Brain abscess with unusual organism Staphylococcus hemolyticus in a renal transplant recipient - A case report

Neeharika Jonnalagadda; Swarnalatha Guditi; Uttara Das; Raja Karthik Kalidindi; Sarang Vijayan; Ravi Kumar Patel; Ashish Nayak; Gangadhar Taduri

doi:10.4103/ijot.ijot_89_20

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CASE REPORT

Year : 2022 | Volume : 16 | Issue : 4 | Page : 431-434

Brain abscess with unusual organism Staphylococcus hemolyticus in a renal transplant recipient - A case report

Neeharika Jonnalagadda, Swarnalatha Guditi, Uttara Das, Raja Karthik Kalidindi, Sarang Vijayan, Ravi Kumar Patel, Ashish Nayak, Gangadhar Taduri
Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Submission	01-Aug-2020
Date of Acceptance	26-Apr-2022
Date of Web Publication	30-Dec-2022

Correspondence Address:
Dr. Swarnalatha Guditi
Department of Nephrology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad - 500 082, Telangana
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_89_20

Abstract

The immunosuppressive medications in renal transplant recipients are associated with increased risk of infections, leading to significant morbidity and mortality. Here, we report a case of focal brain abscess, presented to us, 8 months after deceased donor renal transplantation with headache and altered mentation. Patient had a history of fungal pneumonia 3 months before presenting illness and received intravenous liposomal amphotericin B, for 6 weeks. On evaluation, he was found to have brain abscess, with mild graft dysfunction. Computerized tomography-guided stereotactic aspiration of the brain abscess was done which grew Staphylococcus hemolyticus. Intravenous catheter placed for 6 weeks for antifungal therapy for the management of previous fungal pneumonia was thought to be cause of staphylococcal infection. He was managed with intravenous clindamycin and levofloxacin for 6 weeks as per antibiogram and immunosuppressive medications were reduced. After 6 months of follow-up, patient was asymptomatic with normal renal function and minimal immunosuppressive medications.

Keywords: Brain abscess, renal transplant recipient, Staphylococcal hemolyticus, stereotactic aspiration

How to cite this article:
Jonnalagadda N, Guditi S, Das U, Kalidindi RK, Vijayan S, Patel RK, Nayak A, Taduri G. Brain abscess with unusual organism Staphylococcus hemolyticus in a renal transplant recipient - A case report. Indian J Transplant 2022;16:431-4

How to cite this URL:
Jonnalagadda N, Guditi S, Das U, Kalidindi RK, Vijayan S, Patel RK, Nayak A, Taduri G. Brain abscess with unusual organism Staphylococcus hemolyticus in a renal transplant recipient - A case report. Indian J Transplant [serial online] 2022 [cited 2023 Feb 8];16:431-4. Available from: https://www.ijtonline.in/text.asp?2022/16/4/431/364627

Introduction

Infections are one of the common causes of morbidity and mortality in the transplant recipients in developing countries. Immunosuppressant not only increase the susceptibility to infections but also changes the clinical presentation, leading to difficulty and delay in the diagnosis of infection. The incidence of infection in renal transplant recipients is directly related to net immunosuppressive effect achieved and time from transplantation.^[1] Hence, infections in transplant recipients require systemic approach for prompt and accurate diagnosis. It has been reported that 30% of transplant recipients have some neurological complications and the central nervous system infections is the most common; however, brain abscess is rare.^{[2],[3],[4],[5]} Fungal is the most common cause of brain abscess in transplant recipients. Intracranial abscesses, being life-threatening, pose both diagnostic and therapeutic challenge in the management of transplant recipients. We report of case of brain abscess in a renal transplant recipient due to unusual organism Staphylococcus hemolyticus, successfully managed with intravenous antibiotics and stereotactic aspiration of the pus.

Case Report

A 30-year-old male, end-stage renal disease, with hemodialysis vintage of 2.5 years, underwent deceased donor renal transplantation on May 1, 2018, with two doses of basiliximab 20 mg each on day 0 and day 4 as induction therapy. He had immediate graft function, and was on maintenance triple immunosuppressant; prednisolone 20 mg a day, tacrolimus 2,5 mg twice daily (0.08 mg/kg/day), and mycophenolate mofetil (MMF) 1 g twice a day. Immediate posttransplant period was uneventful and serum creatinine came down to 1 mg/dl on day 4. Patient received cytomegalovirus (CMV), fungal and pneumocystis carinii prophylaxis with valganciclovir 450 mg alternate days, fluconazole 150 mg daily, and trimethoprim sulfamethoxazole single strength daily for 3 months. The tacrolimus level was monitored on the 4 postoperative day, which was 10 ng/ml and there after it was monitored on monthly basis with target of 10–12 ng/ml in 1 month, 8–10 ng/ml in 1–3 months, and 6–8 ng/dl in 4 to 6 months. His course was uneventful till 4 month of transplantation with normal graft function and immunosuppressive medications of prednisolone 10 mg/day, tacrolimus 2 mg twice daily, with tacrolimus level of 7.2 ng/ml, and MMF 1 g twice a day. Valganciclovir, fluconazole, and trimethoprim sulfamethoxazole prophylaxis were stopped after 3 months posttransplant.

