Letter to the Editor
Actinomyces viscosus infection in a kidney–pancreas trasplanted patient
Infección por Actinomyces viscosus en trasplantado de riñón-páncreas
Lara Belmar Vegaa,
, Emilio Rodrigo Calabiaa, Gonzalo Gutiérrez Fernándezb, Daniel Casanova Rituertob, Francisco José González Sánchezc, Carlos Armiñanzas Castillod, María Pía Roiz Mesonese, Manuel Arias Rodrígueza
Corresponding author
a Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
b Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
c Servicio de Radiodiagnóstico, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
d Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
e Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
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"identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infección por <span class="elsevierStyleItalic">Actinomyces viscosus</span> en trasplantado de riñón-páncreas" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Actinomycosis is a rare, chronic, suppurative, infectious disease caused by organisms of the genus <span class="elsevierStyleItalic">Actinomyces</span>. The most common species in humans is <span class="elsevierStyleItalic">Actinomyces israelii</span>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 36-year-old patient with a history of type 1 diabetes mellitus, chronic kidney failure secondary to diabetic nephropathy and bilateral salpingectomy after a non-specific acute salpingitis. The patient had a kidney–pancreas transplant and received induction with thymoglobulin, mycophenolate, tacrolimus and prednisone, after which she had a rapid improvement in renal function, normalisation of amylase and lipase, and well-controlled blood glucose levels without insulin requirements.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Two weeks post-transplant, she developed abdominal pain and fever, and was found to have leukocytosis and raised CRP. Abdominal CT showed a peripancreatic fluid collection in relation to the pancreatic fistula; percutaneous drainage was inserted and antibiotic therapy started. As the pyrexia persisted, a number of further tests were performed: urine culture, blood culture, sputum culture, determination of CMV by PCR, chest X-ray and echocardiography, all with no abnormal findings. Repeated abdominal CT scan ruled out intra-abdominal fluid or other complications.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The fever and pain persisted, accompanied by abdominal distension, abnormal liver function tests with a dissociated cholestasis pattern and pancytopenia. Further abdominal imaging and scintigraphy tests were performed which, respectively showed distension of intestinal loops and intense uptake into bone marrow. Since patient continued to deteriorate clinically, a laparotomy was performed, finding whitish nodules scattered around the intestines and bowel loop adhesions; these were released and ileocecal bypass performed with biopsies of the intestine, liver and bone marrow.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The bone marrow and liver cultures were negative, but <span class="elsevierStyleItalic">Actinomyces viscosus</span> was isolated in an intestinal sample. Histopathology examination showed acute liver damage with necrosis consistent with a toxic-drug reaction, with no significant lesions in the bone marrow. The patient was diagnosed with intestinal actinomycosis and started on intravenous penicillin, the pyrexia resolving after one week. The penicillin was continued for one month, followed by amoxicillin for a further eleven months. The abnormal liver function tests and pancytopenia resolved after withdrawal of the remaining antibiotic therapy. Ten months after transplantation, the patient is afebrile, her general condition is good and both grafts are functioning normally.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Actinomycosis is considered an endogenous, opportunistic infection of immunocompromised patients. The change in the status of <span class="elsevierStyleItalic">Actinomyces</span> from commensal to pathogenic may be the result of mucosal damage or tissue disruption.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a> It mainly affects three areas: the cervicofacial, thoracic and abdominopelvic regions, with the latter accounting for approximately 20% of cases.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Injury to the intestinal mucosa, previous surgery, cancer, diabetes, infections and states of immunodeficiency and immunosuppression generally predispose to invasion of the gastrointestinal tract. Damage to the intestinal mucosa is necessary for the bacteria to multiply and spread, which leads to the formation of fibrous tissue masses with a “woody” consistency. Our patient had mucosal disruption related to the pancreas transplant surgery, but her previous history also included bilateral salpingitis and she was immunosuppressed as a result of the immunosuppressive treatment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Abdominal actinomycosis is frequently confused with acute or malignant inflammatory diseases. Symptoms usually include abdominal pain, anorexia, asthenia, weight loss, pyrexia, deterioration in general condition, chills, diarrhoea and the appearance of irregular abdominal masses. The disease is usually indolent and patients may have symptoms from one month to two years before the definitive diagnosis.