Case Reports in Transplantation https://www.hindawi.com The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Successful Treatment of Recurrent Pulmonary Mucormycosis in a Renal Transplant Patient: A Case Report and Literature Review Mon, 13 Mar 2017 06:54:54 +0000 http://www.hindawi.com/journals/crit/2017/1925070/ Background. We describe the unusual case of a recently transplanted cadaveric renal transplant recipient who presented with recurrent pulmonary mucormycosis. Case Report. An 18-year-old man with end stage renal disease secondary to congenital renal agenesis status after cadaveric kidney transplant 4 months before presented with acute onset of fever, hemoptysis, and back pain. The patient underwent an emergent left lower lobectomy due to the critical nature of his illness. He was also treated with amphotericin with resolution of his symptoms. One week later, he had evidence of recurrent disease on imaging with a surgical site infection. He underwent reexploration with evacuation of an empyema and debridement of a surgical site infection. He was continued on IV antifungal therapy with isavuconazonium and amphotericin. Radiographic clearance of disease with three months of treatment was apparent with no evidence of recurrence at seven-month follow-up. Discussion. Opportunistic infections in solid organ transplant patients represent a significant source of morbidity and mortality. Most patients are treated with prophylactic anti-infective agents. However, rare infections such as pulmonary mucormycosis remain a risk. The transplant physician must be aware of these uncommon infections and their treatment strategies, including the management of uncommon recurrent disease. Morgan S. Martin, Alison A. Smith, Monica Lobo, and Anil S. Paramesh Copyright © 2017 Morgan S. Martin et al. All rights reserved. Immune Reconstitution Inflammatory Syndrome Occurring in a Kidney Transplant Patient with Extrapulmonary Tuberculosis Tue, 07 Mar 2017 00:00:00 +0000 http://www.hindawi.com/journals/crit/2017/6290987/ Tuberculosis (TB) occurring in solid organ transplantation (SOT) is associated with significant morbidity and mortality usually due to delays in diagnosis, drug toxicity encountered with antimycobacterial therapy, and drug-drug interactions. TB in SOT patients may mimic other infectious and noninfectious posttransplant complications such as posttransplant lymphoproliferative disorder (PTLD) and systemic cytomegalovirus infection. Immune reconstitution inflammatory syndrome (IRIS) is a host response resulting in paradoxical worsening of an infectious disease which occurs after the employment of effective therapy and reversal of an immunosuppressed state. We describe the development of immune reconstitution inflammatory syndrome (IRIS), a unique complication occurring during the treatment of extrapulmonary tuberculosis occurring after transplant which resulted from decreasing immunosuppression in a patient who received Alemtuzumab induction therapy. Although (IRIS) has been originally described in HIV/AIDS patients receiving highly active antiretroviral therapy (HAART), solid organ transplant recipients with diagnosed or occult TB whose immune system may undergo immune reconstitution during their posttransplant course represent a new high risk group. Jose Iglesias, Kandria Jumil Ledesma, Paul J. Couto, and Jessie Liu Copyright © 2017 Jose Iglesias et al. All rights reserved. Brincidofovir Use after Foscarnet Crystal Nephropathy in a Kidney Transplant Recipient with Multiresistant Cytomegalovirus Infection Mon, 27 Feb 2017 08:26:53 +0000 http://www.hindawi.com/journals/crit/2017/3624146/ Background. Cytomegalovirus (CMV) antiviral drug resistance constitutes an increasing challenge in transplantation. Foscarnet is usually proposed when resistance for ganciclovir is suspected, but its use is limited by its nephrotoxicity. Case Presentation. We report a case of multiresistant CMV disease in a kidney transplant recipient. Foscarnet was prescribed after ganciclovir treatment failure in a patient with two mutations in the UL97 viral gene. Foscarnet induced biopsy-proven kidney crystal precipitation that resulted in severe acute transplant failure and nephrotic syndrome. Despite a large decrease in immunosuppression, CMV disease was not controlled and a salvage therapy with Brincidofovir (BCV), which is an oral lipid conjugate of cidofovir with limited nephrotoxicity, was attempted. Clinical and virological remission was observed after a 21-day course of BCV, despite mild and reversible liver toxicity. However, a new relapse could not be effectively cured by BCV due to a new mutation in the UL54 gene, which is known to confer resistance to cidofovir. A new course of foscarnet finally resulted in prolonged CMV remission. Herein, we present a review of foscarnet nephropathy cases in solid-organ transplanted patients. Conclusions. This unique case highlights the potential benefit of BCV use during resistant CMV infection, although mutations in the UL54 gene may limit its therapeutic efficacy. These findings need to be confirmed in clinical trials. Romain Vial, Christine Zandotti, Sophie Alain, Alexandre Decourt, Noémie Jourde-Chiche, Raj Purgus, Charleric Bornet, Laurent Daniel, Valérie Moal, and Tristan Legris Copyright © 2017 Romain Vial et al. All rights reserved. Successful Treatment of