Giant cells and pneumonia in a transplant patient. What is the link?

(Section Editor: M. G. Zeier) Supported by an educational grant from

James F. Kleshinski1,, Panduranga S. Rao1, Joan Duggan1 and Aiman Zaher2

1 Department of Medicine 2 Department of Pathology, Medical College of Ohio, Toledo, OH, USA

Case

A 78-year-old white female with a past medical history significant for hypertension and end-stage renal disease secondary to nephrosclerosis underwent cadaveric renal transplantation. She had an uneventful postoperative course, attaining normal renal function. Her medications included cyclosporin (6 mg/kg), prednisone (25 mg) on a tapering schedule and mycophenolate mofetil (2000 mg/day). Approximately 3 months after transplant, she presented with fever of 101.6°F, dyspnea, and hypoxia (oxygen saturation 86% on room air). Physical examination revealed an elderly female in distress. She was pale, her jugular vein was flat, and she had oral thrush. There was no evidence of lymphadenopathy. Examination of the lungs demonstrated equal air entry with scattered rales. She continued to deteriorate and was subsequently intubated. The chest X-ray revealed a diffuse reticulo-nodular pattern greater on the right than the left, without parenchymal calcifications or cavitary lesions (Figure 1Go). The patient then began to develop palpable purpura on the trunk (Figures 2Go and 3Go). A skin biopsy was subsequently performed which revealed numerous multinucleated giant cells (Figure 4Go). Over the next 48 h, the purpura evolved into haemorrhagic vesicles of the face, trunk, back, and extremities.



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Fig. 1.  Chest X-ray with a diffuse reticulo-nodular pattern.

 


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Fig. 2.  Patient’s chest with palpable purpura.

 


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Fig. 3.  Palpable purpura trunk.

 


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Fig. 4.  Patient’s skin biopsy. The arrow indicates a giant cell (H+E; x400).

 

Question

What is your diagnosis?

Answer to the quiz on previous page

With respect to post-transplant infections, there are three time frames that are useful when considering the likely organisms: infections within the first month; infections occurring between 2 and 6 months; and those infections occurring beyond 6 months [1]. Infections within the first month of transplantation are usually caused by organisms similar to those found in any typical surgical population, and include bacteria and fungi from surgical wound infections, pneumonia, intravenous catheter infections, and urinary tract infections [2]. Between 2 and 6 months, viral infections such as cytomegalovirus and varicella-zoster virus should be considered in the differential diagnosis, as should other opportunistic organisms such as Pneumocystis carinii and Nocardia species [3]. Fungal infections due to Candida species, Aspergillus species, and Cryptococcus neoformans may also be implicated although the incidence is generally lower in renal transplant patients as compared to other solid organ transplants [4]. The major risk factor for infection during this time period results from the decrease in cell-mediated immunity from utilization of immunosuppressive agents.

This patient presented with pulmonary symptoms 3 months post-transplant. The chest X-ray, clinical skin findings, and skin biopsy point to a disseminated viral agent (varicella-zoster) as the causative organism (Table 1Go). Her varicella-zoster IgM and IgG antibodies were elevated within the first week of clinical illness and a course of acyclovir was completed. Her pulmonary status continued to improve steadily and she was subsequently extubated. Convalescent titres were not obtained.


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Table 1.  Diseases associated with giant cell lesions in skin

 

Notes

Email: jkleshinski{at}mco.edu Back

References

  1. Patel R, Paya CV. Infections in solid-organ transplant recipients. Clin Microbiol Rev1997; 10: 86–124[Abstract]
  2. Winston DJ, Emmanouilides C, Busuttil RW. Infections in liver transplant recipients. Clin Infect Dis1995; 21: 1077–1091[ISI][Medline]
  3. Dummer JS, Ho M. Infections in solid organ transplant recipients. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. Churchill Livingstone, Philadelphia, 2000; 304.
  4. Paya CV. Fungal infections in solid-organ transplantation. Clin Infect Dis1993; 16: 677–688[ISI][Medline]
  5. Elder E, ed. Lever’s Histopathology of the skin. Lippincott-Raven, Philadelphia, 1997; 525–526




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