Fifth month of transplantation, he presented with lower respiratory tract infection symptoms; fever, productive cough, shortness of breath of 4 days duration. His investigations were normal including chest radiography, blood and urine cultures, and graft function. He was managed with antipyretics, adequate hydration, empirical intravenous antibiotics cefoperazone and sulbactam 1.5 g twice daily, and levofloxacin 500 mg once daily. He continued to have fever; hence, his antibiotic was escalated to intravenous meropenem 1 g twice a day and subjected to high-resolution computerized tomography (CT) chest which showed segmental consolidation involving medial basal segment of both lower lobes [Figure 1]. Bronchoscopy with bronchoalveolar lavage (BAL) was done which was positive for galactomannan (GM) and negative for gram stain, acid-fast bacilli, potassium hydroxide (KOH), CMV, and bacterial and fungal cultures. As he continued to have fever despite escalating the antibiotic and BAL GM being more sensitive than serum GM, he was started on voriconazole 200 mg twice a day considering Aspergillus lung infection. The patient had transient symptomatic relief for few days, followed by worsening of respiratory symptoms. The patient was continued on empirical antibacterial therapy and voriconazole was replaced with liposomal Amphotericin B, 100 mg/day (2 mg/kg) for 6 weeks with the total cumulative dose of 6 g. He had normal renal function and tacrolimus level was 6 ng/ml. His immunosuppressive medications were reduced to prednisolone 5 mg/day, MMF reduced to half the dose 500 mg twice daily, and tacrolimus 1.5 mg twice daily. He became asymptomatic with normal CT chest and normal renal function with 6 weeks of antifungal therapy. Subsequently, his course was uneventful till he presented 3 months later with headache, altered mentation in the form of drowsiness, and decreased food intake for 5 days. There was no history of vomiting, vision impairment, focal motor deficit, seizures, or other symptoms of raised intracranial pressure. He did not have a fever, cough, and breathlessness. On general examination, he was euvolemic and hemodynamically stable. On neurological examination, he was conscious, coherent, and showed no signs of meningeal irritation. Fundus examination was suggestive of papilledema. The cardiovascular examination was unremarkable. Investigations revealed mild leukocytosis and mild graft dysfunction with serum creatinine of 1.9 mg/dl. His serum electrolytes and liver functions were within the normal limits. Chest radiogram and ultrasonogram abdomen were normal. Lumbar puncture for cerebrospinal fluid analysis was deferred in view of papilledema. Noncontrast CT brain was done, which showed hypodensity in the left posterior temporo-parieto-occipital lobe with midline shift suggestive of brain abscess [Figure 2]. Echocardiogram was normal and did not reveal any vegetation. The blood culture and urine culture were sterile.

Figure 1: High-resolution computed tomography chest showing segmental consolidation involving medial basal segment of bilateral lower lobes

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Figure 2: Computerized tomography brain showing hypodensity in the left posterior temporo-parieto-occipital lobe with midline shift

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The patient was started on intravenous dexamethasone 8 mg thrice a day as anti-edema measures for 5 days and followed by oral glycerol, oral levetiracetam 500 mg twice a day as antiepileptics. He was also started on empirical antibiotics with intravenous meropenem 1 g twice a day and intravenous clindamycin 600 mg thrice daily with an intention to cover Gram-positive, Gram-negative, anaerobes, and atypical organisms. Maintenance triple immunosuppressive drug doses were decreased to MMF 250 mg twice a day and tacrolimus to 1 mg twice a day. Anti-proliferative medications were not stopped as he had deceased donor transplantation and had functioning graft. Magnetic resonance imaging of the brain with contrast was done, to have a better assessment of tissue involvement, which showed ring-enhancing cerebral lesion suggestive of brain abscess [Figure 3].

