Nocardia infection in renal transplant recipient: diagnostic and therapeutic considerations

Infecção por Nocardia cm transplante renal: considerações diagnósticas e terapêuticas

L.T. Santamaria Saber J.F.C. Figueiredo S.B. Santos C.E. Levy M.A. Reis A.S. Ferraz About the authors

Abstracts

In the present report the authors discuss the diagnostic difficulties, therapeutic measures and the clinical course of Nocardia infection which occurred among renal transplant recipients at the University Hospital of the Faculty of Medicine of Ribeirão Preto, University of São Paulo (UH-FRP), from 1968 to 1991. Among 500 individuals submitted to renal transplant, 9 patients developed Nocardiosis at varying times after transplant (two months to over two years). All the patients had pulmonary involvement and their most common symptoms were fever, cough and pleural pain. Dissemination of the process is common and three patients presented cutaneous abscesses, four CNS involvement and one had pericarditis due to Nocardia. The diagnostic is quite difficult since there is no specific clinical picture, concomitant infections are frequent and the microorganism presents slow growth in culture (ranging from four to forty days, in our experience). In this report, three cases were only diagnosed by necropsy. The treatment of choice is a combination of Sulfamethoxazole and Trimethoprim (SMX-TMP). In the present series, overall mortality was 77% (7 cases) and in five of the patients who died the diagnosis was late. All the patients who had CNS involvement died.

Renal transplant; Nocardia infection


Foram analisados retrospectivamente 500 prontuários de pacientes transplantados renais no período de 1968 a 1991, sendo identificados 9 casos de Nocardiose; 7 do sexo masculino e 2 do sexo feminino. A idade mediana destes pacientes foi de 33 anos e a infecção ocorreu nos primeiros 6 meses em 6 pacientes, havendo relação direta com pulsoterapia em apenas um paciente. Manifestações pulmonares ocorreram em 100% dos casos, sendo que os sintomas mais frequentes foram febre, tosse e dor pleural. As alterações radiológicas observadas compreenderam infiltrados nodulares em 55% e abcessos em 22% dos casos. Houve disseminação para a pele em 3 pacientes, para o SNC em 4 pacientes, e 1 paciente apresentou, além de comprometimento pulmonar, pericardite por Nocardia. Em nossa casuística o diagnóstico foi post-mortem em 30% dos casos e a mortalidade foi de 77%. Km 3 pacientes, cujo diagnóstico foi precoce, houve resposta satisfatória ao tratamento instituído. As infecções por Nocardia apresentam bom prognóstico quando diagnosticadas a tempo, sendo portanto necessário um alto grau de suspeição, principalmente em pacientes imunossuprimidos com acometimento pulmonar, neurológico ou cutâneo.


ORIGINAL ARTICLES

Nocardia infection in renal transplant recipient: diagnostic and therapeutic considerations

Infecção por Nocardia cm transplante renal: considerações diagnósticas e terapêuticas

L.T. Santamaria SaberII; J.F.C. FigueiredoIII; S.B. SantosII; C.E. LevyIII; M.A. ReisIV; A.S. FerrazI,II,(1 Address for correspondence: Agenor Spallini Ferraz, MD )

ICNPq Investigator

IIDepartment of Surgery and Renal Transplant Unit, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil

IIIDepartment of Internal Medicine and Laboratory of Microbiology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil

IVDepartment of General Pathology, Faculty of Medicine of Triângulo Mineiro, Uberaba (MG), Brazil

Address for correspondence Address for correspondence: Agenor Spallini Ferraz, MD

SUMMARY

In the present report the authors discuss the diagnostic difficulties, therapeutic measures and the clinical course of Nocardia infection which occurred among renal transplant recipients at the University Hospital of the Faculty of Medicine of Ribeirão Preto, University of São Paulo (UH-FRP), from 1968 to 1991.

Among 500 individuals submitted to renal transplant, 9 patients developed Nocardiosis at varying times after transplant (two months to over two years). All the patients had pulmonary involvement and their most common symptoms were fever, cough and pleural pain.

Dissemination of the process is common and three patients presented cutaneous abscesses, four CNS involvement and one had pericarditis due to Nocardia.

The diagnostic is quite difficult since there is no specific clinical picture, concomitant infections are frequent and the microorganism presents slow growth in culture (ranging from four to forty days, in our experience). In this report, three cases were only diagnosed by necropsy.

The treatment of choice is a combination of Sulfamethoxazole and Trimethoprim (SMX-TMP).

In the present series, overall mortality was 77% (7 cases) and in five of the patients who died the diagnosis was late. All the patients who had CNS involvement died.

Key words: Renal transplant; Nocardia infection

RESUMO

Foram analisados retrospectivamente 500 prontuários de pacientes transplantados renais no período de 1968 a 1991, sendo identificados 9 casos de Nocardiose; 7 do sexo masculino e 2 do sexo feminino. A idade mediana destes pacientes foi de 33 anos e a infecção ocorreu nos primeiros 6 meses em 6 pacientes, havendo relação direta com pulsoterapia em apenas um paciente. Manifestações pulmonares ocorreram em 100% dos casos, sendo que os sintomas mais frequentes foram febre, tosse e dor pleural. As alterações radiológicas observadas compreenderam infiltrados nodulares em 55% e abcessos em 22% dos casos.

Houve disseminação para a pele em 3 pacientes, para o SNC em 4 pacientes, e 1 paciente apresentou, além de comprometimento pulmonar, pericardite por Nocardia.

Em nossa casuística o diagnóstico foi post-mortem em 30% dos casos e a mortalidade foi de 77%. Km 3 pacientes, cujo diagnóstico foi precoce, houve resposta satisfatória ao tratamento instituído.

As infecções por Nocardia apresentam bom prognóstico quando diagnosticadas a tempo, sendo portanto necessário um alto grau de suspeição, principalmente em pacientes imunossuprimidos com acometimento pulmonar, neurológico ou cutâneo.

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  • Address for correspondence:
    Agenor Spallini Ferraz, MD
  • Recebido para publicação em 05/05/1993.

    Aceito para publicação em 23/06/1993.

    Unidade de Transplante Renal - Hospital das Clínicas-Campus - 14048-900 Ribeirão Preto, SP

  • (1
    ) (Grant no. 502303/91-3)
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    Address for correspondence: Agenor Spallini Ferraz, MD (1 ) (Grant no. 502303/91-3)

    Publication Dates

    • Publication in this collection
      04 July 2006
    • Date of issue
      Oct 1993

    History

    • Accepted
      23 June 1993
    • Received
      05 May 1993
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