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Disseminated Bartonellosis Complicated with Postinfectious Glomerulonephritis in A Kidney Transplant Recipient

Bartonella henselae, Kidney transplantation, Glomerulonephritis Introduction: Bartonella henselae is the causative agent of cat scratch disease (CSD). CSD is an infectious disease usually characterized by self- limited regional lymphadenopathy. The most common symptoms include fever ; regional lymphadentis and a scab or pustule at the scratch site. However, CSD manifestations can include visceral organ, neurologic, and ocular involvement. In immunocompromised patients B.henslae can cause bacillary angiomatosis (BA), peliosis hepatis, as well as other even rarer manifestations. We report here a case of bartonellosis in a kidney transplant recipient complicated with postinfectious glomerulonephritis (GN). Case presentation: Our patient is a 52-year-old Caucasian man received a deceased-donor kidney transplant a year earlier due to end-stage renal disease of unknown origin. The early post- transplant period was uneventful, with steroid free maintenance immunosuppression (IS). On the 6-month protocol biopsy, acute cellular rejection was diagnosed. The patient was treated with steroid pulses and intensified IS. Maintenance IS consisted of tacrolimus (goal 6-8 ng/mL), mycophenolate mofetil 3g/day, and prednisone (5 mg/day). He presented to the emergency departament with fever, malaise and abdominal pain. Upon examination, ingvinal lymphadenopathy on the right was found. Extensive microbiological and laboratory work-up was performed. The aptient was treated empirically with piperaciline with tazobactame and IS was decreased. . The graft function at that point was excellent. A MSCT of the thorax, abdomen and pelvis was perforemd to evaluate lympadenopathy. The findings were consistent with generalised intraabdominal lymphadenopathy as weel as an enlarged lymph node in the rigth inguinume with erased hilus , measuring 16x22 mm. The inguinal node was excised. Microscopic examination demonstrated scattered necrotizing granulomas. The initial microbiological examinations were broadened to include possible causes of necrotizing granulomas such as Mycobacterium tuberculosis, Non- tuberculous mycobacteria, Brucella spp., Nocardia spp., Bartonella henselae. By that time, the kidney function began to deteriorate, and a kidney allograft biopsy was performed. The patient’s kidney function further deteriorated, and hemodialysis was initiated. The kidney biopsy finding was diffuse endocapillary proliferative GN mediated with immune complexes. B. henselae serology came back positive and 14-day treatment with doxycycline and rifampicin was initiated. Given the severity of the kidney injury and imminent graft-loss, it was decided that the patient should be treated with steroid pulses. After completion of antibiotic therapy, lymphadenopathy and fever resolved. Kidney function gradually recovered, and patient was no longer dialysis dependent. Lastly, the patient remembered that 2 weeks prior to the beginning of the illness, kittens playfully climbed up his lap and was scratched on his right leg. At 3-years follow-up his graft function remains stable, with eGFR=58mL/min/1.73m2. .... Conclusion: Bartonellosis is a rare infection in kidney transplant recipients, but it should be considered in patients presenting with lympadenopathy. In obtaining the diagnosis, role of lymph-node biopsy was crucial allowing to narrow the differential to granulomatous conditions. Up to our knowledge, there are no reports of postinfectious GN due to Bartonellosis in kidney transplant recipients. Nevertheless, there is a growing number of para-infectious or post- infectious disorders that have been reported in association with Bartonella infections affecting various organs such as the kidney or the CNS. To conclude, B. henselae infection should be part of the differential diagnosis not only in kidney transplant recipients presenting with fever and lymphadenopathy but also in those presenting with cryptogenic postinfectious manifestations such as vasculitis or GN.

Bartonella henselae, Kidney transplantation, Glomerulonephritis

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