Severe dengue in the early postoperative period after kidney transplantation: two case reports from Hospital Geral de Fortaleza

Emerging and neglected zoonoses in transplant population

Zoonoses represent a problem of rising importance in the transplant population. A close relationship and changes between human, animal and environmental health (“One Health” concept) significantly influence the transmission and distribution of zoonotic diseases. The aim of this manuscript is to perform a narrative review of the published literature on emerging and neglected zoonoses in the transplant population. Many reports on donor-derived or naturally acquired (re-)emerging arboviral infections such as dengue, chikungunya, West Nile, tick-borne encephalitis and Zika virus infection have demonstrated atypical or more complicated clinical course in immunocompromised hosts. Hepatitis E virus has emerged as a serious problem after solid organ transplantation (SOT), leading to diverse extrahepatic manifestations and chronic hepatitis with unfavorable outcomes. Some neglected pathogens such as lymphocytic choriomeningitis virus can cause severe infection with multi-organ failure and high mortality. In addition, ehrlichiosis may be more severe with higher case-fatality rates in SOT recipients. Some unusual or severe presentations of borreliosis, anaplasmosis and rickettsioses were also reported among transplant patients. Moreover, toxoplasmosis as infectious complication is a well-recognized zoonosis in this population. Although rabies transmission through SOT transplantation has rarely been reported, it has become a notable problem in some countries. Since the spreading trends of zoonoses are likely to continue, the awareness, recognition and treatment of zoonotic infections among transplant professionals should be imperative.

Dengue Virus Infection in Solid Organ Transplant Recipients: A Case Series and Literature Review

Dengue fever is the most prevalent arbovirus infection among humans, and tropical regions are hyperendemic for this infection. The number of solid organ transplant recipients is continuously increasing, and there are few data regarding the clinical course and outcomes of dengue infection among this population. We report on a retrospective case series of solid organ transplant recipients with dengue virus infection from 2001 to 2018 at Fundación Valle del Lili in Cali, Colombia. A total of 20 patients were included. The median age was 50.5 years (interquartile range [IQR] = 31-63.5 years) and 65% were female. Regarding the clinical course, 75% of patients had at least one warning sign, 45% were managed in the intensive care unit, and 30% had severe dengue. The median of time from transplant and dengue infection was 27.6 months (IQR = 3.82-59.12 months), and three patients had the disease in the first month after the transplant. All patients were discharged, and none of them had graft rejection. Dengue is an endemic disease in our region and represents a threat among solid organ transplantation recipients. All patients had a full recovery after the infection, suggesting that timely and effective management of patients and the access to high-complexity services could prevent fatal cases.

Dengue: 30 years of cases in an endemic area

The present study aimed to review literature on studies of dengue cases conducted over 30 years in the state of Ceará.

Between November 2015 and January 2016, articles published in Portuguese and English in 7 databases were searched using keywords and a Boolean operator. A total of 191 articles were identified in the databases; 133 were excluded according to the exclusion criteria, and 58 were included in the study.

Of the 58 articles analyzed, 6 reported data from Brazil; including the Northeast region and the state of Ceará; 41 reported data for only the city of Fortaleza; 7 reported data for the state of Ceará; 4 reported data for cities in the interior of the state; and 3 included only children. The studies adopted different approaches and focused on different aspects of the disease. Study outcomes included the identification of serological, epidemiological, clinical, and laboratory characteristics; potential larvicides and biological predators of mosquitoes; potential antiviral agents; vector density characteristics; and educational dengue prevention and control strategies. Additionally, one vaccine trial was included.

Although studies on dengue in the state of Ceará are scarce, they are encompassing, including several lines of research, and the number of studies and reports on dengue in the state of Ceará continues to increase.

Emergent Arboviruses and Renal Transplantation: A Global Challenge

In recent years, Zika, Chikungunya, Dengue, West Nile Fever, and Yellow Fever epidemics have generated some concerns. Besides difficulties related to vector control, there are challenges related to behavior of pathologies not yet fully understood. The transplanted population requires additional care due to immunosuppressive drugs. Furthermore, the potential risk of transmission during donation is another source of uncertainty and generates debate among nephrologists in transplant centers. Do the clinical outcomes and prognoses of these infections tend to be more aggressive in this population? Is there a risk of viral transmission via kidney donation? In this review article, we address these issues and discuss the relationship between arbovirus and renal transplantation.

Emerging arboviruses and implications for pediatric transplantation: A review

Recent years have brought a rise in newly emergent viral infections, primarily in the form of previously known arthropod-transmitted viruses that have increased significantly in both incidence and geographical range. Of particular note are DENV, CHIKV, and ZIKV, which are transmitted mostly by Aedes species of mosquitoes that exhibit a wide and increasing global distribution. Being important pathogens for the general population, these viruses have the potential to be devastating in the international transplant community, with graft rejection and death as possible outcomes of infection. In this review, we discuss the current state of knowledge for these viruses as well as repercussions of infection in the solid organ and HSCT population, with a focus, when possible, on pediatric patients.

