Reactions 1704, p198 - 2 Jun 2018 haemodialysis. The treatment for the cryptococcosis was escalated with fluconazole after each dialysis session. The lesion in the kidney had become detectable on ultrasound, that was apparently unchanged. Subsequently, she died after Cryptococcoma and fatal sepsis: case report initiation of dialysis during admission to hospital for an An adult woman [age at the time of reaction onset no clearly episode of severe sepsis [not all outcomes stated]. stated] developed cryptococcoma leading to fatal sepsis Author comment: "This case of cryptococcal disease is following treatment with azathioprine, ciclosporin, most likely due to the effects of immunosuppression." "It methylprednisolone, mycophenolate mofetil, prednisone and occurred during a period of intensified immunosuppression tacrolimus [not all dosages stated; routes and duration of by switching to a combination of tacrolimus and treatments to reactions onsets not stated]. mycophenolate mofetil. In addition a course of pulsed The 30-year-old woman was diagnosed with end stage renal steroids had been administered 2 months before the disease, which was suspected to be a complication of her diagnosis of the lesion in the kidney." previous malarial illness. She was started on haemodialysis in 2000 and later underwent a kidney transplant in 2005. Muranda AZ, et al. Cryptococcoma of a transplanted kidney in a patient presenting Thereafter, she was started receiving immunosuppression with recurrent urinary tract infection: A case report. BMC Nephrology 19: 94, No. 1, 23 Apr 2018. Available from: URL: http://doi.org/10.1186/s12882-018-0891-8 - with ciclosporin, azathioprine and prednisone. She was South Africa 803323171 treated in hospital once in 2012, for a urinary tract infection. Over the next six months, in 2014, her renal function deteriorated. Her serum creatinine levels increased, requiring a transplant biopsy. The biopsy revealed nephropathy and her immunosuppression was changed to tacrolimus (target serum trough level 5 7 ng/mL), mycophenolate mofetil 1g twice daily and prednisone 10 mg/day. Her renal function remained stable. However, in 2015, rapid deterioration occurred due to suspected non-adherence to immunosuppressants. Subsequently, she received steroid pulses with methylprednisolone 250 mg daily, and a repeat transplant biopsy was performed. Her renal function improved with a decrease in serum creatine levels, thereafter stabilising at a new baseline of about 380 µmol/L following one further dose of methylprednisone 500mg. Subsequently, viral infection due to cytomegalovirus (CMV; diagnosed by quantitative serum PCR), and BK-virus (diagnosed by urine PCR) occurred at different times. Her CMV infection presented as a febrile illness and she showed a viral load of 250 671 copies/mL, where as the BK-viral load in urine was 269,000 copies/mL. Her treatment included gancyclovir and valgancyclovir. Her immunosuppressant therapy was reduced to a tacrolimus target trough level of 5 ng/mL, mycophenolate mofetil 500mg twice daily and prednisone 5mg daily. In late 2014 and during 2015 she developed recurrent episodes of severe bacterial urinary tract infection, leading to multiple hospitalisations. Her infections responded to empiric treatment with antibiotic therapy for 10–14 days. Initially Klebsiella pneumoniae was cultured from urine and blood, however the last three cultures were positive for Escherichia coli. On each occasion of admission for sepsis, the graft was tender and an FDG-PET/CT scan was performed that revealed a metabolically active lesion in the upper pole of the transplanted kidney, suggestive of an abscess. However, abscess was ruled out because aspiration of the lesion did not yield pus. The biopsy was repeated and the histological sections were stained with haematoxylin and eosin that revealed renal tissue with a prominent infiltrate of cryptococcus round yeast bodies. The fungal elements were organised into groups in a myxoid and inflammatory background in most of the tissue. An alcian blue staining demonstrated a thick mucinous fungal capsule. Microscopy confirmed the presence of chronic allograft nephropathy. There were also certain areas of prominent interstitial fibrosis with atrophic tubuli and occasional sclerotic glomeruli. In the view of the radiological and histological appearances, a diagnosis of cryptococcoma of the transplanted kidney was considered. Her multiple blood and urine specimens were negative for fungal culture. The woman was treated with fluconazole for 6 12 months. During this time, she remained chronically ill with nausea, anorexia and loss of weight, with recurrent urinary tract infections. A follow-up FDGPET/CT scan at 2 months revealed cryptococcoma, with significant increase in size and intensity. A gastroscopy was performed for the upper gastro-intestinal symptoms that revealed mucosal mass and biopsy consistent with Kaposi sarcoma. Eventually, in light of poor renal function and life-threatening infections, she acceded to reduction and cessation of immunosuppressants, and was started on 0114-9954/18/1704-0001/$14.95 Adis © 2018 Springer International Publishing AG. All rights reserved Reactions 2 Jun 2018 No. 1704
Reactions Weekly – Springer Journals
Published: Jun 2, 2018
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