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Less than 10% of cases are diagnosed before surgery, with additional tests being of little diagnostic value. Blood count shows nonspecific findings such as anaemia, leukocytosis and elevated acute-phase reactants. Imaging studies usually only show the consequences of infection, such as obstruction. This can make a specific diagnosis impossible, but allows the dimensions and extent of the infection to be more precisely defined.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4–6</span></a> The treatment of choice is high-dose antibiotic therapy over long periods of time, which may need to be continued for up to one year. The drug of choice is penicillin at a dose of 10–20<span class="elsevierStyleHsp" style=""></span>million<span class="elsevierStyleHsp" style=""></span>U/day intravenously for 4–6 weeks, followed by oral penicillin at a dose of 30<span class="elsevierStyleHsp" style=""></span>mg/kg/day or amoxicillin.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6,7</span></a> In individuals allergic to penicillin, tetracycline and erythromycin are suitable alternatives. The exact treatment regimen should be individualised according to the location of the infection, severity of the disease, and the patient's response to treatment, with clinical and radiological follow-up required to confirm that the problem is resolved.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">There have been very few reported cases of actinomycosis in transplanted patients. Nevertheless, it should be considered in the differential diagnosis in cases of pyrexia of unknown origin accompanied by abdominal discomfort. Antibiotic treatment in transplant patients produces results similar to those in immunocompetent patients.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-08-01" "fechaAceptado" => "2017-01-10" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Belmar Vega L, Rodrigo Calabia E, Gutiérrez Fernández G, Casanova Rituerto D, González Sánchez FJ, Armiñanzas Castillo C, et al. Infección por <span class="elsevierStyleItalic">Actinomyces viscosus</span> en trasplantado de riñón-páncreas. Nefrología. 2017;37:431–432.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Actinomycosis: diagnostic and therapeutic considerations and a review of 32 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D. Bennhoff" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Laryngoscope" "fecha" => "1984" "volumen" => "94" "paginaInicial" => "1198" "paginaFinal" => "1217" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6381942" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0050" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary actinomycosis of the anterior abdominal wall: case report and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B. Filipović" 1 => "N. Milinić" 2 => "G. Nikolić" 3 => "T. Ranthelović" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1440-1746.2004.03564.x" "Revista" => array:6 [ "tituloSerie" => "J Gastroenterol Hepatol" "fecha" => "2005" "volumen" => "20" "paginaInicial" => "517" "paginaFinal" => "520" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15836698" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0055" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Abdominal actinomycosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.P. Garner" 1 => "M. Macdonald" 2 => "P.K. Kumar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijsu.2006.06.009" "Revista" => array:6 [ "tituloSerie" => "Int J Surg" "fecha" => "2007" "volumen" => "5" "paginaInicial" => "441" "paginaFinal" => "448" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18078685" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0060" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Abdominal actinomycosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.R. Cintron" 1 => "A. del Pino" 2 => "B. Duarte" 3 => "D. Wood" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Dis Colon Rectum" "fecha" => "1996" "volumen" => "39" "paginaInicial" => "105" "paginaFinal" => "108" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8601346" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0065" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diverticulitis abscesificante por <span class="elsevierStyleItalic">Actinomyces israelii</span> en un trasplante renal" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Valero" 1 => "E. Rodrigo" 2 => "J.C. Ruiz" 3 => "J. González-Cotorruelo" 4 => "P. Lastra" 