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Opportunistic infections or pathogens that reactivate from latent infection in the renal transplant recipients often arise during the peak immunosuppression period and infections such as Pneumocystis jirovecii may arise in the late period of posttransplant. In developing countries, tuberculosis (TB) is a major concern among transplant patients. Here, we present a case of 42-year-old male who presented after 10 years of renal transplant with a history of fever. On evaluation, he was diagnosed to have concomitant multiple infections like disseminated TB, Cryptococcal meningitis, Cytomegalovirus viremia, and Pneumocystis infection. He was treated with appropriate antibiotics, antifungal, and antiviral with close monitoring of drug-related side effects and graft function. Detailed evaluation and to look for concomitant infections is required for transplant patients who had no response to one particular group of drugs after initial diagnosis. He had stable graft function and developed drug-related side effects which required dose reduction intermittently. This case taught us how to manage four major infections with balancing immunosuppression, antibiotics, and graft function that we see in day-to-day practice of transplant clinics.

Introduction: The aim of the study was to study the clinical profile and outcomes of nocardiosis in renal allograft recipients. Methods: This was a retrospective study of clinical outcomes in consecutive renal allograft recipients with Nocardia infection over a 22-year period (2000–2022) from a tertiary care center in Southern India. The clinical data were obtained from electronic medical records and patient files. Results: A total of 1970 patients underwent renal transplantation at Christian Medical College, Vellore, India, between January 1, 2000, and December 31, 2022. During this period, 26 patients were diagnosed to have Nocardia infection. Half (50%) of the patients had fever and cough as their initial presentation, 7 (26.9%) patients presented with cutaneous abscesses, 2 (7.6%) patients were incidentally detected to have lung nodules during routine follow-up, 2 (7.6%) patients presented with headache accompanied by fever, and 3.8% had graft abscess. The diagnosis was made by isolating the organism in culture from one or more of the following samples: sputum, blood, pus, or lung biopsy (either computed tomography [CT]-guided or bronchoscopic aspirate culture). Eight patients required bronchoscopy and two patients required CT-guided biopsy for obtaining samples for diagnosis. All patients were similarly managed initially with a reduction of immunosuppression and appropriate antibiotics as per culture sensitivity. All 26 patients responded to induction treatment with meropenem (or imipenem) and trimethoprim–sulfamethoxazole (co-trimoxazole) followed by maintenance treatment with co-trimoxazole. Five (19.2%) out of 26 patients received Minocycline in induction and maintenance treatment regimens as in four patients isolates were resistant and one patient had allergic reaction to Cotrimoxazole. All patients had stable graft function. Two patients succumbed after 2 months of diagnosis with Gram-negative sepsis. Conclusions: At present, there exists no single serological test to diagnose Nocardia infection in patients. Multiple initially obtained cultures may be negative because of the slow growth of the organism and variable colony morphology. Hence, infected specimens should be obtained by aggressive approaches if the index of suspicion is high. Procedures such as bronchoscopic lavage and aspiration of abscess are invaluable toward making a diagnosis. In our study, eight patients required invasive diagnostic procedures such as bronchoalveolar lavage and CT-guided lung biopsy since initial Gram stain and sputum culture were negative. In conclusion, it is crucial to maintain a high level of suspicion and conduct thorough investigations among post renal transplant recipients. This approach facilitates early diagnosis, prompt initiation of appropriate treatment which helps prevent the spread of disease.