Diffuse parenchymal form of malakoplakia in renal transplant recipient: a case report

Abstract

Malakoplakia is an unusual chronic inflammatory disease related to prior urinary tract infection. It is characterized by the presence of macrophages with foamy cytoplasm exhibiting larger PAS positive inclusions that stain for calcium and iron. Malakoplakia affects renal allograft and is associated with severe morbidity. Herein, the authors report a new case of renal graft malakoplakia in a 23-year-old female patient. The patient received a living-related donor renal transplantation with a high immunological risk. Plasmapheresis and intravenous immunoglobulin (i.v. Ig) treatment, pre- and post-transplant, and induction with rabbit anti-thymocyte globulins were used due to presence of donor specific antibodies and positive B cross match by flow cytometry. The patient had an early urinary tract infection with a good outcome. On Day 36 post-transplant (PO), the patient returned to the clinic with fever, graft pain and acute renal dysfunction leading to hemodialysis. Escherichia coli (E. coli) was present in the blood and urine culture. At the time, the renal biopsy revealed numerous sheets of macrophages with foamy, eosinophilic cytoplasm showing several PAS positive granules and large inclusions that stained strongly with hematoxylin, calcium (von Kossa method) and iron (Prussian blue). The patient was diagnosed with malakoplakia related to a kidney transplant. Despite prolonged treatment with antibiotics, determined by a susceptibility test, the patient did not recover renal function and remained on dialysis.

Malakoplakia after kidney transplantation: Case report and literature review

“…Regarding prognosis, a cure was achieved in approximately 53% of all cases, and in 40% with involvement of the genitourinary tract. Cases have been reported of transplantation recipients with chronic graft dysfunction as a consequence of renal parenchymal disease, without recovery of the renal graft function, thus requiring nephrectomy in up to 5% of cases; or, in cases of extra‐bladder involvement, with an aggressive course that leads to a fatal outcome, with a mortality of 15% . 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 ;…”

Disseminated Mycobacterium Simiae with Pelvic Malakoplakia in an AIDS Patient

“…One of the most serious adverse events reported was irreversible renal allograft dysfunction due to malakoplakia in a renal transplant recipient with E. coli infection, pyelonephritis, and bacteremia. 14 In an allogeneic stem cell transplant recipient, pleural malakoplakia caused by R. equi , presenting with a large tumor mass, required a lobectomy. 12 In patients with residual disease, successful results have been reported by treating the underlying infection, reducing immunosuppression, improving the bactericidal activity of monocytes with a cholinergic agonist, such as bethanechol, and administering a multivitamin supplement.…”

Renal Parenchymal Malakoplakia Presenting as Acute Renal Failure in a Young Woman

“…Under electron microscopy, there are different stages of phagolysosomes and bacterial fragments in foamy macrophages. [ 2 ]…”