transplantation; Male; Middle Aged; Mycophenolic Acid; Nocardia Infections; Polyomavirus Infections; Treatment Outcome; Tumor Virus Infections

Topics: Abscess; Anti-Bacterial Agents; Azithromycin; Ethambutol; Female; Humans; Immunocompromised Host; Immunosuppressive Agents; Leg; Lung Diseases, Interstitial; Middle Aged; Mycobacterium avium-intracellulare Infection; Mycophenolic Acid; Polymyositis; Prednisone; Rifabutin; Skin Diseases, Bacterial

Nocardia thyroid abscess with pneumonia is a rare clinical presentation. We reported a liver transplant recipient with Nocardia thyroiditis and pneumonia after receiving high dose immunosuppressants to preserve his graft. The patient is a 50-year-old male who developed hepatitis C virus-related liver cirrhosis and received a liver transplant. Seven months post-transplantation the patient developed graft rejection, which was treated with 3 days pulse dose methyl-prednisolone followed by an increased dose of his tracolimus, mycophenolate and prednisolone. He presented to the hospital with a 2 week history of fever, tenderness in his anterior neck and dry cough. On admission his temperature was 39.5°C. The right wing of his thyroid gland was swollen to 3 cm in size, fluctuant and tender. On auscultation of his lungs there were fine crepitations and increased vocal resonance in the right middle lung field. On laboratory testing, a complete blood count (CBC) revealed leukocytosis (19,900/mm3) with neutrophils (97%). A chest X-ray showed an patchy infiltrates and round circumscribed densities in the superior segment of the right lower lobe of his lung. A CT scan of his neck revealed a diffusely enlarged right wing of the thyroid gland, 3.8 cm in diameter that had an abnormal hyposignal area. A CT of his chest revealed consolidation of the superior segment of the right lower lobe and necrotic right paratracheal lymph nodes with inflamed strap muscles. Fine needle aspiration of the right lobe of thyroid gland was performed. Modified acid-fast bacilli (MAFB) staining showed partially acid-fast beaded branching filamentous organisms and a culture grew out Nocardia asteroides. He was treated with trimethoprim-sulfamethoxazole for 6 months. He improved clinically and his chest X-ray also cleared.

Topics: Abscess; Fever; Graft Rejection; Humans; Immunosuppressive Agents; Liver Transplantation; Male; Middle Aged; Mycophenolic Acid; Nocardia Infections; Pneumonia, Bacterial; Prednisolone; Tacrolimus; Thyroiditis

We present a renal allograft recipient 16 months posttransplant with an unusual infectious complication. This gentleman was antihepatitis C virus pretransplant, had a live unrelated transplant, and was taking cyclosporine, mycophenolate mofetil, and prednisolone. He developed diabetes and left scrotal abscess 3 months posttransplant and underwent left orchiectomy. He developed acute right epididymitis progressing to epididymal abscess, septicemia, and acute chronic graft dysfunction. Blood cultures and aspirated pus cultures grew Klebsiella pneumoniae and were treated with intravenous antibiotics, to which he responded. This case highlights an unusual complication in renal transplant and its successful management.

Topics: Abscess; Adult; Cephalosporins; Cyclosporine; Epididymis; Genital Diseases, Male; Humans; Immunosuppressive Agents; Kidney Transplantation; Klebsiella Infections; Klebsiella pneumoniae; Male; Mycophenolic Acid; Prednisolone; Sepsis

Topics: Abscess; Amphotericin B; Antifungal Agents; Aspergillosis; Aspergillus fumigatus; Biopsy, Fine-Needle; Caspofungin; Contraindications; Cyclosporine; Delayed Graft Function; Drug Interactions; Echinocandins; Fever of Unknown Origin; Gram-Negative Bacterial Infections; Humans; Immunocompromised Host; Immunosuppressive Agents; Kidney Failure, Chronic; Kidney Transplantation; Lipopeptides; Male; Middle Aged; Mycophenolic Acid; Peptides, Cyclic; Postoperative Complications; Prednisone; Pyrimidines; Radionuclide Imaging; Stenotrophomonas maltophilia; Surgical Wound Infection; Thyroiditis; Triazoles; Ultrasonography; Voriconazole