Plasma Cell-Rich Acute Rejection Using Pulse Steroid Therapy Alone: A Case Report Tue, 10 Jan 2017 12:49:27 +0000 http://www.hindawi.com/journals/crit/2017/1347052/ Despite the recent development of immunosuppressive agents, plasma cell-rich acute rejection (PCAR) has remained refractory to treatment. Herein, we report an unusual case of PCAR that responded well to pulse steroid therapy alone. A 47-year-old man was admitted for a protocol biopsy three months after kidney transplantation, with a stable serum creatinine level of 1.6 mg/dL. Histological examination showed focal aggressive tubulointerstitial inflammatory cell infiltration of predominantly polyclonal mature plasma cells, leading to our diagnosis of PCAR. Three months following three consecutive days of high-dose methylprednisolone (mPSL) therapy, an allograft biopsy performed for therapy evaluation showed persistent PCAR. We readministered mPSL therapy and successfully resolved the PCAR. Although PCAR generally develops more than six months after transplantation, we diagnosed this case early, at three months after transplantation, with focally infiltrated PCAR. This case demonstrates the importance of early diagnosis and prompt treatment of PCAR to manage the development and severity of allograft rejection. Yo Komatsuzaki, Yasuyuki Nakada, Izumi Yamamoto, Mayuko Kawabe, Takafumi Yamakawa, Ai Katsuma, Haruki Katsumata, Aki Mafune, Akimitsu Kobayashi, Yusuke Koike, Hiroki Yamada, Jun Miki, Yudo Tanno, Ichiro Ohkido, Nobuo Tsuboi, Keitaro Yokoyama, Hiroyasu Yamamoto, and Takashi Yokoo Copyright © 2017 Yo Komatsuzaki et al. All rights reserved. Tacrolimus Toxicity due to Biliary Obstruction in a Combined Kidney and Liver Transplant Recipient Mon, 09 Jan 2017 07:13:05 +0000 http://www.hindawi.com/journals/crit/2017/9096435/ The immunosuppressant tacrolimus has a narrow therapeutic window, necessitating therapeutic drug monitoring to maintain efficacy and minimise toxicity. There are very few reports examining the impact of impaired biliary excretion on tacrolimus blood levels or toxicity. We report the case of a 26-year-old combined liver and kidney transplant recipient, who developed acute biliary obstruction leading to tacrolimus toxicity with very high blood tacrolimus levels. Despite a careful evaluation, no alternative cause was found for her acute kidney injury, and her kidney function returned to previous baseline within several days following treatment of the biliary obstruction and temporary withdrawal of tacrolimus. Samuel Chan, Michael T. Burke, David W. Johnson, Ross S. Francis, and David W. Mudge Copyright © 2017 Samuel Chan et al. All rights reserved. Urinary Obstruction of Transplanted Kidney Caused by Uterine Adenomyosis and 2-Year Posthysterectomy Psoas Abscess in Conjunction with Transplanted Kidney Tue, 20 Dec 2016 15:39:09 +0000 http://www.hindawi.com/journals/crit/2016/7142537/ Urinary obstruction of the transplanted kidney caused by uterine leiomyoma is an extremely rare condition. To the best of our knowledge, there are only two reports in English literature. Psoas abscess secondary to renal graft pyelonephritis is also uncommon. We present this unusual case and its treatment course. A 43-year-old female presented with renal dysfunction. She was started on peritoneal dialysis from the age of 26 years and received kidney transplantation from her mother (living donor) at the age of 27 years. Computed tomography (CT) revealed right hydronephrosis and a large uterine mass compressing the distal ureter of the transplanted kidney. After a simple total hysterectomy, her renal function improved. Two years following the hysterectomy, she experienced painful urination, fever, right abdominal pain, and right lower limb pain. CT and T2-weighed magnetic resonance imaging of her pelvis demonstrated right psoas abscess in conjunction with transplanted kidney. She was treated with broad-spectrum antibiotics alone, which resulted in a good response. Urinary obstruction of the transplanted kidney caused by uterine leiomyoma is an extremely rare condition. Psoas abscess secondary to transplanted kidney pyelonephritis is also rare. We should keep these rare diseases in mind when treating such cases. Yuta Takezawa, Yoshifumi Kadono, Takahiro Nohara, and Atsushi Mizokami Copyright © 2016 Yuta Takezawa et al. All rights reserved. Emergent Management of Intracardiac Thrombosis during Liver Transplantation Wed, 14 Dec 2016 12:44:39 +0000 http://www.hindawi.com/journals/crit/2016/6268370/ Intraoperative thromboembolism is a well-documented complication associated with orthotopic liver transplantation (OLT) but its identification and intraoperative treatment are still an emerging topic in anesthesia. Intracardiac thrombus during OLT is associated with a high mortality rate. There are only a few reports describing the successful management of thromboembolism during OLT. We describe a case where routine intraoperative transesophageal echocardiography during a live donor liver transplantation enabled early detection of an intracardiac thrombus with subsequent successful heparin treatment. Our case suggests that if an intracardiac thrombus is identified early (before hemodynamic instability occurs), the use of IV heparin may be a safe therapeutic option. Caroline Protin, Dmitri Bezinover, Zakiyah Kadry, and Thomas Verbeek Copyright © 