RESISTANT MYCOBACTERIUM AVIUM COMPLEX INFECTION – A DIAGNOSTIC MANAGEMENT CONUNDRUM IN A DIALYSIS DEPENDENT PATIENT FOLLOWING GRAFT FAILURE
Dr Pamela Wu1, Dr Venkat Manicakavasagam1, Dr Sanjeev Baweja1, Dr Victoria Sasongko1, Dr William James1
1Lismore Base Hospital, Lismore, Australia
Background: Infection remains a feared complication following renal transplantation. Non-tuberculous mycobacterial infection, including Mycobacterium Avium Complex (MAC) can be difficult to diagnose and treat in renal transplant and haemodialysis population.
Case Report: We report the case of a 50-year-old female who presented with an incidental finding of a right lung lesion. Subsequent PET scan shows widespread lymphadenopathy and a large right lung mass. She had minimal respiratory symptoms initially but developed low grade fever with unclear focus. Concurrently, she developed graft failure requiring re-commencement of haemodialysis and reduction of immunosuppressant. Her initial lung biopsy revealed granulomatous inflammation with positive acid-fast bacilli (AFB) smears, with inadequate tissue sampling for an AFB culture. MAC was subsequently detected on polymerase chain reaction testing only. Isolated MAC was identified in the urine additionally.
She was initially treated empirically with 300mg rifabutin daily, 400mg ethambutol thrice weekly post haemodialysis and 500mg azithromycin daily. Treatment was complicated by arthralgias and further recurrent fevers. 4 months later, she presented with worsening fevers, myalgias, and thoracic pain despite compliance with treatment. Further PET imaging has shown para-aortic lymphadenopathy, right lower lobe pneumonic changes with enlarging pulmonary mass. An excisional biopsy of mesenteric lymph node revealed positive acid-fast bacilli smear and with positive MAC tissue culture, which was consistent with treatment failure of the disseminated MAC infection. Intravenous Ceftriaxone 2g post haemodialysis was introduced as a fourth agent.
Conclusion: Non-tuberculous mycobacterium disseminated infection is increasingly recognised as a complications post transplantation due to cumulative burden of immunosuppression. Disseminated MAC infection presenting in a failed renal transplant on minimal immunosuppression whilst on haemodialysis is rare and can be difficult to manage and diagnose.