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Simhadri PK, Contractor R, Chandramohan D, McGee M, Nangia U, Atari M, Bushra S, Kapoor S, Velagapudi RK, Vaitla PK. Malakoplakia in kidney transplant recipients: Three case reports. World J Nephrol 2025; 14:100530. [DOI: 10.5527/wjn.v14.i2.100530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 02/03/2025] [Accepted: 03/04/2025] [Indexed: 04/09/2025] Open
Abstract
BACKGROUND Malakoplakia is a rare chronic granulomatous disease associated with gram-negative infection, predominantly by Escherichia coli. It is induced by defective phagolysosomal activity of the macrophages. Malakoplakia commonly affects the urinary bladder but has been shown to affect any solid organ, including the native and transplanted kidney. However, isolated malakoplakia of the kidney allograft is rare. Transplant recipients with compromised immune systems are more likely to develop malakoplakia.
CASE SUMMARY We report three cases of kidney allograft parenchymal malakoplakia in kidney transplant recipients on immunosuppression that were successfully managed with good outcomes. We described the clinical characteristics of all the kidney allograft malakoplakia cases documented in the literature. A total of 55 cases of malakoplakia were reported in recipients with a history of kidney transplant. A total of 27 recipients had malakoplakia involving the allograft, and others had malakoplakia in other organs. The common presentations included allograft dysfunction, pyelonephritis, and allograft or systemic mass. Most recipients had favorable outcomes with appropriate management that included prolonged antibiotic therapy and adjustment of immunosuppression. We reviewed the published literature on all the cases of malakoplakia in kidney transplant recipients so far and summarized the etiology, management, and outcomes.
CONCLUSION This case series provides an overview of the etiology, presentation, pathogenesis, and management of malakoplakia in kidney transplant recipients.
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Affiliation(s)
- Prathap Kumar Simhadri
- Internal Medicine/Nephrology, Advent Health, Daytona Beach, FL 32117, United States
- Department of Medicine, FSU College of Medicine, Daytona Beach, FL 32117, United States
| | - Renish Contractor
- Department of Medicine, FSU College of Medicine, Daytona Beach, FL 32117, United States
| | - Deepak Chandramohan
- Department of Nephrology, UAB School of Medicine, Birmingham, AL 35001, United States
| | - Matthew McGee
- Department of Medicine, Lark Erie College of Osteopathic Medicine, Bradenton, FL 34205, United States
| | - Udit Nangia
- Department of Internal Medicine, University Hospitals-Parma Medical Center, Parma, OH 44129, United States
| | - Mohammad Atari
- Department of Nephrology, University of Mississippi Medical Center, Jackson, MS 39056, United States
| | - Syed Bushra
- Department of Nephrology, University of Mississippi Medical Center, Jackson, MS 39056, United States
| | - Sanjana Kapoor
- Department of Nephrology, University of Mississippi Medical Center, Jackson, MS 39056, United States
| | - Ramya Krishna Velagapudi
- Department of Pathology, University of Mississippi Medical Center, Jackson, MS 39056, United States
| | - Pradeep K Vaitla
- Division of Nephrology, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS 39216, United States
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Outgrowing skin involvement in malakoplakia after kidney transplantation: A case report. Transplant Proc 2022; 54:1627-1631. [PMID: 35811147 DOI: 10.1016/j.transproceed.2022.03.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/10/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Malakoplakia is a rare pseudotumor that arises in the context of recurrent infections, particularly in immunocompromised states. We report a case of renal allograft parenchymal malakoplakia. CASE REPORT A 59-year-old woman successfully received a cadaveric renal transplant in June 2018. Two months after transplantation, she was treated for a urinary tract infection (UTI). In March 2019, she underwent allograft biopsy for increasing creatinine. The biopsy identified T cell mediated rejection and steroid pulse therapy was performed. In December 2019, she was hospitalized for right flank pain and pyuria, and her creatinine level was 1.9 mg/dL. Radiographic findings were suggestive of a hematoma or abscess in the perirenal area, and septated fluid collection was suspected. Biopsy results suggested malakoplakia, and von Kossa stain was positive for Michaelis- Gutmann bodies. Tissue culture demonstrated Escherichia coli, and this was treated with antibiotics. The dose of tacrolimus was reduced. The patient was discharged after 1 month of hospitalization and was maintained on oral antibiotics. Follow-up imaging revealed an increase in the extent of lesion into the adjacent abdominal wall. Assuming the case to be refractory, we performed surgical resection and abscess drainage. Although the renal parenchymal involvement persisted, the size showed a decreasing trend over 2 months of serial observation with ultrasonography. CONCLUSIONS Malakoplakia should be considered as a differential diagnosis for recurrent UTI with graft dysfunction. Malakoplakia can be successfully treated with reduction in immunosuppression and medical therapy using long-term antibiotic treatment in most cases. However, early surgical treatment must be considered for refractory cases.
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Successful use of azithromycin for Escherichia coli-associated renal allograft malakoplakia: a report of two cases. Eur J Clin Microbiol Infect Dis 2021; 40:2627-2631. [PMID: 33990891 DOI: 10.1007/s10096-021-04270-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
Malakoplakia is a chronic granulomatous disease associated with incomplete clearance of bacterial pathogens. A multimodal approach to therapy includes antimicrobials with intracellular activity, reduction in immunosuppression, and debulking of lesions. Azithromycin has an intracellular mechanism of action and enhanced Gram-negative activity compared to other macrolides. Despite some in vitro data to support its use, there are no clinical breakpoints or epidemiological cut-off values for most Enterobacterales from the European Committee on Antimicrobial Susceptibility Testing (EUCAST) or the Clinical and Laboratory Standards Institute (CLSI). We present two cases, previously unreported, of Escherichia coli associated renal allograft malakoplakia successfully treated with azithromycin.
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