2016 Caroline Protin et al. All rights reserved. Scedosporiosis in a Combined Kidney and Liver Transplant Recipient: A Case Report of Possible Transmission from a Near-Drowning Donor Tue, 13 Dec 2016 14:22:01 +0000 http://www.hindawi.com/journals/crit/2016/1879529/ Scedosporium spp. are saprobic fungi that cause serious infections in immunocompromised hosts and in near-drowning victims. Solid organ transplant recipients are at increased risk of scedosporiosis as they require aggressive immunosuppression to prevent allograft rejection. We present a case of disseminated Scedosporium apiospermum infection occurring in the recipient of a combined kidney and liver transplantation whose organs were donated by a near-drowning victim and review the literature of scedosporiosis in solid organ transplantation. Rachael Leek, Erika Aldag, Iram Nadeem, Vikraman Gunabushanam, Ajay Sahajpal, David J. Kramer, and Thomas J. Walsh Copyright © 2016 Rachael Leek et al. All rights reserved. Successful Stem Cell Transplantation in a Patient with Pretransplant Hepatic Inflammatory Pseudotumour Mon, 28 Nov 2016 07:54:03 +0000 http://www.hindawi.com/journals/crit/2016/6801916/ Inflammatory pseudotumours (IPT) are rare benign neoplasms of unknown aetiology. We present a case of hepatic IPT which was incidentally discovered in a patient with relapsed B-acute lymphoblastic leukaemia (B-ALL) undergoing pretransplant workup. After investigation to exclude an infective cause she underwent a reduced intensity conditioning stem cell transplant (SCT) successfully and currently remains well and in remission. On repeat liver MRI after SCT, the IPT was seen to be resolving. To the best of our knowledge this is the first report of an adult patient with hepatic IPT successfully undergoing SCT. The reduction in size of the IPT after SCT also suggests an inflammatory rather than an infective aetiology for IPT. Sanjay de Mel, Zarni Soe, Benjamin Wong, Ching Ching Ong, Lynette Teo, and Lip Kun Tan Copyright © 2016 Sanjay de Mel et al. All rights reserved. ST Elevation Infarction after Heart Transplantation Induced by Coronary Spasms and Mural Thrombus Detected by Optical Coherence Tomography Thu, 17 Nov 2016 09:38:23 +0000 http://www.hindawi.com/journals/crit/2016/1863869/ The case illustrates the possible link between coronary spasms, intraluminal thrombus formation, and widespread organized and layered thrombi in HTx patients. Furthermore, the case underlines the clinical value of OCT as a novel method for high-resolution vessel imaging in heart-transplanted (HTx) patients with coronary spasms and suspected coronary artery disease. Coronary spasms and sudden death are frequent complications after HTx. The underlying mechanisms leading to these complications are unknown. The present case displays the clinical course of a 19-year-old HTx patient who was hospitalized due to acute myocardial infarction induced by severe coronary spasms. The patients remained unstable on conservative therapy. Therefore, an optical coherence tomography (OCT) was performed and revealed massive, organized thrombi in the left main coronary artery, the circumflex coronary artery, and the left anterior descending coronary artery. The patient was stabilized after percutaneous coronary intervention. As a mural thrombus often goes undetected by coronary angiography, OCT may prove benefit in HTx patients with myocardial infarction or suspected coronary spasms. Tor Skibsted Clemmensen, Niels Ramsing Holm, Hans Eiskjær, Steen Hvitfeldt Poulsen, Michael Maeng, Christian Juhl Terkelsen, and Evald Høj Christiansen Copyright © 2016 Tor Skibsted Clemmensen et al. All rights reserved. Massive Ascites in a Renal Transplant Patient after Laparoscopic Fenestration of a Lymphocele Mon, 07 Nov 2016 13:54:38 +0000 http://www.hindawi.com/journals/crit/2016/7491627/ Retroperitoneal lymphocele is a common complication of renal transplantation. Here, we report the case of a 67-year-old woman with massive ascites after fenestration surgery for a lymphocele that developed following renal transplantation. She had been on continuous ambulatory peritoneal dialysis for 9 years. Living donor renal transplantation was performed and an intrapelvic lymphocele subsequently developed. The lymphocele did not resolve after aspiration therapy; therefore, laparoscopic fenestration was performed. Although the lymphocele disappeared, massive ascites appeared in its stead. Half a year later, the ascites was surgically punctured, which then gradually resolved and disappeared 6 weeks later. Aspiration therapy should be considered in patients on long-term peritoneal dialysis, although laparoscopic fenestration is safe and effective. Shohei Kawaguchi, Takahiro Nohara, Takashi Shima, Satoko Matsuyama, Chikako Nose, Junya Yamahana, Yoshifumi Kadono, Chikashi Seto, Masahiko Kawabata, and Atsushi Mizokami Copyright © 2016 Shohei Kawaguchi et al. All rights reserved. Fatal Donor-Derived Carbapenem-Resistant Klebsiella pneumoniae Infection in a Combined Kidney-Pancreas Transplantation Sun, 16 Oct 2016 08:03:32 +0000 http://www.hindawi.com/journals/crit/2016/7920951/ Carbapenem-resistant Klebsiella pneumoniae (CR-KP) infections in solid organ transplant recipients are associated with high morbidity and mortality. We report a case of a fatal donor-derived CR-KP infection in a combined kidney-pancreas