Galloping Caseous Pneumonia with Miliary Dissemination in a Renal Transplant Recipient: Emphasis on Pretransplant Detection and Prophylaxis

Kang-Jey Ho, MD PhD, Department of Pathology, University of Alabama at Birmingham, University Station, Birmingham, AL 35233 (USA) Dear Sir, Screening of renal transplant candidates for tuberculosis has not been routinely practiced in the United States because of its low prevalence in the general population [1]. Presented here is a patient with end-stage renal disease who developed galloping caseous pneumonia with systemic dissemination 2 months after renal transplantation and expired. Should pretransplant screening and preor post-transplant prophylaxis for tuberculosis be carried out, such tragedy could certainly be avoided. A 56-year-old man was diagnosed to have idiopathic membranous glomerulonephritis in 1977. He was treated medically unitil February 1986, when he started hemodialysis therapy. In September 1990, the patient underwent a cadaveric renal transplantation. Two immunosuppressive drugs, ciclosporin and prednisone, were used throughout his hospitalization. Immediate postoperative course was complicated by intestinal obstruction with abdominal distention. Colonoscopy was then performed but no mass lesion was found throughout the entire large intestine. The procedure was complicated by perforation of the sigmoid colon which required emergency repair. Meanwhile, blood urea nitrogen and creatinine rose. The patient was then treated with additional immunosuppressive agent OKT3. Renal function improved with OKT3 therapy. However, peripheral lymphopenia with absolute lymphocyte count ranging from 28 to 800/mm3 persisted. Two months after transplantation, the patient started to spike fever. Cytomegalic inclusion disease was suspected and the patient was treated with an antiviral agent, gan-ciclovir, in addition to antibiotics. His immunosuppressive medication was also tapered. Repeated blood and sputum cultures up to the time of his demise grew neither viruses nor bacteria. Bilateral pulmonary reticulonodu-lar infiltrate was noted 2.5 weeks after the onset of fever. Skin tests for trichophyton, mumps, Candida and tuberculosis were all negative. Bronchoscopy was attempted but unsuccessful because the patient could not tolerate the procedure. The infectious disease consultant raised the possibility of mycobac-terial infection and suggested initiation of antituberculous therapy. The patient, however, developed sepsis syndrome and expired 3 months after the transplantation. At autopsy, the contracted native kidneys showed acquired or dialysis-associated cystic disease. The kidney allograft revealed no evidence of rejection. However, many small poorly-