Central Nervous System Infection in a Kidney Transplant Recipient Consultant ID: INBA Elena Maiolo Laura Ducatenzeiler Hospital Argerich Unidad de Ablación e implante Comisión TOS SADI

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 serologydonorreceptor HepatitisA-B-Cnegative HIVnegative Toxoplasmosisnegativepositive CMV IgGpositive EBV IgGpositive Chagaspositivenegative VDRLnegative

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

1. Cerebral chagoma 2. Fungal abscess 3. CNS lymphoma  PTLD 4. Cerebral nocardiosis 5. CNS abscess 6. CNS Toxoplasmosis Most Probable Diagnosis

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 Transpl int. 2009;22(3):269 CID. 2003;37:221 Transpl infect Dis 2000:2:101 Transplantation 2006: 81: 408 A 70% FungalNocardia ToxoGCPTLD INF: 5-10%FOCAL LESIONS: 1% Non A

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