Dengue fever in a kidney transplant recipient with complicated clinical course: a case report

BACKGROUND

Dengue fever is the commonest mosquito-borne illness in the tropics and subtropics. Renal transplantation is one of the ever expanding modes of treatment of end-stage renal disease. Hepatitis B is a common infection in South and East Asia, but rare in Sri Lanka. Here we describe a recipient of a renal transplant with a stable graft, on antiviral treatment for hepatitis B infection, developing dengue superinfection and entering a complex clinical course. To the best of our knowledge this is the first report of such a case.

CASE PRESENTATION

A 59-year-old Sri Lankan woman developed acute renal failure and needed dialysis support; she had upper gastrointestinal bleeding that needed transfusions, pancytopenia, and a prolonged phase of thrombocytopenia. She eventually recovered from illness, and her renal functions returned to baseline levels. The differences in presentation, signs, symptoms, and mortality of renal transplant recipients infected with dengue fever from the general population are discussed, with possible reasons for altered presentation.

CONCLUSIONS

Dengue superinfection in transplant recipients with hepatitis B infection can lead to management difficulties. The recovery can be slow as seen from this case, with prolonged thrombocytopenia.

Transmission of dengue virus from deceased donors to solid organ transplant recipients: case report and literature review

Dengue fever is a vector-transmitted viral infection. Non-vectorial forms of transmission can occur through organ transplantation. We reviewed medical records of donors and recipients with suspected dengue in the first post-transplant week. We used serologic and molecular analysis to confirm the infection. Herein, we describe four cases of dengue virus transmission through solid organ transplantation. The recipients had positive serology and RT-PCR. Infection in donors was detected through serology. All cases presented with fever within the first week after transplantation. There were no fatal cases. After these cases, we implemented dengue screening with NS1 antigen detection in donors during dengue outbreaks, and no new cases were detected. In the literature review, additional cases had been published through August 2017. Transmission of Dengue virus can occur through organ donation. In endemic regions, it is important to suspect and screen for dengue in febrile and thrombocytopenic recipients in the postoperative period.

Emerging Infections and Pertinent Infections Related to Travel for Patients with Primary Immunodeficiencies

In today's global economy and affordable vacation travel, it is increasingly important that visitors to another country and their physician be familiar with emerging infections, infections unique to a specific geographic region, and risks related to the process of travel. This is never more important than for patients with primary immunodeficiency disorders (PIDD). A recent review addressing common causes of fever in travelers provides important information for the general population Thwaites and Day (N Engl J Med 376:548-560, 2017). This review covers critical infectious and management concerns specifically related to travel for patients with PIDD. This review will discuss the context of the changing landscape of infections, highlight specific infections of concern, and profile distinct infection phenotypes in patients who are immune compromised. The organization of this review will address the environment driving emerging infections and several concerns unique to patients with PIDD. The first section addresses general considerations, the second section profiles specific infections organized according to mechanism of transmission, and the third section focuses on unique phenotypes and unique susceptibilities in patients with PIDDs. This review does not address most parasitic diseases. Reference tables provide easily accessible information on a broader range of infections than is described in the text.

Dengue fever in renal transplant patients: a systematic review of literature

Background

Dengue fever in renal transplanted patients has not been studied well, and we review all the literature about episodes dengue fever in renal transplant patients.

Methods

The aim was to describe clinico-pathological characteristics, immunosuppressive protocols, need renal outcome and mortality. PubMed, LILACS, Google Scholar and Research Gate were searched for “Dengue” and “Renal/Kidney Transplantation” with no date limits. Hits were analyzed by two researchers separately.

Results

Fever, myalgia, arthralgia and headache was significantly lower than normal population, while pleural effusions and ascites were observed more. Incidence of severe dengue is significantly higher among transplant patients in this review, as well as they had a significantly higher mortality (8.9% vs 3.7%, p = 0.031). Age, period after transplantation and immunosuppressive profile had no effect on disease severity, mortality or graft out come. Presence of new bleeding complications and ascites was associated with more severe disease (p < 0.001 and p = 0.005), death (p = 0.033) or graft loss (p = 0.035). Use of tacrolimus was associated with new bleeding complications (p = 0.027), and with ascites (p = 0.021), but not with thrombocytopenia. 25% of patients with primary disease fail to mount an IgG response by 15 weeks of the illness. 58.9% had graft dysfunction during illness. Postoperative transplanted patients were at risk of severe disease and unfavorable outcome.

Conclusions

The physical and laboratory findings in dengue fever in renal transplanted patients differ from the general population. Some degree of graft dysfunction is common during the illness, but only a minority develops graft failure.

Large hematoma over the puncture site of percutaneous transluminal coronary angioplasty as a presenting sign of severe dengue infection

Dengue fever is a common arboviral infection all over the world. It is endemic in the tropical and subtropical areas of the world with periodic epidemics in these areas. In its severe form dengue patients may develop life-threatening bleeding manifestations. We report here a case of large hematoma formation precisely located over the puncture site of percutaneous transluminal coronary angioplasty as a presenting sign of severe dengue infection for its unusual occurrence. <Learning objective: Severe dengue including dengue shock syndrome is a potentially life-threatening condition. Dengue virus-induced coagulopathy and thrombocytopenia may further complicate cardiological interventions like percutaneous transluminal coronary angioplasty or coronary artery bypass grafting as such patients are already on antiplatelet drugs. Performing any cardiovascular intervention in an endemic area of dengue needs proper vigilance to avoid such potentially life-threatening complications.>.