A 34-year-old woman with a cadaveric renal transplant was admitted with a history of fever for 2 days and productive cough.
She had undergone a cadaveric renal transplantation in July 2010, 10 months before this hospitalization. The immunosuppression for her renal transplant consisted of IV methylprednisolone and IV thymoglobulin, followed by oral tacrolimus, mycophenolate acid (Myfortic) and prednisolone. She had delayed graft function, requiring 3 sessions of hemodialysis immediately post-transplantation. The case was further complicated by an episode of acute cellular rejection (Banff 4b, type 1A), which responded to IV methylprednisolone for 3 days. Subsequent graft biopsy showed severe hypertensive changes, with only mild tubulitis. Prior to the transplantation she was on hemodialysis for 14 years (since 1996, primary etiology was unknown). She was a non-smoker, and a housewife.
On admission, she was noted to have high-grade fever and mild tachypnea. She was otherwise hemodynamically stable. The result of lung examination was essentially normal. An initial chest X-ray revealed a mass in the right upper zone, which developed into a cavity with an air-fluid level (chest X-ray 2 days post-admission) (Figures 1, 2). A CT scan of the thorax showed a cavity in the right lung, which could represent an infective lesion with endobronchial spread. Her renal function deteriorated acutely, and serum creatinine rose from her baseline of 110 umol/L to more than 200 umol/L. Her CRP was raised, at 11.4 mg/dL (normal <0.30 mg/dL), and ESR was 43 mm/hour. Her white blood cell count was not raised, at 6.5x103/uL. She was initially treated with IV ceftriaxone 2 g daily and oral azithromycin 500 mg daily.
On her 4th day of admission, her blood culture grew Rhodococcus species, sensitive to cefuroxime (parenteral), linezolid, rifampicin, vancomycin and meropenem, and resistant to chloramphenicol and tetracycline. In view of the culture findings and her persistent spiking fever, the antibiotics were switched to IV meropenem and metronidazole, her dose of mycophenolic acid (Myfortic) was halved, and her tacrolimus dosage was also reduced.
On her 10th day of admission, she was still having persistent spiking fever; IV fluconazole was added to cover the possibility of fungal infection, and her mycophenolic acid was stopped. Bronchoscopy was done, and the findings showed pus secretions from the lateral segment of the right upper lobe, and due to bleeding, transbronchial lung biopsy was not performed.
Her fever eventually subsided on day 12 of admission, with improvement in her cough. The bronchial washing results showed a negative culture, with no evidence of acid-fast bacilli or malignant cells. Endobronchial biopsy showed no evidence of granuloma or malignancy. Her serum creatinine slowly improved to her baseline of 110 umol/L.
IV metronidazole and fluconazole were stopped after 2 weeks, and she was continued on IV meropenem 1 g bd, and oral azithromycin 250 mg od was added. She remained afebrile, and her renal function was stable on tacrolimus and prednisolone. Her CRP and ESR were coming down to normal level as well. She was given IV meropenem for a total duration of 4 weeks, and was then put on a prolonged course (we initially planned for at least 2 months) of oral azithromycin and ciprofloxacin. Mycophenolic acid was restarted at a low dose (180 mg bd). She was discharged after a month of hospitalization.
One month after her discharge she developed fever and cough again, with greenish/chocolate coloured sputum. The repeated chest X-ray showed the same lesion (Figure 3), with no evidence of reduction in size. Repeated blood and sputum cultures, and tuberculosis work-up had all been negative. She was continued on oral azithromycin and ciprofloxacin, while IV meropenam was restarted and her mycophenolic acid was stopped again. A repeat CT scan of the thorax showed reduction of the cavity (from 7.3x9.3 cm to 5.6x5.7 cm). She was treated with meropenem for another week, and was discharged after 2 weeks of hospitalization. Again, mycophenolic acid was started at a low dose (180 mg bd).
One month after her second discharge, the repeated chest X-ray showed the same lesion (Figure 4), her ESR has come down to 14 mm/hour and CPR was 0.10 mg/dL. Although lobectomy was considered by the cardiothoracic team, the patient was reluctant.
A repeat CT scan of thorax was done 6 months after her first presentation, and it showed resolution of the abscess, and her chest X-ray also showed the lesion was cleared up (Figure 5). Her oral azithromycin and ciprofloxacin were stopped after 6 months. She remained well 7 months after the initial presentation, with her renal function at the post-transplantation baseline level (110 umol/L).