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Open Access Highly Accessed Case report

A rare case of cytomegalovirus, scedosporium apiospermum and mycobacterium tuberculosis in a renal transplant recipient

Manish Rathi1*, Srikant Gundlapalli1, Raja Ramachandran1, Sandeep Mohindra3, Harsimran Kaur2, Vivek Kumar1, Harbir Singh Kohli1, Krishan Lal Gupta1 and Vinay Sakhuja1

Author Affiliations

1 Department of Nephrology, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India

2 Department of Mycology, Postgraduate Institute of Medical Education & Research, Chandigarh, India

3 Department of Neurosurgery, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India

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BMC Infectious Diseases 2014, 14:259  doi:10.1186/1471-2334-14-259

Published: 14 May 2014

Abstract

Background

Renal transplant recipients are at high risk of developing multiple infections, often concomitantly because of their immunocompromised status. Post renal transplant infections are often elusive and require extensive evaluation for proper diagnosis and treatment. A high index of suspicion is required and an attempt should be made to confirm the microbiological diagnosis from each site involved to rule out multiple infections.

Case presentation

We report a 50-year-old female, a renal allograft recipient who presented with left hemiplegia, esophageal ulcers and fever 3 months after her transplant. Esophageal biopsy revealed Cytomegalovirus (CMV) inclusions and the whole blood quantitative CMV polymerase chain reaction (PCR) was positive. Neuroimaging showed a brain abscess, stereotactic biopsy from which revealed Scedosporium apiospermum on fungal culture. Her tacrolimus and mycophenolate were stopped and she was managed with intravenous ganciclovir and voriconazole. With these measures, she showed marked improvement in her general and neurological condition. Two months later, she developed recurrence of fever with dry cough. Radiological investigation revealed a cavitating lung lesion, a needle aspiration from which demonstrated acid-fast bacilli. She was started on antituberculous treatment. With these measures, she recovered completely and maintained good graft function despite being on only prednisolone 10 mg once a day.

Conclusion

Although CMV disease is not uncommon in the first three months post transplant, Scedosporium is a rare cause of brain abscess. On the other hand, tuberculosis is common in transplant recipients, especially in developing countries, like India. However, this is the first case report of occurrence of these three infections in the same patient, demonstrating the importance of a good microbiological work-up from each site involved in immunosuppressed subjects.

Keywords:
Cytomegalovirus; Scedosporium apiospermum; Renal transplant; Brain abscess; Post transplant tuberculosis