K Lau, M Hastings, S Arnold, D Jones, T Boulden, H Shokouh-Amiri, R Wyatt, B Ault
bartonella, fever, immunosuppression, renal transplant
K Lau, M Hastings, S Arnold, D Jones, T Boulden, H Shokouh-Amiri, R Wyatt, B Ault. Bartonella Infection Presenting With Prolonged Fever in a Pediatric Renal Transplant Recipient. The Internet Journal of Infectious Diseases. 2005 Volume 5 Number 1.
A 16-year-old Caucasian female with history of fever for one week was admitted to the renal service. She complained of back and neck pain for three days prior to the onset of fever. The family recalled that the patient had a maximum temperature of 38.5°C at home. She had been given acetaminophen with limited antipyretic effects. Vomiting and loose stools developed one day before hospital admission.
The patient was born with complex cloacal anomalies and obstructive uropathy requiring multiple surgical procedures for her uro-genital malformations. She received a non-related live donor kidney transplant 19 months before this admission. At the time of transplantation, her cytomegalovirus (CMV) and Epstein Barr virus (EBV) antibodies were negative and positive respectively. The donor was positive for both CMV and EBV. The patient received CMV immunoglobulin and valganciclovir prophylaxis after the transplant. She had never experienced a rejection episode. She had been admitted several times for lymphocele drainage before this admission. Her immunosuppression included prednisone 5 mg daily, mycophenolate mofetil 750 mg twice daily and tacrolimus 2.5 mg twice daily. She was also receiving cotrimoxazole at night for urinary tract infection prophylaxis due to the need for self-catheterization through a Mitrofanoff catheterizable stoma. She did not have any history of traveling to a foreign country. There were three adult cats and a dog in the household. She had also played with stray cats but she reported no recent bite or scratch by her cats. There was no other animal exposure or history of potential tick exposure.
Vital signs at time of admission were as follows: temperature 38.9°C, pulse 116 per minute, and blood pressure 113/69 mmHg. She weighed 47.4 kg and her height was 149.5 cm. On physical examination, she was mildly ill looking without signs of dehydration. No lymphadenopathy, rashes or skin lesions were detected. Her ear, nose and throat examinations were normal. She also had normal respiratory and cardiovascular examinations except for mild tachycardia. Abdominal examination showed no hepatomegaly, but her spleen was palpable 4 cm below the left costal margin. She had a Mitrofanoff catheterizable stoma in her lower abdomen; this appeared normal.
She was empirically started on intravenous piperacillin sodium/tazobactam and itraconazole to cover for bacterial or fungal infection. Post-transplant lymphoproliferative disease was also considered and immunosuppression was decreased. Her EBV viral load by polymerase chain reaction (PCR) showed 150 to 15,999 copies/ml whole blood on day 2 of admission. This is a level that has not typically been associated with clinical disease in transplant patient. Ultrasound of her abdomen upon admission showed a small collection of fluid in the pelvis and a normal appearing renal allograft. It also revealed a normal appearing liver, a poorly visualized gallbladder, and an enlarged spleen with multiple hypoechoic lesions. Two days later, she had a MRI with contrast of her abdomen in order to search for other intra-abdominal pathology. Despite the fact that no lesion was found in the liver on the ultrasound, the MRI showed multiple enhancing nodules in the both the liver and spleen (Fig. 1).
Table 1 depicts the patient's initial laboratory data including the results of her work-up for sepsis.
Para-aortic lymphadenopathy was also noted. Bone marrow aspirate done after five days of admission showed normal cellularity and culture for Mycobacterium mycobacteria and fungius were subsequently negative. Doxycycline was started on day six of hospitalization when she was found to have an IgG antibody titer of 1:64 to
The empirical antibiotics and anti-fungal agents were discontinued. A diagnosis of bartonellosis was confirmed when her
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Peliosis hepatis is a well-characterizedn, angiogenic lesion with invasion of endothelial cells by
As illustrated by our patient, Bartonella infection in immunosuppressed patients may be difficult to diagnose due to its non-specific clinical manifestations. A recent study from Israel indicated that anti-Bartonella henselae immunoglobulin M (IgM) antibodies remained positive for less than 3 months in most patients with Bartonella infection (17), and the presence of IgM antibodies against Bartonella henselae indicated an acute infection. Our patient had a more than four fold increase in the IgM titers, which was highly suggestive of recent infection. Although she received IVIG for possible systemic Enterovirus infection (blood PCR for Enterovirus was negative), this should not have affected her Bartonella IgM titers. In addition, her Bartonella IgG titers increased from 1:64 to 1:256 before the administration of IVIG. The diagnosis of Bartonella infection was further confirmed by detection of Bartonella henselae DNA in blood by real time PCR.
Keith K Lau Room 301, WPT 50 North Dunlap Memphis, TN 38103 Tel: (901) 572 5376 Fax: (901) 572 5036 E mail: firstname.lastname@example.org