transplant. Given the short interval of time between donor hospitalization and organ procurement, information concerning the donor CR-KP positivity arrived only 72 hours after transplant. Based on this experience, we believe that knowledge of the donor’s CR-KP status should be mandatory before procurement and, if positive, pancreas donation should be contraindicated. Giovanni Varotti, Ferdinando Dodi, Anna Marchese, Alessia Terulla, Massimo Bertocchi, and Iris Fontana Copyright © 2016 Giovanni Varotti et al. All rights reserved. Immune Complex Mediated Glomerulonephritis with Acute Thrombotic Microangiopathy following Newly Detected Hepatitis B Virus Infection in a Kidney Transplant Recipient Sun, 09 Oct 2016 14:06:06 +0000 http://www.hindawi.com/journals/crit/2016/3152495/ Hepatitis B virus (HBV) presents a risk to patients and staff in renal units. To minimise viral transmission, there are international and UK guidelines recommending HBV immunisation for patients commencing renal replacement therapy (RRT) and HBV surveillance in kidney transplant recipients. We report the case of a 56-year-old male who was immunised against HBV before starting haemodialysis. He received a deceased donor kidney transplant three years later, at which time there was no evidence of HBV infection. After a further six years he developed an acute kidney injury; allograft biopsy revealed an acute thrombotic microangiopathy (TMA) with glomerulitis, peritubular capillaritis, and C4d staining. Due to a “full house” immunoprofile, tests including virological screening were undertaken, which revealed acute HBV infection. Entecavir treatment resulted in an improvement in viral load and kidney function. HBV genotyping demonstrated a vaccine escape mutant, suggesting “past resolved” infection that reactivated with immunosuppression, though posttransplant acquisition cannot be excluded. This is the first reported case of acute HBV infection associated with immune complex mediated glomerulonephritis and TMA. Furthermore, it highlights the importance of HBV surveillance in kidney transplant recipients, which although addressed by UK guidelines is not currently practiced in all UK units. Tracey Salter, Hannah Burton, Sam Douthwaite, William Newsholme, Catherine Horsfield, and Rachel Hilton Copyright © 2016 Tracey Salter et al. All rights reserved. Strongyloides Hyperinfection Syndrome Combined with Cytomegalovirus Infection Thu, 15 Sep 2016 12:21:30 +0000 http://www.hindawi.com/journals/crit/2016/1786265/ The mortality in Strongyloides hyperinfection syndrome (SHS) is alarmingly high. This is particularly common in bone marrow, renal, and other solid organ transplant (SOT) patients, where figures may reach up to 50–85%. Immunosuppressives, principally corticosteroids, are the primary triggering factor. In general, the clinical features of Strongyloides stercoralis hyperinfection are nonspecific; therefore, a high index of suspicion is required for early diagnosis and starting appropriate therapy. Although recurrent Gram-negative sepsis and meningitis have been previously reported, the combination of both cytomegalovirus (CMV) and strongyloidiasis had rarely been associated. We here describe a patient who survived SHS with recurrent Escherichia coli (E. coli) urosepsis and CMV infection. Fatehi Elnour Elzein, Mohammed Alsaeed, Sulafa Ballool, and Ashraf Attia Copyright © 2016 Fatehi Elnour Elzein et al. All rights reserved. High on Cannabis and Calcineurin Inhibitors: A Word of Warning in an Era of Legalized Marijuana Tue, 09 Aug 2016 07:48:46 +0000 http://www.hindawi.com/journals/crit/2016/4028492/ Tacrolimus, a potent immunosuppressant medication, acts by inhibiting calcineurin, which eventually leads to inhibition of T-cell activation. The drug is commonly used to prevent graft rejection in solid organ transplant and graft-versus-host disease in hematopoietic stem cell transplant patients. Tacrolimus has a narrow therapeutic index with variable oral bioavailability and metabolism via cytochrome P-450 3A enzyme. Toxicity can occur from overdosing or from drug-drug interactions with the simultaneous administration of cytochrome P-450 3A inhibitors and possibly P-glycoprotein inhibitors. Tacrolimus toxicity can be severe and may include multiorgan damage. We present a case of suspected tacrolimus toxicity in a postallogeneic hematopoietic stem cell transplant patient who was concurrently using oral marijuana. This case represents an important and growing clinical scenario with the increasing legalization and use of marijuana throughout the United States. Naomi Hauser, Tanmay Sahai, Rocco Richards, and Todd Roberts Copyright © 2016 Naomi Hauser et al. All rights reserved. Preserved Renal Function in Kidney Transplantation over a Thrombosed Aortobifemoral Bypass Graft: The Role of Retrograde Flow and Early Thrombolysis Thu, 04 Aug 2016 13:18:32 +0000 http://www.hindawi.com/journals/crit/2016/6579591/ Aortobifemoral bypass (ABFB) thrombosis is not uncommon, and when the artery of a renal graft is implanted on a bypass the risk of graft loss is high. We report the case of a 48-year-old woman with a previous history of ABFB under antiplatelet therapy and a kidney allograft implanted on the vascular prosthesis, who presented with acute limb ischemia and severe renal impairment. Imaging techniques revealed a complete