Figure 3: Magnetic resonance imaging brain with contrast with T1. T2 images showing ring-enhancing lesion – likely brain abscess

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In view of midline shift, and papilledema neurosurgery consultation was sought, and was advised stereotactic aspiration of brain abscess. On stereotactic aspiration, 30 ml pus was drained, which was subjected to diagnostic analysis. Gram stain was showing plenty of pus cells, Ziehl–Neelsen staining was negative, KOH staining for fungal elements was negative and culture grew S. hemolyticus which was sensitive to ampicillin, ciprofloxacin, levofloxacin, clindamycin, trimethoprim-sulfamethoxazole, and gentamicin and resistant to methicillin. There were no medical devices, prosthetic valves, orthopedic prostheses, and prolonged urinary catheters. Intravenous line secured for 6 weeks for the management of the previous fungal pneumonia episode was thought to be the source of staphylococcal infection. The patient was treated with intravenous clindamycin 600 mg twice daily and levofloxacin 500 mg once daily. Patient had symptomatic improvement within few days of antibiotic therapy, graft function normalized to serum creatinine of 1.2 mg/dl, and repeat CT brain showed decreased hypodensity compared to previous films. Antibiotics were continued for 6 weeks. After 6 months of follow-up, the patient was on minimal immunosuppressants; wysolone 5 mg, MMF 250 mg twice daily, and tacrolimus of 0.5 mg twice daily with normal graft function.

Discussion

Brain abscess is a focal collection within the brain parenchyma, surrounded by an inflammatory exudates, which can arise as a complication of a variety of infections, trauma, or surgery. Brain abscess is an uncommon infectious complication in renal transplant recipients. Selby et al.^[6] described disparate groups of patients with brain abscesses with regard to timing, susceptibility, and predisposition. He found that while fungi (i.e., Aspergillus, Candida, and Mucorales sp) contributed to most of the early onset brain abscesses (median 24 days); abscesses that developed late after transplantation (mean 264 days) were caused by nonfungal organisms (i.e., Nocardia and Toxoplasma sp). In another report, Aspergillus species were the most commonly isolated organism.^[7]

In the immunocompetent host, brain abscess is usually bacterial etiology, whereas, in the immunocompromised host, fungal brain abscess predominates and usually originates as hematogeneous dissemination from a primary site of invasion. In general, opportunistic infections by organisms such as Listeria monocytogenes, Aspergillus fumigatus, Cryptococcus neoformans, and Nocardia asteroides lead to brain abscess formation in renal transplant recipients.^{[2],[4],[8],[9],[10]} Our patient had bacterial brain abscess with the unusual organism of S. hemolyticus. The intravenous catheter secured for 6 weeks for antifungal therapy for previous fungal pneumonia episodes was thought to be the source.

Arun Kumar et al. reported a case of brain abscess secondary to methicillin-resistant Staphylococcus aureus who succumbed to his illness even after stereotactic aspiration of abscess, because of septicemia.^[11] In our case, the brain abscess due to S. hemolyticus was methicillin resistant.

Headache, fever, and altered mental status are common findings among patients with brain abscess.^{[12],[13],[14]} Immunosuppressed patients usually present with atypical symptoms. Hence, a high index of suspicion is necessary and may require invasive procedures for accurate diagnosis (e.g., stereotactic brain biopsy/aspiration).

Stereotactic surgery has a very low mortality and morbidity and therefore plays an important role in the management of many intracranial lesions. It can be used for biopsy and aspiration of deep-seated lesions in eloquent locations.^[15] The mortality rate for CT-guided stereotactic biopsies has been reported to be 0.6%–2.6% and the morbidity 1%–5.9%.^[15],[16] Most of the stereotactic biopsy series report a positive yield of 90%–96% which helps in avoiding empiric therapy.^{[15],[16],[17]}

Treatment of brain abscess is usually delayed and requires prolonged antibiotic therapy for a few months and with poor outcomes However, stereotaxy helps in both early diagnosis and therapeutic management of patients with brain abscess with good outcomes. We could successfully treat brain abscess with early diagnostic and therapeutic stereotaxy and prolonged antibiotic therapy in a renal transplant recipient with reduction in the immunosuppressant and normal graft function.

Conclusion

Renal transplant recipients can develop a brain abscess with the unusual organism of S. hemolyticus due to prolonged intravenous catheters. CT-guided stereotaxy is an ideal, minimally invasive strategy to arrive at a definite etiology and also therapeutic management of the patient. Although the overall prognosis is poor, few patients may have a good outcome, if diagnosed early and treated with appropriate antibiotic therapy with or without surgical maneuvers.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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