tacrolimus and Brain-Abscess

Renal transplant patients are immunosuppressed and are at increased risk of opportunistic infections, including

Topics: Aged; Aged, 80 and over; Antilymphocyte Serum; Basiliximab; Brain Abscess; Cohort Studies; Cyclosporine; Female; Humans; Immunosuppressive Agents; Incidence; Kidney Transplantation; Male; Middle Aged; Nocardia; Nocardia Infections; Opportunistic Infections; Retrospective Studies; Tacrolimus; Treatment Outcome; United States

We present a 50-year-old female who experienced generalized convulsion 3 months after a successful cadaveric renal transplantation. The first cerebral CT scan indicated cerebral frontal infarction. Repeat CT some days later revealed progressive lesions, and a highly malignant tumor or abscess was suspected. Antifungal and broad-spectrum antibacterial therapy was initiated. Cerebral MRI could not differentiate between these conditions, but a neutrophil granulocyte scan strongly suggested an infectious process. A stereotactic puncture of the frontal lobe was followed by temporary improvement. A severe progressive left-sided hemiparalysis gave indication for a craniotomy with evacuation of the abscess 9 days later. Culture of aspirated pus yielded growth of a gram-positive, rod-shaped bacterium, later identified as Nocardia otitidiscaviarum by sequencing the 16S rRNA. The patient was treated with meropenem plus rifampicin intravenously for 6 weeks followed by oral ciprofloxacin and rifampicin for 2 months. Due to pharmacokinetic interaction with rifampicin, the prednisolone dose was doubled, and the dose of tacrolimus had to be tripled for maintenance of adequate trough concentrations. Five months following cessation of antibiotic treatment, the patient has regained normal strength and function in her left-sided extremities and has a serum creatinine level of about 160 micromol/l (1.8 mg/dl).

Topics: Anti-Bacterial Agents; Brain Abscess; Craniotomy; Female; Humans; Immunosuppressive Agents; Inhalation; Kidney Transplantation; Middle Aged; Nocardia; Nocardia Infections; Prednisolone; Radionuclide Imaging; Radiopharmaceuticals; Stereotaxic Techniques; Tacrolimus; Technetium Tc 99m Exametazime; Tomography, X-Ray Computed

Infection with Nocardia spp. is an uncommon but important cause of morbidity and mortality in organ transplant recipients. Cotrimoxazole prophylaxis against urinary tract infection and Pneumocystis carinii pneumonia in these patients usually prevents nocardial infection also. We report the case of a patient on tacrolimus and mycophenolate mofetil who developed drug-induced diabetes mellitus followed by nocardial brain infection. This infection occurred despite conventional cotrimoxazole prophylaxis. Physicians should be aware that newer, more potent and more diabetogenic immunosuppressive regimens may increase the risk of opportunistic infections such as nocardiosis, even in the presence of "adequate" antimicrobial preventive measures.

Topics: Adult; Anti-Bacterial Agents; Brain Abscess; Diabetes Mellitus; Humans; Immunosuppressive Agents; Kidney Transplantation; Male; Mycophenolic Acid; Nocardia asteroides; Nocardia Infections; Opportunistic Infections; Tacrolimus; Trimethoprim, Sulfamethoxazole Drug Combination