#3176 STUDY OF UNUSUAL/RARE INFECTIONS IN RENAL TRANSPLANT RECIPIENTS
Authors: Chilaka Rajesh , Mishra Utkarsh , Jayaprakash T , Jain Ankit , Alam Rizwan , Johny Joseph , Jose Nisha , Mani Selvin Sundar Raj , Yusuf Sabina , Eapen Jeethu Joseph , Thomas Athul , John Elenjickal Elias , Alexander Suceena , David Vinoi George , Michael Joy Sarojini , Balaji V , Mammen Shoba , Varughese Santosh 
Published: June 2023

Abstract

Background and Aims
Infections are the most common cause of mortality in solid organ transplant patients. Kidney transplant is the most common organ transplantation worldwide. Since its successful outcomes and longevity of patients, wide literature is available about the long term outcomes and infections. They are more susceptible to infections in the first six months of transplant as per Rubin's calendar when immunosuppression is high. The most common opportunistic infections like Pneumocystis jirovecii, CMV infection, reactivation of tuberculosis, other viral infections like hepatitis B and hepatitis C viruses and fungal infections like Cryptococcus were well studied. There are very few studies on atypical infections about their clinical presentation, anibiogram and outcomes of the patients.

Method
It is retrospective analysis of clinical presentation, methods of diagnosis, antibiogram, graft's & patient's outcomes of renal allograft recipients with atypical infections. All renal allograft recipients from 2006 to 2021 who had atypical infections were included. The clinical data obtained from hospital data and collected using epidata software and results were analyzed using PSPP software.

Results
A total of 1498 patients underwent renal transplant in this center during 2006 to 2021. Only 33 patients had unusual/rare infections like nocordosis (12), Rhodococcus (1), Meliodosis (2), Pheohypomycosis (3), Aspergillosis (6), Histoplasmosis (1), and Parvovirus (8). Nocorodiosis occurred after mean duration of 6.3 years after transplant. Most of the patients with nocordiosis, presented with prolonged fever and cutaneous abscesses, culture which grew nocordiosis. They responded to Imipenem and Septran, but few strains were septran resistant for which fluroquinolones were given. Overall the outcomes of graft and Patients were good. The patient with rhodococcus presented with sepsis with MODS and was expired. The patients with pheohyphomycosis presented with cutaneous abscess and responded to prolonged course of Itraconazole with good graft outcome without mortality. Out 6 patients with Aspergillus Pneumonia which developed after 4.6 years after renal transplantation, 3 patients were expired with graft loss. The patients of parvovirus infection presented with refractory post-transplant anemia and evaluation showed pure red cell aplasia on bone marrow studies. Most of them developed within one year of transplant and four of them received anti-rejection therapy. Five patients responded to standard treatment with IV immunoglobulin, but three patients required 2 doses of Inj. Rituximab 500 mg each in view of probable Parvo virus triggered auto immune hemolytic anemia.

Conclusion
This study focused on the atypical infections like nocordosis, Rhodococcus, Meliodosis,Pheohypomycosis, Aspergillosis, Histoplasmosis, Parvovirus and their antibiogram and outcomes of graft and mortality. The high index of suspicion should be present when patient is not responding to empirical antibiotics and culture didn't grow routine organsims. The role of invasive investigations like bronchoscopy with BAL fluid whoudl be considered whenever the infections like nocordiosis and aspergillus were considered. Transplant with cutaneous abscesses should not be treated with empirical antibiotics and always culuture should be done to rule out infections like nocordiosis, pheohypomycosis and histoplasmosis as treatment is different for each orgaims. Post-transplant refractory anemia requires bone marrow evaluation to look for Parvovirus infection which responds to IVIg. Overall, the high index of suspicion, timely diagnosis, correct drug and duration of treatment will save the graft and patient.