thrombosis of the proximal left arm of the ABFB. However, a faint retrograde flow over the graft was observed thanks to the recanalization of distal left bypass by collateral native arteries. This unusual situation not previously reported in a kidney transplant setting, together with an early diagnosis, allowed graft survival until an early local thrombolysis resolved the problem. Two years later, renal function remains normal. Saúl Pampa-Saico, Sara Jiménez-Alvaro, Fernando Caravaca-Fontán, Ana Fernández-Rodríguez, Maite Rivera-Gorrín, Juan Sánchez, Antonio Chinchilla, and Roberto Marcén Copyright © 2016 Saúl Pampa-Saico et al. All rights reserved. Eculizumab for the Treatment of Severe Antibody-Mediated Rejection: A Case Report and Review of the Literature Sun, 10 Jul 2016 12:43:51 +0000 http://www.hindawi.com/journals/crit/2016/9874261/ In renal transplantation, treatment options for antibody-mediated rejection are limited. Here, we report a case of severe AMR treated with eculizumab. A 50-year-old woman known for end stage kidney disease secondary to IgA nephropathy received a kidney transplant from a 50-year-old deceased donor. At 5 months after transplantation, she presented with acute graft dysfunction and biopsy showed a severe antibody-mediated rejection associated with thrombotic microangiopathy. Despite an aggressive conventional immunosuppressive regimen, signs of rejection persisted and the patient was treated with 3 doses of eculizumab. Following the therapy, markers of TMA improved and graft function stabilized. However, ongoing signs of rejection remained in the repeated biopsy. In kidney transplantation, eculizumab is an expensive treatment and its role in the treatment of antibody-mediated rejection remains to be determined. Duy Tran, Anne Boucher, Suzon Collette, Alexis Payette, Virginie Royal, and Lynne Senécal Copyright © 2016 Duy Tran et al. All rights reserved. Rapid Resolution of Cholangitic Abscess and Biliary Sepsis in a Liver Transplant Recipient after Hepatic Artery Revascularization Wed, 01 Jun 2016 08:02:10 +0000 http://www.hindawi.com/journals/crit/2016/1520849/ Hepatic arterial flow is paramount in preserving biliary integrity. We present an interesting clinical scenario of a liver transplant recipient with biliary anastomotic stricture who developed biliary abscess and sepsis after Endoscopic Retrograde Cholangiopancreatography. The abscess did not respond to maximal medical management, percutaneous drainage, and adequate endoscopic biliary drainage. Clinically, patient continued to deteriorate and imaging identified hepatic artery stenosis which was treated with percutaneous intra-arterial stenting. Revascularization and perfusion of infected area led to rapid resolution of abscess and sepsis. This case emphasizes the anatomic basis of biliary ductal pathology. An important educational point is to understand that interrupted hepatic arterial supply can lead to biliary complications in liver transplant recipients and early correction of perfusion deficit should be pursued in such cases. In nonresolving hepatobiliary infections after liver transplantation, hepatic arterial compromise should be looked for and if present promptly treated. Reperfusion of biliary system in our patient led to improved antibiotics penetration, resolution of abscess and sepsis, and healing of biliary stricture. Sushrut Trakroo and Kamran Qureshi Copyright © 2016 Sushrut Trakroo and Kamran Qureshi. All rights reserved. Early Posttransplant Isolated v1 Lesion Does Not Need to Be Treated and Does Not Lead to Increased Fibrosis Tue, 17 May 2016 09:44:45 +0000 http://www.hindawi.com/journals/crit/2016/4603014/ Acute vascular rejection (AVR) is characterized by intimal arteritis in addition to tubulitis and interstitial inflammation. It is associated with a poorer prognosis compared to tubulointerstitial rejection (AIR) and AVR is associated with a higher rate of graft loss than AIR. The prognosis and treatment of arteritis without tubulitis and interstitial inflammation (isolated v1 lesion) are still controversial. We report a case of a patient who had a biopsy of the kidney allograft for evaluation of slow graft function. The biopsy revealed an isolated v1 lesion. However, we chose not to augment immunosuppression. The patient’s kidney allograft function improved over time with close monitoring. Repeat biopsy a year later showed no evidence of endothelialitis and relatively unchanged fibrosis and no other abnormalities. Although it is suggested that most cases of isolated v1 lesions will respond to corticosteroids or T cell depleting therapies, some cases will improve with conservative management. Further studies are needed to determine which cases could be managed conservatively. Irfan Moinuddin, Bijin Thajudeen, Amy Sussman, Machaiah Madhrira, Erika Bracamonte, Mordecai Popovtzer, and Pradeep V. Kadambi Copyright © 2016 Irfan Moinuddin et al. All rights reserved. Application of the Liver Maximum Function Capacity Test in Acute Liver Failure: A Helpful Tool for Decision-Making in Liver Transplantation? Wed, 04 May 2016 11:42:20 +0000 http://www.hindawi.com/journals/crit/2016/7074636/ Background. Despite aggressive intensive medical management acute liver failure (ALF) may require high-urgency liver transplantation (LTx). Available prognostic scores do not apply for all patients; reliable