Reactions 1704, p272 - 2 Jun 2018 Mycophenolate mofetil/prednisolone/ tacrolimus Cerebral toxoplasmosis and associated complications: case report A 72-year-old man developed cerebral toxoplasmosis, necrosis of brain tissue, ataxia, urinary incontinence and septic shock during treatment with tacrolimus, mycophenolate mofetil [Cellcept] and prednisolone [dosages, routes and durations of treatments to reactions onsets not stated]. The man who had undergone right kidney transplantation, was transferred to the hospital due to urinary incontinence and ataxia for about 3 weeks. He was receiving treatment with prednisolone, tacrolimus and mycophenolate mofetil. A physical examination was significant for a pulse rate of 78 /min, temperature 36°C, BP of 112/86mm Hg, respiratory rate of 20 /min. Laboratory testing showed normocytic anaemia and leucocytosis. A brain MRI scan revealed at least four lobulated nodular lesions over both right and frontal temporal lobes with marked perifocal oedema and rim- enhancement. He was admitted and a stereotactic brain biopsy was performed, which demonstrated necrosis of the brain tissue with a few macrophages, neutrophils and nuclear debris. The biopsy tissue was negative for acid fast stain and bacterial culture. Nocardiosis, toxoplasmosis or other fungal infection was suspected due to chronic immunosuppression for right kidney transplantation. Paired Toxoplasma immunoglobulin G and immunoglobulin M were negative. A brain MRI scan showed enlargement of the right frontal region. A whole body positron emission tomography scan showed a tiny nodule in the posterior segment of right upper lung and multiple brain lesions, mainly right cerebrum with mass effect. The man received treatment with cotrimoxazole [sulfamethoxazole/trimethoprim] for possible cerebral toxoplasmosis. Subsequently, the patient developed hyperkalaemia and was transferred to the surgical ICU. Cotrimoxazole treatment was withdrawn and he underwent craniotomy with tumour resection. Haemodialysis was performed after the operation. However, he developed septic shock and his condition deteriorated. He was discharged on day 22 due to terminal status. Tachyzoites were observed in the necrotic brain tissue. A diagnosis of toxoplasmosis was confirmed after Toxoplasma immunohistochemistry, periodic acid-Schiff stain and Grocott’s methenamine silver stain. Author comment: " Immunodeficiency is a known risk factor of cerebral toxoplasmosis. Causes of immunodeficiency include usage of immunosuppressants." "Long term immunosuppressants after kidney transplantation led to immunodeficiency in our patient, which became the risk factor of the infection of Toxoplasma gondii" Lu P-C, et al. Cerebral toxoplasmosis in a patient who had kidney transplant. International Journal of Antimicrobial Agents 50 (Suppl. 2): S200, Nov 2017 [abstract] - Taiwan 803323783 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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