Mycoplasma hominis infection in renal transplantation

Myriam Pastural1, Vincent Audard1, Marie-Pierre Bralet2, Philippe Rémy1, Laurent Salomon3, Jacques Tankovic4, Christian Brun Buisson5 and Philippe Lang1,

Services de 1 Néphrologie, 2 Pathologie, 3 Urologie, 4 Bacteriologie-Virologie and 5 Réanimation Médicale, Hôpital Henri Mondor, Université Paris XII, Créteil, France

Keywords: graft loss; infection; kidney transplantation; Mycoplasma hominis



   Introduction
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 Introduction
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 Discussion
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Mycoplasma hominis is a common inhabitant of the human genital tract. M. hominis has been recognized as an extragenital pathogen and is associated with immunosuppression in 50% of reported cases [1]. We report a case of M. hominis infection associated with graft loss in a renal transplant recipient. Current literature on M. hominis infection in renal transplantation is also reviewed.



   Case
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 Introduction
 Case
 Discussion
 References
 
A 30-year-old man received his first renal transplant in 1999, after 8 years on intermittent haemodialysis for renal failure secondary to Goodpasture's syndrome. The donor was an 18-year-old man. Immunosuppressive therapy consisted of cyclosporine (6 mg/kg/day), mycophenolate mofetyl (3 g/day), prednisone (1 mg/kg/day). Antimicrobial prophylaxis consisted of cefotaxim for 48 h, and cotrimoxazole for 3 months. During the immediate post-operative period, the patient had abdominal tenderness but no fever and no sign of wound infection. A leucocyturia (2x105 cells/ml) without bacteriuria was noted but remained unexplained. Recovery of graft function was delayed until day 9. On day 18 post-transplantation, a haemorrhagic shock requiring emergency surgical exploration, revealed a graft artery rupture which was sutured. Ceftazidim, vancomycin and fluconazole were given perioperatively, but cultures of the haematoma remained negative. On the following days, the patient's white blood cell count rose to 18200 cells/mm3 with an elevated C-Reactive-Protein level (214 mg/l). Fever (38.5°C) and coma developed on day 26. Cerebrospinal fluid, blood, urine and stool samples remained negative for bacterial, fungal and viral growth. A cerebral CT scan, cerebral angio-MRI and an EEG were all normal. An abdominal CT scan indicated a perinephric collection, and a percutaneous drainage was performed. The Gram stain indicated numerous altered polymorphonuclear leukocytes without any pathogens. A laparotomy was performed to drain the purulent collection but, due to false membranes adherent to the kidney graft capsule mimicking kidney necrosis, the graft was removed. Pathological examination showed a fibrino-polymorphonuclear exudate on the renal capsule and a microabcess in the medulla. The glomeruli and vessels were normal, and there was no evidence for acute rejection. Examination of the renal artery revealed a dissection between intima and media without evidence of rupture. Three days later, cultures of intra-operative samples from the perinephric exudate and haematoma and from the surgical wound only showed M. hominis, which was susceptible to ofloxacin. Three days after the beginning of ofloxacin therapy, the patient regained consciousness, and this treatment was continued for 12 days. Infection has not recurred after 2 years and the patient remains on intermittent haemodialysis.



   Discussion
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 Introduction
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 Discussion
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M. hominis has been described as a possible cause of blood, wound, central nervous system, joint and respiratory tract infection [2,3]. Diagnosis of non-genito-urinary M. hominis infection is often difficult, as in the present case. Mycoplasma spp. are small organisms without cell walls, and cannot be Gram stained. M. hominis growth is quite slow (72 h), and/or requires specific media. Furthermore, the symptomatology of M. hominis infection is latent and pleomorphic, especially in immunocompromised hosts. It is likely that infections due to these organisms are often not diagnosed. A polymerase chain reaction assay has recently been developed for M. hominis and should facilitate the diagnosis.

Few cases of extragenital infections caused by M. hominis have been reported in organ transplant literature. Most transplant patients with these infections have received kidneys (n=14), but others have received heart (n=3), heart and lung (n=5), liver (n=3) or pancreas (n=1) allografts [4]. Although M. hominis is an organism of low pathogenicity, it can lead to severe infections with unfavorable outcomes in immunocompromised patients. Four of the kidney recipients lost their grafts and one died (Table 1Go). Among patients receiving other organs, eight died, but M. hominis has not always been identified as the direct cause of death.


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Table 1.  Renal transplant recipients with Mycoplasma hominis infections: review of medical literature

 
As in our patient, perirenal collection and wound infection are the most common symptoms of M. hominis infection after renal transplantation, which develop a few weeks after surgery [3]. While coma is more commonly described with M. pneumoniae infection, Jacobs et al. [11] also reported confusion and delirium in a liver transplant recipient with an M. hominis infection of a perihepatic haematoma.

The patient in the current study presented with haemorrhagic shock as the result of renal artery rupture without a surgical anastomosis defect. An histological examination performed after removing the graft indicated a renal artery dissection without congenital abnormalities. A mycotic aneurism may have been involved, although the possibility of traumatic renal artery dissection occurring during kidney removal or grafting could not be ruled out. The broad-spectrum antibiotics which were first introduced to treat a potential mycotic aneurism were, unfortunately, not effective for M. hominis. In the literature, there has been one case of active bleeding of the cystic artery associated with M. hominis infection, and one renal arterial thrombosis in a renal recipient presenting with perinephric fluid and wound infection with M. hominis [11]. Two cases of arterial aneurisms secondary to Mycoplasma infections are reported after vascular surgery [12].

Our case emphasizes that ‘atypical’ pathogens may cause infection during renal transplantation. Since such microorganisms are difficult to isolate, they should be considered during the selection of antibiotics in immunocompromised hosts with infections and negative Gram stains. Also, Mycoplasma infection may cause potentially serious infections in organ transplant recipients, possibly leading to graft loss or patient death.



   Notes
 
Correspondence and offprint requests to: Dr P. Lang, Services de Néphrologie, CHU Henri Mondor, 51 Avenue du Maréchal de Lattre de Tassigny, F-94000 Creteil, France. Email: philippe.lang{at}hmn.ap\|[hyphen]\|hop\|[hyphen]\|paris.fr Back



   References
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 Introduction
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Received for publication: 11. 8.01
Accepted in revised form: 7.11.01