Disseminated mycobacteria chelonae infection in a kidney-pancreas transplant recipient: A case report and review of the literature

Abstract

A 40-year-old male with a long-standing history of type 1 diabetes with end-stage renal failure underwent combined kidney-pancreas (KP) transplant from a standard criteria donor. Post-operative course was uncomplicated with good primary function of both transplant grafts. Induction was with thymoglobulin and maintenance immunosuppression was with tacrolimus, mycophenolate mofetil and prednisolone. Nine weeks post-transplant, the patient developed dysfunction of both grafts. Panel reactive antibody testing revealed that the patient had developed a de novo donor-specific antibody and considering an antibody-mediated rejection the patient was treated with intravenous pulse methyl prednisone 500 mg ×3 doses, IV immunoglobulin 2 mg/kg in two divided doses, and ATG 7 mg/kg (total dose of 700 mg). In addition, his baseline immunosuppression was increased. Cr decreased to baseline levels, and blood sugars were in the range of 7-8 mmol/L, serum amylase normalized to 63 U/L, and the patient was discharged home. Nine days post-discharge, the patient presented to the hospital with a five-day history of fever, pain, and swelling in the left knee along with subcutaneous, erythematous, tender, nodular lesions in both legs and both arms. Skin biopsy showed Ziehl-Neelsen stain positive rods and biopsy culture and blood culture grew Mycobacteria chelonae. Antimicrobials were switched to azithromycin 500 mg OD, moxifloxacin 400 mg OD, and linezolid 600 mg BID and baseline immunosuppression was reduced to tacrolimus trough target 8-10 ng/mL and MMF to 250 mg BID. The patient gradually improved and was discharged after 28 days in the hospital. Six weeks following the diagnosis of nontuberculous mycobacteria infection, the patient′s pancreas graft failed, presumably due to reduction in immuno-suppression and he is now back on insulin treatment. His renal graft continued to function well. Although rapidly growing mycobacterial infections are rare among transplant recipients, it should be suspected among those who have received augmented immunosuppression. Blood cultures and skin biopsy of the lesions are important to establish the diagnosis.