5 => "G. López-Rasines" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Nefrologia" "fecha" => "2007" "volumen" => "27" "paginaInicial" => "511" "paginaFinal" => "513" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17944591" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0070" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Actinomicosis torácica: una entidad de difícil diagnóstico" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P. Martín-Peral" 1 => "J.E. González-Moya" 2 => "L. García-Agudo" 3 => "A. Arnedillo-Muñoz" 4 => "P. García-Martos" 5 => "A. León-Jiménez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rce.2012.03.006" "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2012" "volumen" => "212" "paginaInicial" => "e53" "paginaFinal" => "e56" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22559994" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0075" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "quiz 1262–1263" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Actinomycosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.A. Smego Jr." 1 => "G. Foglia" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "1998" "volumen" => "26" "paginaInicial" => "1255" "paginaFinal" => "1261" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9636842" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0080" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Actinomycosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "V.K. Wong" 1 => "T.D. Turmezei" 2 => "V.C. Weston" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "BMJ" "fecha" => "2011" "volumen" => "343" "paginaInicial" => "d6099" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21990282" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003700000004/v1_201708310023/S2013251417301256/v1_201708310023/en/main.assets" "Apartado" => array:4 [ "identificador" => "35436" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003700000004/v1_201708310023/S2013251417301256/v1_201708310023/en/main.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251417301256?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 8 | 13 |
| 2024 October | 48 | 30 | 78 |
| 2024 September | 61 | 22 | 83 |
| 2024 August | 69 | 53 | 122 |
| 2024 July | 65 | 34 | 99 |
| 2024 June | 77 | 45 | 122 |
| 2024 May | 65 | 41 | 106 |
| 2024 April | 55 | 36 | 91 |
| 2024 March | 38 | 19 | 57 |
| 2024 February | 39 | 29 | 68 |
| 2024 January | 26 | 23 | 49 |
| 2023 December | 36 | 25 | 61 |
| 2023 November | 51 | 39 | 90 |
| 2023 October | 39 | 30 | 69 |
| 2023 September | 37 | 29 | 66 |
| 2023 August | 35 | 29 | 64 |
| 2023 July | 43 | 20 | 63 |
| 2023 June | 40 | 22 | 62 |
| 2023 May | 44 | 37 | 81 |
| 2023 April | 35 | 17 | 52 |
| 2023 March | 51 | 22 | 73 |
| 2023 February | 46 | 16 | 62 |
| 2023 January | 42 | 25 | 67 |
| 2022 December | 51 | 31 | 82 |
| 2022 November | 58 | 24 | 82 |
| 2022 October | 41 | 43 | 84 |
| 2022 September | 51 | 35 | 86 |
| 2022 August | 62 | 46 | 108 |
| 2022 July | 37 | 39 | 76 |
| 2022 June | 45 | 43 | 88 |
| 2022 May | 40 | 29 | 69 |
| 2022 April | 45 | 43 | 88 |
| 2022 March | 53 | 47 | 100 |
| 2022 February | 84 | 37 | 121 |
| 2022 January | 56 | 38 | 94 |
| 2021 December | 42 | 53 | 95 |
| 2021 November | 47 | 26 | 73 |
| 2021 October | 61 | 43 | 104 |
| 2021 September | 53 | 39 | 92 |
| 2021 August | 37 | 34 | 71 |
| 2021 July | 83 | 36 | 119 |
| 2021 June | 41 | 34 | 75 |
| 2021 May | 73 | 39 | 112 |
| 2021 April | 151 | 61 | 212 |
| 2021 March | 117 | 38 | 155 |
| 2021 February | 107 | 34 | 141 |
| 2021 January | 63 | 22 | 85 |
| 2020 December | 54 | 14 | 68 |
| 2020 November | 68 | 12 | 80 |
| 2020 October | 54 | 24 | 78 |
| 2020 September | 60 | 18 | 78 |
| 2020 August | 47 | 17 | 64 |
| 2020 July | 59 | 8 | 67 |
| 2020 June | 64 | 27 | 91 |
| 2020 May | 67 | 17 | 84 |
| 2020 April | 55 | 20 | 75 |
| 2020 March | 52 | 15 | 67 |
| 2020 February | 77 | 21 | 98 |
| 2020 January | 81 | 20 | 101 |
| 2019 December | 67 | 23 | 90 |
| 2019 November | 51 | 29 | 80 |
| 2019 October | 49 | 7 | 56 |
| 2019 September | 66 | 12 | 78 |
| 2019 August | 41 | 9 | 50 |
| 2019 July | 38 | 25 | 63 |
| 2019 June | 34 | 18 | 52 |
| 2019 May | 62 | 18 | 80 |
| 2019 April | 73 | 27 | 100 |
| 2019 March | 45 | 24 | 69 |
| 2019 February | 34 | 20 | 54 |
| 2019 January | 34 | 21 | 55 |
| 2018 December | 126 | 37 | 163 |
| 2018 November | 236 | 23 | 259 |
| 2018 October | 207 | 15 | 222 |
| 2018 September | 124 | 27 | 151 |
| 2018 August | 81 | 12 | 93 |
| 2018 July | 101 | 13 | 114 |
| 2018 June | 86 | 12 | 98 |
| 2018 May | 131 | 14 | 145 |
| 2018 April | 177 | 13 | 190 |
| 2018 March | 172 | 17 | 189 |
| 2018 February | 180 | 10 | 190 |
| 2018 January | 168 | 17 | 185 |
| 2017 December | 128 | 14 | 142 |
| 2017 November | 84 | 14 | 98 |
| 2017 October | 48 | 11 | 59 |
| 2017 September | 56 | 15 | 71 |
| 2017 August | 58 | 17 | 75 |
| 2017 July | 25 | 5 | 30 |
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