tools to identify individuals in need of LTx are highly required. The liver maximum function capacity test (LiMAx) might represent an appropriate option. Referring to a case of ALF after Amanita phalloides-intoxication the potential of the LiMAx-test in this setting is discussed. Presentation of Case. LiMAx was performed in a 27-year-old patient prior to and after high-urgency LTx. In accordance with clinical appearance of hepatic encephalopathy, coagulopathy, and acute kidney failure, the LiMAx-test constituted a fulminant course of ALF with hardly any detectable metabolic activity. Following LTx with a marginal donor organ (95% hepatosteatosis), uptake of liver function was demonstrated by postoperative increase of the LiMAx-value. The patient was discharged from hospital on postoperative day 26. Discussion. ALF often is associated with a critical state of the patient that requires almost immediate decision-making regarding further therapy. Application of a noninvasive liver function test might help to determine the prognosis of ALF and support decision-making for or against LTx as well as acceptance of a critical donor organ in case of a critically ill patient. Florian Wolfgang Rudolf Vondran, Carsten Schumacher, Kai Johanning, Björn Hartleben, Wolfgang Knitsch, Olaf Wiesner, Elmar Jaeckel, Michael Peter Manns, Juergen Klempnauer, Hueseyin Bektas, and Frank Lehner Copyright © 2016 Florian Wolfgang Rudolf Vondran et al. All rights reserved. First Autologous Cord Blood Therapy for Pediatric Ischemic Stroke and Cerebral Palsy Caused by Cephalic Molding during Birth: Individual Treatment with Mononuclear Cells Sat, 30 Apr 2016 11:06:36 +0000 http://www.hindawi.com/journals/crit/2016/1717426/ Intracranial laceration due to traumatic birth injury is an extremely rare event affecting approximately one newborn per a population of 4.5 million. However, depending on the mode of injury, the resulting brain damage may lead to lifelong sequelae, for example, cerebral palsy for which there is no cure at present. Here we report a rare case of neonatal arterial ischemic stroke and cerebral palsy caused by fetal traumatic molding and parietal depression of the head during delivery caused by functional cephalopelvic disproportion due to a “long pelvis.” This patient was treated by autologous cord blood mononuclear cells (45.8 mL, cryopreserved, TNC ) with a remarkable recovery. Active rehabilitation was provided weekly. Follow-up examinations were at 3, 18, 34, and 57 months. Generous use of neonatal head MRI in case of molding, craniofacial deformity, and a sentinel event during parturition is advocated to enhance diagnosis of neonatal brain damage as a basis for fast and potentially causative treatment modalities including autologous cord blood transplantation in a timely manner. A. Jensen and E. Hamelmann Copyright © 2016 A. Jensen and E. Hamelmann. All rights reserved. False Positive B-Cells Crossmatch after Prior Rituximab Exposure of the Kidney Donor Thu, 28 Apr 2016 11:38:29 +0000 http://www.hindawi.com/journals/crit/2016/4534898/ Crossmatching is essential prior to kidney transplantation to confirm compatibility between the donor and the recipient, particularly to prevent acute antibody-mediated rejection. An unexpected positive crossmatch may be obtained in recipients with an autoimmune disease or preexisting antibodies not detected by single-antigen bead array due to complement interference or who have been previously treated by desensitization protocols such as rituximab, antithymocyte globulin, or intravenous immunoglobulins. We report donor and recipient investigations that revealed unexpected positive B-cells crossmatch, probably due to donor cells, as the donor had received rituximab therapy shortly before organ harvesting, in a context of severe idiopathic thrombocytopenic purpura. We consequently detected unexpected Class II IgG complement-dependent cytotoxicity for all sera tested. Other laboratory investigations failed to elucidate the reasons for this recipient-related positivity. Judith Desoutter, Marie-Joëlle Apithy, Ségolène Bartczak, and Nicolas Guillaume Copyright © 2016 Judith Desoutter et al. All rights reserved. Lung Transplant Recipient with Pulmonary Alveolar Proteinosis Sun, 24 Apr 2016 08:40:17 +0000 http://www.hindawi.com/journals/crit/2016/4628354/ Pulmonary alveolar proteinosis (PAP) is a progressive lung disease characterized by accumulated surfactant-like lipoproteinaceous material in the alveoli and distal bronchioles. This accumulation is the result of impaired clearance by alveolar macrophages. PAP has been described in 11 solid organ transplant recipients, 9 of whom were treated with mammalian target of rapamycin inhibitors. We report a case of a lung transplant recipient treated with prednisone, mycophenolate mofetil (MMF), and tacrolimus who ultimately developed PAP, which worsened when MMF was replaced with everolimus. Sofya Tokman, M. Frances Hahn, Hesham Abdelrazek, Tanmay S. Panchabhai, Vipul J. Patel, Rajat Walia, and Ashraf Omar Copyright © 2016 Sofya Tokman et al. All rights reserved. Different Management Options for Transplant Ureteral Obstructions within an Inguinal Hernia Sun, 10 Apr 2016 08:20:34 +0000 http://www.hindawi.com/journals/crit/2016/4730494/ Ureteral obstruction secondary to an inguinal hernia with transplant ureteral component