Lesions and Transplantation
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Prognosis is dependent on the location and extent of disease as well as the underlying health of the patient [ 3 , 6 , 7 , 8 , 9 , 10 , 11 ]. As malakoplakia may occur as a complication of immunosuppression, whether primary or secondary, renal transplant recipients are at risk. The graft itself [ 12 ] or extra-renal sites may be involved [ 3 ].
Regarding the latter, six cases of colorectal involvement have been reported [ 6 , 7 , 8 , 9 , 10 , 11 ], with all but one patient experiencing significant morbidity. Herein, we describe a further example of colorectal malakoplakia following renal transplantation, in which the presenting features were at first suggestive of likely diverticular disease.
Ten months previously she had received a cadaveric renal transplant right lower flank for chronic renal failure due to focal segmental glomerulosclerosis. Her immunosuppressive medications were prednisone, mycophenolate and tacrolimus. Six weeks prior to this visit she had been treated with valganciclovir for cytomegalovirus viremia. Now, she stated that she had recently begun to experience mild left lower quadrant abdominal pain and that vaginal bleeding had occurred the previous week.
Fever was absent. Her bowel movements were unchanged and she did not report blood in her stool.
Her past medical history included iron deficiency anemia, arterial hypertension, diabetes type II, and hysterectomy with right ovariectomy for benign disease. At physical examination the patient was afebrile with a mildly distended abdomen that was supple without tenderness or guarding. There was no palpable mass. The white blood cell count was 5. Renal function was normal. She was admitted to hospital for further investigations.
Hepatocellular Carcinoma: Current Thoughts on Liver Transplantation
Abdomino-pelvic computerized tomography CT scanning without intravenous iodine contrast was performed Fig. Rectal contrast was used to distend the colon. Two non-stenotic ill-defined moderately dense masses were found in the mesocolon: the first was adjacent to the descending colon, and the second involved the sigmoid colon As the second mass was in a diverticular bowel segment and contained few extraluminal air bubbles, a diagnosis of sub-acute perforated diverticulitis with two phlegmons was proposed.
However, the findings were acknowledged as being somewhat atypical for this diagnosis because the proximal mass was completely separate from the distal one and contained no air. The differential diagnosis included a perforated sigmoid neoplasm with a metastatic implant next to the descending mesocolon and post-transplant lymphoproliferative disease. In light of these findings, a planned colonoscopy was canceled. Abdomino-pelvic CT scan images.
The transplanted kidney is partially seen in the right lower quadrant thick red arrow. Incidentally, a partially calcified renal lesion is seen in the left native kidney red star. Given the presumptive diagnosis of perforated diverticular disease, empirical antibiotic therapy was begun and three days later laparotomy was performed. At surgery, two masses involving the descending colon and the sigmoid were found, the latter with perforation.
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The sigmoid lesion was resected and a terminal colostomy performed. The descending colon lesion was treated by creation of a cutaneous fistula and placement of a Jackson-Pratt drain. Macroscopic examination Fig. There was no evidence of neoplasia.
PREMALIGNANT AND MALIGNANT SKIN LESIONS IN RENAL TRANSPLANT : Transplantation
Macroscopy of the resected sigmoid. The underlying bowel wall and mesentary are infiltrated and distorted by malakoplakia infiltrates which are friable and have visible cracking artefact. Microscopic examination Fig. The infiltrate involved the entire thickness of the bowel, causing mucosal ulceration and bowel wall perforation. Calculospherules MG bodies were readily identified in the cytoplasm.
The cells were positive with the immunohistochemical markers leukocyte common antigen and CD68, confirming their histiocytic nature. The findings were diagnostic of malakoplakia. Microscopy of the resected sigmoid.
They are of variable size with a round to ovoid shape. Many have a targetoid appearance. The immediate postoperative course was uneventful. Nine months later, no longer receiving antibiotic therapy, the patient reported lower left quadrant discomfort and episodes of nausea.
She had also noted a vulvar nodule which subsequent biopsy, as well as that of a vaginal mass discovered by pelvic examination, showed to be malakoplakia. The following month she was admitted to hospital because of steadily worsening anal and pelvic pain, anorexia, weight loss, malnutrition, and an inability to walk unaided.
She was afebrile. The colostomy site was unremarkable; the cutaneous fistula had a malodorous greenish discharge. There was no evidence of peritonitis. A CT scan showed para-rectal and pelvic abdominal masses with cutaneous and intestinal fistulas. The patient was discharged home after several weeks.
She is currently being closely followed without current antibiotic treatment.
Malakoplakia involving the colorectum is a possible consequence of immunosuppression following renal transplantation. Although the small number of case reports suggests this is a rare complication, the one account of fortuitous diagnosis in an asymptomatic patient suggests the frequency is perhaps greater. In general, the disease is characterized by significant morbidity. As the present case illustrates, bowel perforation may lead to a difficult and protracted clinical course. Our case provides the second illustration of CT scan imaging of colorectal malakoplakia following renal transplant [ 7 ].
The images from these two cases suggest, however, that the CT scan findings of colorectal malakoplakia are nonspecific. Treatment of malakoplakia is currently based on antibiotic therapy and reduction of immunosuppression.
Gingival Lesions and Nasal Obstruction in an Immunosuppressed Patient Post-Liver Transplantation
Surgery may be indicated for diagnosis and therapy when mass lesions are present. Although a discussion of specific treatment protocols is beyond the scope of this report, it is noteworthy that inadequate response to current protocols represents a major challenge in the treatment of certain patients. We conclude that physicians caring for renal transplant recipients should be aware of colorectal malakoplakia as a rare but serious complication. The clinical presentation is varied, nonspecific and will likely suggest more common diseases. Clinical and laboratory studies into the pathogenesis of malacoplakia.
J Clin Path. McClure J. Malakoplakia of the gastrointestinal tract. Postgrad Med J. Malakoplakia and immunosuppressive therapy.
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