Volume 50, Issue 3 , Pages A45-A46, September 2007
Quiz Page September 2007
Article Outline
Clinical Presentation
A 50-year-old white woman with end-stage renal disease secondary to type 2 diabetes and hypertension received a renal transplant from a deceased donor. The patient received induction therapy with alemtuzumab, 30 mg, intravenously (IV) and 3 IV doses of methylprednisolone sodium succinate. Her maintenance immunosuppression therapy included tacrolimus and mycophenolate mofetil. Postoperatively, her serum creatinine level decreased to 2.0 mg/dL (177 μmol/L), with estimated glomerular filtration rate of 28 mL/min/1.73 m2 (0.47 mL/s/1.73 m2) using the Modification of Diet in Renal Disease Study equation. The patient presented 2 months later with fever up to 38.2°C. She was found to have acute renal failure with a serum creatinine level of 7.1 mg/dL (628 μmol/L). Urinalysis showed trace protein, 18 white blood cells/high-power field, 5 red blood cells/high-power field, and occasional yeasts. Renal ultrasound with Doppler study showed patent vessels with no evidence of hydronephrosis or perinephric fluid collection. The patient did not respond to IV fluid hydration, and a renal transplant biopsy was performed.
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■What is your differential diagnosis of the cause of acute renal failure in this patient?
■What do you see by light and electron microscopy?
■What is your clinico-pathologic diagnosis?
Discussion
What is your differential diagnosis of the cause of acute renal failure in this patient?
The differential diagnosis of acute renal failure occurring beyond 1 week after transplantation would include acute humoral and/or cellular rejection, calcineurin-inhibitor nephrotoxicity, thrombotic microangiopathy, urinary tract obstruction, systemic infection, or infection of the allograft.
What do you see by light and electron microscopy?
On the periodic acid–Schiff stain shown in Fig 1A, there was massive interstitial, tubular, and glomerular infiltration with yeast spores. On the Jones silver methylamine stain shown in Fig 1B, Bowman’s capsule is seen to be infiltrated with yeast forms of the fungus. Electron microscopy (Fig 1C) also shows Bowman’s capsule with yeast forms of the fungus.
Figure 1.
(A, B) Light microscopy ([A] periodic acid–Schiff stain; original magnification ×200; [B] Jones silver methylamine stain; original magnification ×600).
Figure 1.
(C) Electron microscopy (original magnification ×15,000).
What is your clinico-pathologic diagnosis?
The patient had a fungal infection of the renal allograft. Her blood culture was positive for Candida glabrata, for which she was treated initially with IV amphotericin B and later switched to oral voriconazole.
Fungal infections account for about 5% of infections in renal transplant recipients.1 Candida species are the most common fungal pathogen, and the most common site of infection is the urinary tract. Although rare, fungal infections portend greater mortality compared with bacterial and viral infections and therefore need special attention.
The prime time for fungal infections in transplant recipients is 1 to 6 months posttransplantation. Increased risk of fungal infections is associated with induction with muromonab-CD3, maintenance immunosuppression with tacrolimus, allograft rejection, recipients with diabetes mellitus, and prolonged pretransplantation dialysis time.2 The present patient had received induction therapy with alemtuzumab, a humanized monoclonal antibody directed against CD-52 expressed on B and T lymphocytes, monocytes, and natural killer cells. The risk of infection associated with alemtuzumab use as an induction agent in the organ transplant population is reported to be low,3 although a recent report showed that patients who received it as an antirejection therapy were 5 times more likely to develop an opportunistic infection.4
In our patient, the presence of yeast on the admission urinalysis was a surrogate marker of Candida infection of her allograft.
Final Diagnosis
Acute renal failure caused by renal allograft infection with C glabrata.
References
- . Infectious complications after renal transplantation. In: Morris PJ editors. Kidney Transplantation: Principles and Practice. (ed 3). Philadelphia, PA: Saunders; 1988;p. 533–573
- Hospitalization for fungal infections after renal transplant in the United States. Transplant Infect Dis. 2001;3:203–211
- . Campth-1H induction and the incidence of infectious complications in adult renal transplantation. Transplantation. 2006;81:17–20
- Opportunistic infections in 547 organ transplant recipients receiving alemtuzumab, a humanized monoclonal CD-52 antibody. Clin Infect Dis. 2007;44:204–212
Case provided by Nadia Wasi, MD,1 Venkata Reddivari, MD,2 Luis Salinas-Madrigal, MD,3 Paul Garvin, MD,4 Cherise Cortese, MD,5 and Bahar Bastani, MD,6 1Division of Nephrology, Saint Louis University School of Medicine; 2Department of Internal Medicine, Saint Luke’s Hospital; 3Department of Pathology, 4Division of Abdominal Transplant, 5Department of Pathology, and 7Division of Nephrology, Saint Louis University School of Medicine; Saint Louis, MO.Support: None.Financial Disclosure: None.
PII: S0272-6386(07)00893-1
doi:10.1053/j.ajkd.2007.06.001
Volume 50, Issue 3 , Pages A45-A46, September 2007