is an extremely rare entity with only several case reports found in literature. In all previously reported cases, management of the obstruction involved temporary drainage with ureteral stenting or nephrostomy tube placements followed by delayed definitive repair. We present two case reports, here one being the first one managed by immediate definitive repair via ureteral reimplant and herniorrhaphy and a second case by delayed definitive repair after percutaneous nephrostomy tube placement. Both patients continued to do well postoperatively with normalization of renal function on follow-up. Felix Cheung, Merrit Marion Debartolo, Leonard Michael Copertino, April Adams Szafran, Chelsea Caron Estrada, Patrick Gerard Lynch, and Frank Sam Darras Copyright © 2016 Felix Cheung et al. All rights reserved. Successful Treatment of Focal Segmental Glomerulosclerosis after Kidney Transplantation with Plasma Exchange and Abatacept in a Patient with Juvenile Rheumatoid Arthritis Sun, 20 Mar 2016 13:51:15 +0000 http://www.hindawi.com/journals/crit/2016/7137584/ Recurrent focal segmental glomerulosclerosis (FSGS) after renal transplantation is difficult to treat. Recently a series of four patients unresponsive to plasma exchange (PE) and rituximab, who were successfully treated with abatacept, has been reported. We present a 26-year-old Caucasian patient who suffered from juvenile rheumatoid arthritis and developed severe proteinuria eleven days after transplantation. An allograft biopsy was suggestive of recurrent focal segmental glomerulosclerosis. He did not respond to PE therapy. A first dose of abatacept produced partial remission. Four weeks later proteinuria again increased and a second biopsy showed progression of disease. After another ineffective course of PE he was given a second dose of abatacept, which was followed by rapid, complete, and sustained resolution of proteinuria. This treatment caused a significant increase in BK and JC viremia. Whether abatacept ameliorated proteinuria via an effect on podocytes or on the patient’s primary disease remains speculative. Hannelore Sprenger-Mähr, Emanuel Zitt, Afschin Soleiman, and Karl Lhotta Copyright © 2016 Hannelore Sprenger-Mähr et al. All rights reserved. Treatment of Cytomegalovirus Infection with Cidofovir and CMV Immune Globulin in a Lung Transplant Recipient Wed, 13 Jan 2016 13:07:39 +0000 http://www.hindawi.com/journals/crit/2016/4560745/ Cytomegalovirus (CMV) infection after lung transplantation is associated with increased risk for pneumonitis and bronchiolitis obliterans as well as allograft rejection and opportunistic infections. Ganciclovir is the mainstay of prophylaxis and treatment but CMV infections can be unresponsive. Apart from direct antiviral drugs, CMV immunoglobulin (CMVIG) preparations may be considered but are only licensed for prophylaxis. A CMV-seronegative 42-year-old man with cystic fibrosis received a lung from a CMV-seropositive donor. Intravenous ganciclovir prophylaxis was delayed until day 12 due to acute postoperative renal failure and was accompanied by five doses of CMVIG (10 g). By day 16, CMV-DNA was detectable and rising; CMV-specific T-cells were undetectable. Switch from ganciclovir to foscarnet prompted a transient decrease in CMV viral load, but after increasing again to reach 3600 copies/mL foscarnet was changed to intravenous cidofovir and CMVIG was restarted. CMV load continued to fluctuate and declined slowly, whereas CMV-specific T-cells were detected five months later and increased thereafter. At last follow-up, the patient was in very good clinical condition with no evidence of bronchiolitis obliterans. No side effects of this treatment were observed. In this hard-to-treat case, the combination of cidofovir with off-label use of CMVIG contributed to a successful outcome. Heinrike Wilkens and Martina Sester Copyright © 2016 Heinrike Wilkens and Martina Sester. All rights reserved. Septic Shock Induced by Bacterial Prostatitis with Morganella morganii subsp. morganii in a Posttransplantation Patient Mon, 21 Dec 2015 11:54:52 +0000 http://www.hindawi.com/journals/crit/2015/850532/ Bacterial infection is a common complication after Hematopoietic Stem Cell Transplantation (HSCT). Morganella morganii is ubiquitous Gram-negative facultative anaerobe, which may cause many kinds of opportunistic infection. Herein we report a case of a 55-year-old man who presented with frequent urination, urgency, and mild pain that comes and goes low in the abdomen and around the anus. The patient had a medical history of chronic prostatitis for 4 years. He received HLA-matched sibling allo-HSCT because of angioimmunoblastic T-cell lymphoma 29 months ago. The routine examination of prostatic fluid showed increased leukocytes and the culture of prostatic fluid showed Morganella morganii subsp. morganii. The patient developed chills and fever 18 hours after examination. Both urine culture and blood culture showed Morganella morganii subsp. morganii. The patient was successfully treated with antibiotic therapy and septic shock management. Taken together, Morganella morganii should be considered a possible pathogen when immunocompromised patients develop prostatitis. Also, prostatic massage could be a possible trigger of septic shock induced by Morganella morganii subsp. morganii in a posttransplantation