title: A rare case of Cytomegalovirus, Scedosporium apiospermum and Mycobacterium tuberculosis in a renal transplant recipient.
abstract: BACKGROUND
  Renal transplant recipients are at high risk of developing multiple infections, often concomitantly because of their immunocompromised status. Post renal transplant infections are often elusive and require extensive evaluation for proper diagnosis and treatment. A high index of suspicion is required and an attempt should be made to confirm the microbiological diagnosis from each site involved to rule out multiple infections.
  
  
  METHODS
  We report a 50-year-old female, a renal allograft recipient who presented with left hemiplegia, esophageal ulcers and fever 3 months after her transplant. Esophageal biopsy revealed Cytomegalovirus (CMV) inclusions and the whole blood quantitative CMV polymerase chain reaction (PCR) was positive. Neuroimaging showed a brain abscess, stereotactic biopsy from which revealed Scedosporium apiospermum on fungal culture. Her tacrolimus and mycophenolate were stopped and she was managed with intravenous ganciclovir and voriconazole. With these measures, she showed marked improvement in her general and neurological condition. Two months later, she developed recurrence of fever with dry cough. Radiological investigation revealed a cavitating lung lesion, a needle aspiration from which demonstrated acid-fast bacilli. She was started on antituberculous treatment. With these measures, she recovered completely and maintained good graft function despite being on only prednisolone 10 mg once a day.
  
  
  CONCLUSIONS
  Although CMV disease is not uncommon in the first three months post transplant, Scedosporium is a rare cause of brain abscess. On the other hand, tuberculosis is common in transplant recipients, especially in developing countries, like India. However, this is the first case report of occurrence of these three infections in the same patient, demonstrating the importance of a good microbiological work-up from each site involved in immunosuppressed subjects.
authors.affiliation: Department of Nephrology, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India. drmanishrathi2000@yahoo.co.in.
authors.forename: Manish
authors.initials: M
authors.lastname: Rathi
authors.forename: Srikant
authors.initials: S
authors.lastname: Gundlapalli
authors.forename: Raja
authors.initials: R
authors.lastname: Ramachandran
authors.forename: Sandeep
authors.initials: S
authors.lastname: Mohindra
authors.forename: Harsimran
authors.initials: H
authors.lastname: Kaur
authors.forename: Vivek
authors.initials: V
authors.lastname: Kumar
authors.forename: Harbir Singh
authors.initials: HS
authors.lastname: Kohli
authors.forename: Krishan Lal
authors.initials: KL
authors.lastname: Gupta
authors.forename: Vinay
authors.initials: V
authors.lastname: Sakhuja
mesh_terms: D000935:Antifungal Agents / Q000627:therapeutic use; D000995:Antitubercular Agents / Q000627:therapeutic use; D000998:Antiviral Agents / Q000627:therapeutic use; D003587:Cytomegalovirus / Q000302:isolation & purification; D003586:Cytomegalovirus Infections / Q000150:complications* / Q000188:drug therapy; D003906:Developing Countries; D005260:Female; D015774:Ganciclovir / Q000627:therapeutic use; D006801:Humans; D016867:Immunocompromised Host; D007166:Immunosuppressive Agents / Q000009:adverse effects; D007676:Kidney Failure, Chronic / Q000601:surgery; D016030:Kidney Transplantation; D008875:Middle Aged; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification; D009181:Mycoses / Q000150:complications* / Q000188:drug therapy; D011183:Postoperative Complications / Q000382:microbiology*; D021681:Scedosporium / Q000302:isolation & purification; D066027:Transplant Recipients; D014184:Transplantation, Homologous; D014376:Tuberculosis / Q000150:complications*; D065819:Voriconazole / Q000627:therapeutic use
chemical_list: D000935:Antifungal Agents; D000995:Antitubercular Agents; D000998:Antiviral Agents; D007166:Immunosuppressive Agents; D065819:Voriconazole; D015774:Ganciclovir