Cured malakoplakia of the renal allograft followed by long-term good function: A case report

Abstract

Background. Malakoplakia is an unusual chronic inflammatory disease with distinctive histopathological features rarely involving the parenchyma of a transplanted kidney, and to date less than ten cases have been reported. Methods and results. We present a case of malakoplakia of a kidney graft in a 31 year old woman after simultaneous kidney and pancreas transplantation, which was successfully treated with quinolones. After the treatment of malakoplakia, she was monitored regularly, and her renal and pancreas grafts functioned well for the following 9 years, which is 12 years post transplantation. Moreover, 1 year after treatment of malakoplakia she became pregnant and gave birth to a healthy child. Conclusion. Evaluation of a kidney biopsy sample represents the key to diagnosis of malakoplakia which is important for correct patient management. Treatment with antibiotics with intracellular penetration (quinolone type) may result in curing the disease. According to our knowledge, this is the first case of allograft renal malakoplakia after combined kidney and pancreas transplantation.

Malakoplakia after kidney transplantation: Case report and literature review

“…Cases have been reported of transplantation recipients with chronic graft dysfunction as a consequence of renal parenchymal disease, 18 without recovery of the renal graft function, thus requiring nephrectomy in up to 5% of cases 5,17,19 ; or, in cases of extra-bladder involvement, with an aggressive course that leads to a fatal outcome, with a mortality of 15%. 2,3,7,14,25 In the case that we have reported, the malakoplakia involvement was localized to the bladder, without an extension to the graft, with initial refractoriness to immunosuppression reduction and long-term antibiotic therapy; therefore, endoscopic surgical management was needed, which led to resolution of the disease.…”

“…In some patients, presentation of malakoplakia was associated with the management of previous rejection; this is not a constant description (22% of cases), but in up to 74% of cases, chronic dysfunction of the allograft is present. E. coli is the most frequently isolated microorganism in these cases (61% of cases), even though other organisms have been reported, such as Klebsiella pneumoniae , Corynebacterium hofmannii , Citrobacter species, Providencia species, Candida albicans , Burkholderia cepacia , and Proteus vulgaris .…”

“…In some patients, presentation of malakoplakia was associated with the management of previous rejection 2,7,19,21,23,31 ; this is not a constant description (22% of cases), but in up to 74% of cases, chronic dysfunction of the allograft is present. E. coli is the most frequently isolated microorganism in these cases (61% of cases), even though Malakoplakia has also been reported in SOT other than kidney transplantation; for example, liver transplantation with colon 40-42 and kidney involvement, 43 cardiac transplantation with cutaneous form 44 ;…”

Pulmonary malakoplakia associated with immunodeficiency by HTLV-1 and HIV

“…The most accepted theory holds that chronic bacterial infections in patients with chronic weakness or immunosuppression would cause a deficit of cyclic guanosine monophosphate (cGMP) in microtubule and defective macrophage, causing them to phagocyte bacteria, but, in contrast, they would be unable to digest them due to intra-lisosomal failure. This situation would lead to intracytoplasmic deposition of fragments from bacteria, iron, and calcium, which would form the MG bodies (1,3,6,9) . In support of this theory, many studies state that these inclusions represent intake and persistence of bacteria in macrophages (4,5) .…”

“…Within this prevail in descending order: bladder, ureter, pelvis, and renal parenchyma (1,3,6,10,11) . The gastrointestinal tract and retroperitoneal region are the secondary most affected sites (12%-15%) by the disease.…”