patient. Xiaofan Li and Jianhui Chen Copyright © 2015 Xiaofan Li and Jianhui Chen. All rights reserved. Gastrointestinal Bleeding and Diffuse Skin Thickening as Kaposi Sarcoma Clinical Presentation Thu, 10 Dec 2015 12:20:36 +0000 http://www.hindawi.com/journals/crit/2015/424508/ A 56-year-old African patient received a kidney from a deceased donor with 4 HLA mismatches in April 2013. He received immunosuppression with basiliximab, tacrolimus, mycophenolate mofetil, and prednisone. Immediate diuresis and a good allograft function were soon observed. Six months later, the serum creatinine level increased to 2.6 mg/dL. A renal allograft biopsy revealed interstitial fibrosis and tubular atrophy grade II. Toxicity of calcineurin inhibitor was assumed and, after a switch for everolimus, renal function improved. However, since March 2014, renal function progressively deteriorated. A second allograft biopsy showed no new lesions. Two months later, the patient was admitted due to anuria, haematochezia with anaemia, requiring 5 units of packed red blood cells, and diffuse skin thickening. Colonoscopy showed haemorrhagic patches in the colon and the rectum; histology diagnosis was Kaposi sarcoma (KS). A skin biopsy revealed cutaneous involvement of KS. Rapid clinical deterioration culminated in death in June 2014. This case is unusual as less than 20 cases of KS with gross gastrointestinal bleeding have been reported and only 6 cases had the referred bleeding originating in the lower gastrointestinal tract. So, KS should be considered in differential diagnosis of gastrointestinal bleeding in some kidney transplant patients. Sara Querido, Henrique Silva Sousa, Tiago Assis Pereira, Rita Birne, Patrícia Matias, Cristina Jorge, André Weigert, Teresa Adragão, Margarida Bruges, and Domingos Machado Copyright © 2015 Sara Querido et al. All rights reserved. Utility of Iron Staining in Identifying the Cause of Renal Allograft Dysfunction in Patients with Sickle Cell Disease Tue, 01 Dec 2015 09:28:03 +0000 http://www.hindawi.com/journals/crit/2015/528792/ Sickle cell nephropathy (SCN) is associated with iron/heme deposition in proximal renal tubules and related acute tubular injury (ATI). Here we report the utility of iron staining in differentiating causes of renal allograft dysfunction in patients with a history of sickle cell disease. Case 1: the patient developed acute allograft dysfunction two years after renal transplant. Her renal biopsy showed ATI, supported by patchy loss of brush border and positive staining of kidney injury molecule-1 in proximal tubular epithelial cells, where diffuse increase in iron staining (2+) was present. This indicated that ATI likely resulted from iron/heme toxicity to proximal tubules. Electron microscope confirmed aggregated sickle RBCs in glomeruli, indicating a recurrent SCN. Case 2: four years after renal transplant, the patient developed acute allograft dysfunction and became positive for serum donor-specific antibody. His renal biopsy revealed thrombotic microangiopathy (TMA) and diffuse positive C4d stain in peritubular capillaries. Iron staining was negative in the renal tubules, implying that TMA was likely associated with acute antibody-mediated rejection (AAMR, type 2) rather than recurrent SCN. These case reports imply that iron staining is an inexpensive but effective method in distinguishing SCN-associated renal injury in allograft kidney from other etiologies. Yingchun Wang, Mona Doshi, Salman Khan, Wei Li, and Ping L. Zhang Copyright © 2015 Yingchun Wang et al. All rights reserved. Treatment of Recurrent Posttransplant Lymphoproliferative Disorder with Autologous Blood Stem Cell Transplant Wed, 25 Nov 2015 12:49:46 +0000 http://www.hindawi.com/journals/crit/2015/801082/ Background. Posttransplant lymphoproliferative disorders (PTLDs) occur after solid organ transplantation. Treatment guidelines include reduction in immunosuppression (RIS), radiation, rituximab, chemotherapy, and immunological agents. We present a rare case of recurrent diffuse large B-cell lymphoma presenting as a PTLD in a heart transplant patient treated with autologous blood stem cell transplant (ASCT) after failure of conventional therapy. Case Presentation. A 66-year-old male presented with a neck mass. He has a history of Hodgkin’s disease status after staging laparotomy with splenectomy and heart transplantation due to dilated nonischemic cardiomyopathy 8 years prior to the development of PTLD. His examination was remarkable for right submandibular swelling. An excisional biopsy confirmed the diagnosis of diffuse large B-cell NHL. Patient received RIS, rituximab, chemotherapy, and radiation therapy with a complete remission. His lymphoma relapsed and he subsequently was treated with RICE salvage chemotherapy and consolidative high-dose chemotherapy with BEAC regimen followed by ASCT resulting in a complete remission. Conclusion. Patients with PTLD present a difficult therapeutic challenge. In this case, the patient’s prior history of Hodgkin’s disease, splenectomy, and a heart transplant appear to be unique features, the significance of which is unclear. ASCT might be a promising therapy for patients with relapsed or refractory PTLD. Bharat Malhotra, Ahmad K. Rahal, Hussam Farhoud, Dennis F. Moore Jr., and K. James Kallail Copyright © 2015 Bharat Malhotra et al. All rights reserved.