exciting cases in transplant infectious diseases wanessa clemente digestive transplant service...
DESCRIPTION
Case Presentation Time of transplantation 31 yo female, DM since age 17 y Hemodialysis (9 mo before transplantation) Kidney-pancreas transplant (Enteric drainage) IS regimen: Steroid + FK + MMF Hematoma (reopperated), Urinary fistula + UTI (clinical approach) E. coli MS Length of stay: 1 month Prophylaxis: – GCV, trimethoprim-sulfamethoxazole, ivermectin +albendazoleTRANSCRIPT
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Exciting Cases in Transplant Infectious Diseases
Wanessa ClementeDigestive Transplant Service
University of Minas Gerais - Brazil
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Outline
• Case Presentation
• Question
• Literature information
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Case Presentation Time of transplantation
• 31 yo female, DM since age 17 y• Hemodialysis (9 mo before transplantation)• Kidney-pancreas transplant (Enteric drainage)• IS regimen: Steroid + FK + MMF• Hematoma (reopperated), Urinary fistula + UTI (clinical
approach) E. coli MS• Length of stay: 1 month• Prophylaxis:
– GCV, trimethoprim-sulfamethoxazole, ivermectin +albendazole
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~ 18 months after transplantation: Persistent diarrhea + vomiting of 2 weeks duration.
Sore throat: 4 weeks before hospital admission.
Distended and diffused painful abdomen.
No cutaneous lesions.
During hospitalization: Fever Cefepime
Admission Laboratory
Findings:
Case Presentation
CMV antigenemia Negative
Clostridium toxin Negative
Acid-staining test (Cryptosporidium and Isospora)
Negative
Blood cultures Negative
Urine culture >100,000 UFCK pneumoniae
Stool Negative, including Baermann-Moraes method
Blood exam Hemoglobin 11.8g/dL; WBC 6630/mm3
Eosinophilia 21%/1390/mm3 Platelets 376,000/ mm3
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Upper intestinal obstruction
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Esophagogastroduodenoscopy
Normal esophagus, mild
pangastritis, nonspecific
duodenitis. Diffusely
ulcerated duodenal mucosa.
Duodenal wall thickening with
obstruction of the lumen.
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Abdominal CT
Pancreas and kidney grafts with usual appearance. Absence of lymphadenomegaly. Marked thickening of theduodenum and jejunum wall with reduction of the lumen. Significant dilation of the stomach.
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Biopsy
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Chest radiograph
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Follow-up
• Immunosuppresion was reduced
• Ivermectin (200 μg/kg/d for 30 days)
• Control EGD (after 2 wk): GI CMV Gancyclovir
• Hospital discharge: Day 31
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On the other hand...
TID, Vilela 2008
Fatal case of SS hyperinfection in 43 yo LT recipient. Two weeks after IS treatment for graft rejection. Cause of death: alveolar hemorrhage + secondary sepsis
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Questions
Q1: What is the Ss epidemiology?
Q2: When to suspect?
Q3: Should prophylaxis or empiric treatment be done?
Q4: Which treatment regimen is better?
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Epidemiological aspects
Strongyloidiasis is a worldwide infection, but unusually reported in SOT
recipients Schwartz & Mawhorter AJT 2013
SS hyperinfection syndrome is more frequent within 3 mo of transplantation
Classically follows corticosteroid therapy Fardet Journal of Infection 2007
Diagnostic methods lacks in sensitivity and specificity Buonfrate CMI 2015
Mortality can approach 70%
DD Ss infection is rare but recognized transplant complication Le AJT 2014
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Geographic Distribution
Plos 2013
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Which drug should be chosen?
Preferred: Ivermectin
Alternative: Thiabendazole/ Albendazole (Second-line drugs)
Consider intermittent treatment in high-risk patients
Which regimen?
Daily oral ivermectin 5 - 7d 30 dVeterinary preparationsConsider adjuvant ATM therapy
Fox Curr Opin Infect Dis 2006
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• Patients who have lived in an endemic region should be screened before procedure/ IS (stool examination and eosinophilia) or treated without screening (e.g. false negative testing)
• Antibody testing may be useful in non-endemic setting
• DDI has been documented, mainly intestinal and pancreatic transplant recipient
Considerations
Ahead of print Transplantation. Wright et al