Rajesh Chilaka, Thomas Athul, Eapen Jeethu Joseph, Yusuf Sabina, John Elenjickal Elias, Valson Anna T, Alexander Suceena, David Vinoi George, Michael Joy Sarojini, Varughese Santosh
Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India.
Department of Microbiology, Christian Medical College, Vellore, Tamil Nadu, India.
J Glob Infect Dis. 2024 Dec 21;16(4):135-139. doi: 10.4103/jgid.jgid_81_24. eCollection 2024 Oct-Dec.
The aim of the study was to study the clinical profile and outcomes of nocardiosis in renal allograft recipients.
This was a retrospective study of clinical outcomes in consecutive renal allograft recipients with infection over a 22-year period (2000-2022) from a tertiary care center in Southern India. The clinical data were obtained from electronic medical records and patient files.
A total of 1970 patients underwent renal transplantation at Christian Medical College, Vellore, India, between January 1, 2000, and December 31, 2022. During this period, 26 patients were diagnosed to have infection. Half (50%) of the patients had fever and cough as their initial presentation, 7 (26.9%) patients presented with cutaneous abscesses, 2 (7.6%) patients were incidentally detected to have lung nodules during routine follow-up, 2 (7.6%) patients presented with headache accompanied by fever, and 3.8% had graft abscess. The diagnosis was made by isolating the organism in culture from one or more of the following samples: sputum, blood, pus, or lung biopsy (either computed tomography [CT]-guided or bronchoscopic aspirate culture). Eight patients required bronchoscopy and two patients required CT-guided biopsy for obtaining samples for diagnosis. All patients were similarly managed initially with a reduction of immunosuppression and appropriate antibiotics as per culture sensitivity. All 26 patients responded to induction treatment with meropenem (or imipenem) and trimethoprim-sulfamethoxazole (co-trimoxazole) followed by maintenance treatment with co-trimoxazole. Five (19.2%) out of 26 patients received Minocycline in induction and maintenance treatment regimens as in four patients isolates were resistant and one patient had allergic reaction to Cotrimoxazole. All patients had stable graft function. Two patients succumbed after 2 months of diagnosis with Gram-negative sepsis.
At present, there exists no single serological test to diagnose infection in patients. Multiple initially obtained cultures may be negative because of the slow growth of the organism and variable colony morphology. Hence, infected specimens should be obtained by aggressive approaches if the index of suspicion is high. Procedures such as bronchoscopic lavage and aspiration of abscess are invaluable toward making a diagnosis. In our study, eight patients required invasive diagnostic procedures such as bronchoalveolar lavage and CT-guided lung biopsy since initial Gram stain and sputum culture were negative. In conclusion, it is crucial to maintain a high level of suspicion and conduct thorough investigations among post renal transplant recipients. This approach facilitates early diagnosis, prompt initiation of appropriate treatment which helps prevent the spread of disease.
本研究的目的是探讨肾移植受者诺卡菌病的临床特征及预后。
这是一项对印度南部一家三级医疗中心2000年至2022年期间连续的肾移植受者感染情况进行的回顾性临床结局研究。临床数据来自电子病历和患者档案。
2000年1月1日至2022年12月31日期间，共有1970例患者在印度韦洛尔基督教医学院接受了肾移植。在此期间，26例患者被诊断为诺卡菌感染。一半（50%）的患者最初表现为发热和咳嗽，7例（26.9%）患者表现为皮肤脓肿，2例（7.6%）患者在常规随访中偶然发现肺部结节，2例（7.6%）患者表现为头痛伴发热，3.8%的患者有移植肾脓肿。通过从以下一种或多种样本中培养分离出病原体来确诊：痰液、血液、脓液或肺活检（计算机断层扫描[CT]引导或支气管镜吸取培养）。8例患者需要进行支气管镜检查，2例患者需要CT引导下活检以获取诊断样本。所有患者最初均采取了类似的治疗措施，即根据培养药敏结果减少免疫抑制并使用适当的抗生素。所有26例患者对美罗培南（或亚胺培南）和甲氧苄啶-磺胺甲恶唑（复方新诺明）的诱导治疗有反应，随后接受复方新诺明维持治疗。26例患者中有5例（19.2%）在诱导和维持治疗方案中使用了米诺环素，原因是4例患者的分离株耐药，1例患者对复方新诺明过敏。所有患者的移植肾功能均稳定。2例患者在诊断后2个月因革兰阴性菌败血症死亡。
目前，尚无单一的血清学检测方法可用于诊断患者的诺卡菌感染。由于该菌生长缓慢且菌落形态各异，最初多次培养可能为阴性。因此，如果怀疑指数较高，应通过积极的方法获取感染标本。支气管镜灌洗和脓肿穿刺等操作对诊断非常重要。在我们的研究中，由于最初的革兰染色和痰液培养均为阴性，8例患者需要进行支气管肺泡灌洗和CT引导下肺活检等侵入性诊断操作。总之，肾移植术后受者保持高度怀疑并进行全面检查至关重要。这种方法有助于早期诊断，及时开始适当治疗，从而有助于预防疾病传播。
