BACILLARY ANGIOMATOSIS IN A RENAL TRANSPLANT RECIPIENT

V KHELGI1, 2, A GUPTA1, 2, A MAHER1, AND S GOVINDARAJULU1, 2

1Renal service, Darling Downs Hospital and Health Service, Toowoomba, Queensland; 2Rural School of Medicine, University of Queensland, Toowoomba, Queensland

Background: Bacillary angiomatosis (BA) is a potentially fatal opportunistic infection caused by two species of gram negative bacilli: Bartonella Henselae and Bartonella Quintana characterised by typical features of neovascular proliferation on histology mimicking Kaposi’s sarcoma. We report a case of systemic BA in a renal transplant recipient.

Case report: A 56-year-old female patient was admitted to hospital with 2 week history of fevers, lethargy, nodular skin lesions, 3 years post cadaveric renal transplant. She had 1/6 mismatch (completely DR matched) and maintained on standard triple immunosuppression. She had acquired a cat as pet recently. Examination revealed hepatosplenomegaly and nodular violaceous skin lesions over the forearm and legs. Serial blood cultures and a septic screen proved negative. CMV and EBV serology were negative.

Skin biopsy showed dense dermal inflammatory cell infiltrate comprising predominantly of histiocytes, sparse rod shaped organisms were identified which was positive for bartonella immunohistochemical stain. Skin sample tested positive for Bartonella Henselae DNA.

She was treated with Doxycycline 100 mg BD, IV Gentamicin 240 mg OD and reduction in her mycophenolate dose. Drug toxicities and levels were monitored closely. Her creatinine remained stable between 80 – 90 umol/L. Her skin lesions started to regress and she remained afebrile following 2 weeks of treatment and was discharged on oral doxycycline 100 mg BD for further 3 months.

Conclusion: BA is a rare opportunistic infection occurring in organ transplant recipients in the context of immunosuppression. A thorough history of contact with animals and high index of suspicion for zoonotic diseases in immunosuppressed patients presenting with febrile illnesses is important. Regular use of flea control products or avoidance of cats is the best preventative method.

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