Successful treatment of renal malakoplakia via the reduction of immunosuppression and antimicrobial therapy after kidney transplantation: a case report

Abstract

Malakoplakia is a rare, granulomatous disease that usually affects immunocompromised individuals and is generally associated with poor graft and patient survival. We present a case of renal malakoplakia after kidney transplantation (KT). A 33-year-old woman with chronic kidney disease underwent living-donor KT at Severance Hospital. The patient was administered 375 mg/m 2 rituximab due to high panel reactive antibodies. Immunosuppression was initiated with 1.5 mg/kg anti-thymocyte globulin and intravenous methylprednisolone and maintained with tacrolimus, oral methylprednisolone, and mycophenolate mofetil (MMF). Six months after KT, the patient was hospitalized for a urinary tract infection with an elevated serum creatinine level of 3.14 mg/dL. Renal biopsy revealed malakoplakia involving the renal parenchyma. Upon this diagnosis, the dose of tacrolimus was reduced and MMF was stopped. Fluoroquinolone was used for 16 days, and the trimethoprim/sulfamethoxazole dose was doubled for 6 days. The patient was hospitalized for 3 weeks and closely observed during outpatient visits. Follow-up ultrasonography revealed mass-like lesions of renal malakoplakia, which disappeared 5 months after diagnosis. The serum creatinine level decreased to 1.29 mg/dL 28 months after diagnosis. Our results suggest that renal malakoplakia can be successfully treated by the reduction of immunosuppression and sustained antimicrobial therapy.

Cutaneous malakoplakia arising on the ankle of a patient with pyoderma gangrenosum

“…In general, the overall prognosis for malakoplakia is good with initiation of the appropriate treatment. While consideration may be given to lowering or removing immunosuppressive therapy, the decision must be balanced with the condition for which the agents are being used and likely involve a multidisciplinary decision‐making strategy 19,20 …”

“…While consideration may be given to lowering or removing immunosuppressive therapy, the decision must be balanced with the condition for which the agents are being used and likely involve a multidisciplinary decision-making strategy. 19,20 There is only one known reported case of cutaneous malakoplakia masquerading as pyoderma gangrenosum, but no known reports in the literature documenting development of cutaneous malakoplakia on the ankle in the setting of previously diagnosed pyoderma gangrenosum. In this particular case, it is likely that the immunosuppressive agents used to manage the patient's previously biopsyproven, treatment-refractory pyoderma gangrenosum predisposed him to developing a bacterial infection, which in turn may have contributed to the development of cutaneous malakoplakia.…”