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Central Nervous System Infection
in a Kidney Transplant Recipient
Elena Maiolo
Laura Ducatenzeiler
Hospital Argerich
Unidad de Ablación e implante
Comisión TOS SADI
roberta.lattes @gmail.com
Consultant ID: INBA
Clinical case
• Male, 47 y, diabetes and hypertensive nephropathy in HD since
1999
• Kidney Tx 15/Oct/03 with a DD.
• Immunosuppressed Tymoglobulin, and then CsA, MMF and C-ST
serology
donor
receptor
HepatitisA-B-C
negative
negative
HIV
negative
negative
Toxoplasmosis
negative
positive
CMV IgG
positive
positive
EBV IgG
positive
positive
Chagas
positive
negative
VDRL
negative
negative
 Good clinical evolution, with good kidney function.
 Chagas transmission controls according to protocol: Strout test weekly
for 2 months and twice a month thereafter for 1 more month.
 3 months post Tx (Jan 04): febrile syndrome and lesion in right leg
anterior face, bland, tender and with purulent material drainage .
 Material direct exam: positive for amastigotes.
 Strout test: Positive
 Started with benznidazole 4mg/Kg and was left only with low dose cortico-
steroids.
 Good evolution of lesion on the leg
 26/Jan/04: Rejection diagnosis  3 pulses of cortico-steroids
 Re-started Chagas control transmission: weekly for 2 months, twice a
month until 6th month and monthly thereafter until 2 years post-Tx.
Always negative.
 Starts again with IS with lower doses than before
 15/Feb/06 (28 m. fromTx). Comes to control with:
 Level of consciousness weakening
 Headacke
 Bitemporal hemianopsia
 Labs:
 WBC 4700/mm3 (80/20); Hto 37 %; Creatinine 1,2 mg/dl
 Strout test: negative
 MRI: Extensive temporo-parietal and occipital lesions with
mass effect
 imagenes
Most Probable Diagnosis
1. Cerebral chagoma
2. Fungal abscess
3. CNS lymphoma  PTLD
4. Cerebral nocardiosis
5. CNS abscess
6. CNS Toxoplasmosis
What to do next
1.
Wait and see until you get CNS biopsy
2.
Empirical treatment with: Amphotericine,
pirimetamine/clindamicine, ceftriaxone, TMP/SMX, dexametasone,
CNS biopsy and no IS
3.
Empirical treatment with: Amphotericine,
pirimetamine/clindamicine, ceftriaxone, TMP/SMX, dexametasone,
CNS biopsy and with IS
4.
Empirical treatment with: Amphotericine,
pirimetamine/clindamicine, ceftriaxone, TMP/SMX, beznidazole ,
dexametasone, CNS biopsy and no IS
 Started empirically on:
• amphotericine, pirimetamine/clindamicine, ceftriaxone,
TMP/SMX, benznidazole, dexametasone,
• stopped IS and
• CNS biopsy performed.
 Results of sterotactic biopsy: amastigotes nests and
necrosis
 The patient was discharged with:
• Bitemporal hemianopsia
 Treated for 2 years for CNS edema and inflammation
with no side effects of medication
 Is on 4md/d of C-ST
CNS Infections
FOCAL LESIONS: 1%
INF: 5-10%
liver
kidney
lung
heart
0
A
70%
Non
A
Fungal
Nocardia
GC
Toxo
PTLD
0,2
0,4
0,6
0,8
1
Transpl int. 2009;22(3):269
CID. 2003;37:221
Transpl infect Dis 2000:2:101
Transplantation 2006: 81: 408
CNS involvement in post-Tx Chagas
disease
 Not frequent
Simple supratentorial lesions of withe matter
CNS biopsy allows for amastigotes observation
Search for tripomastigotes in CSF
PCR in CSF could be a useful diagnostic tool
No recommendation can be made at this time in CNS
involvement
Treatment time
Adjuste to clinical aspects, labs and imaging
Transpl Proc 2010; 42:3354
Neurol reserch 2010; 32 (3):238
Thank you
for
your
attention