1. Central Nervous System Infection in a Kidney Transplant Recipient roberta.lattes @gmail.com Consultant ID: INBA Elena Maiolo Laura Ducatenzeiler Hospital Argerich Unidad de Ablación e implante Comisión TOS SADI

2. 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

3. 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

4. 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

5. imagenes

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

7. 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

8. 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

9. 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

10. 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

11. Thank you for your attention