Cavitary lung lesion 6 years after renal transplantation

Abstract

The differential diagnoses of a cavitary lung lesion in renal transplant recipients would include infection, malignancy and less commonly inflammatory diseases. Bacterial infection, Tuberculosis, Nocardiosis, fungal infections like Aspergillosis and Cryptococcosis need to be considered in these patients. Pulmonary cryptococcosis usually presents 16-21 mo after transplantation, more frequently in patients who have a high level of cumulative immunosuppression. Here we discuss an interesting patient who never received any induction/anti-rejection therapy but developed both BK virus nephropathy as well as severe pulmonary Cryptococcal infection after remaining stable for 6 years after transplantation. This case highlights the risk of serious opportunistic infections even in apparently low immunologic risk transplant recipients many years after transplantation. Core tip: Here we discuss an interesting patient who never received any induction/anti-rejection therapy but developed both BK virus nephropathy as well as severe pulmonary Cryptococcal infection after remaining stable for 6 years after transplantation. This case highlights the risk of serious opportunistic infections even in apparently low immunologic risk transplant recipients many years after transplantation. CASE REPORTA 40-year-old Indian man was admitted with low grade fever and dry cough for one month. He had end stage renal disease due to unclassified primary disease and had a live related renal transplantation with his sister as the donor in 2009. He was detected hepatitis B surface antigen (HBsAg) positive before transplantation and has been on Tenofovir since then. He received no induction and was initially maintained on Tacrolimus, Mycophenolate Mofetil (MMF) and Steroids. After a year, MMF was changed to Azathioprine due to financial constraints. He received Trimethoprim-Sulfamethoxazole for 6 mo after transplantation but no primary prophylaxis for Cytomegalovirus (CMV), Tuberculosis (TB) or fungal infection. His postoperative course was uneventful and he maintained serum creatinine of 1.1-1.2 mg/dL. He is a non smoker. Clinically, the patient was febrile, hemodynamically stable and hypoxemic (SPO2 92% on room air) requiring oxygen by mask. Investigations revealed pancytopenia (Hb 7.4 g/dL, total leucocyte count -3400/cu mm, platelet count -87000/cu mm) and high serum creatinine (2.5 mg%). Azathioprine was stopped. Tacrolimus trough level was 3.7 ng/mL. Urinalysis was unremarkable. Graft biopsy showed BK virus (BKV) nephropathy and serum BKV plasma load was more than 10 4 copies/mL.He was started empirically on broad spectrum antibiotics. Blood and urine cultures and quantitative CMV PCR assay were non-contributory. A non-contrast CT thorax showed bilateral, multiple, diffuse centrilobular and peribronchovascular cavitating nodules coalescing to form areas of consolidation with a larger cavity in apico posterior segment of upper lobe of left lung (Figure 1). Bronchoscopy with bronchoalveolar lavage (BAL) fluid cultures was unrevealing. Se...

Cavitary pulmonary disease in a patient on dialysis

“…7 The differential diagnosis of cavitary lung lesions is broad, including both infectious and non-infectious etiologies (Table 1). [8][9][10] This is particularly true for patients with end-stage kidney disease, who have an underlying state of immune dysregulation. Tuberculosis remains a leading cause in endemic countries.…”