enlarged Tonsils post Kidney Transplant
May 23, 2019

Thank you Dr.Yasser for your Presentation

CASE PRESENTATION

37 Year old female patient , married

s/p non related cadaveric renal transplant in Philippine 2005
on preds 2.5 alternative days , parograf 2.5/2 , cellcept 500/500

cause of underlying renal etiology is unknown
as she had complicated biopsy so they stop it
and progress to transplant after 3 month of HD

have good UOP with sCr Baseline 135 umol/l

had progressive sore throat over one month with exudate , treated with week of augmentin continue to progress ,
seek advice with ENT booked for tonsillectomy with
[[ hypertrophied kissing tonsils causing significant compromise of the airway with snoring, voice change
and obstructive sleep apnea, causing night suffocation requiring the patient to sleep semisitting.
needs tonsillectomy.]]

Had Minimal cough and sputum production

No Chest Pain , Palpitation , SOB , or LL Swelling
No Abdominal Pain or Changed Bowel Habits
No DLOC , Weakness , Neck Stiffness , Fits or Falls

Vitally Stable , Conscious , Look ill , lethargic , dyspnic but not in distress
BP 130/90 – HR 105 – RR 21 – Temp 38.5 > 37.9 > 37.5
HEENT : Hypertrophied hyperemic thyroid , no exudates
Chest : EBAE , Wit End Insp Wheez – CVS : S1+S2+0
Abd : Soft and Lax , No Tenderness – LL : No Edema

WBC 4.76 – NE 93.2 – Hb 12.7 – Plt 146
CRP 20.9 – Lactic Acid 2.24 – Procalcitonin 18.39
sCr 1.46 – Na 137 – K 3.8 – Cl 108 – Ph 7.41 – Hco3 18
Anion Gap By VBG 22 – Anion Gap By Serum 11

DISCUSSION

  • How would you Approach this patient in ER ?
  • what are DDx ?
  • and how could the history of kidney transplant affect your approach?
  • which medication should you be precautions when you prescribe ?

Patient Needs admission as she has Severe infection , with no Clear definite source , however she has high Procalcitonin level in patient who is immunocompromised, Need further investigation and to start Empirical Abx.

DDX

  • Infectious Tonsillitis: Viral ( including CMV, EBV ), Bacterial ( GBS , An-aerobes ) Fungal
  • Lymphoprolifrative condition [ post kidney transplant] : Lymphoma
  • PeriTonsilar Abscess
  • Retropharyngeal abscess
  • infectious mononucleosis

Based on DDx investigations should be done include:

  • Septic screening ( Blood, Sputum and Urine culture ) , CXR
  • CMV , EBV igG+ igM and monspot test ( for EBV )
  • Assessment using “Centor criteria” to differentiate bacterial vs viral
  • Lateral Neck Xray ( preferred CT with Contrast to r/o Abscess )
  • US abdomen : to check for Hepatosplenomegally
Source: Knowmedge

WHICH MEDICATIONS YOU SHOULD BE CAUTION WITH ?

As patient has URTI and Tonsilits , it is common to use Azithromycin , and as she is Immuno-compromised with possibility of using Fluconazole during admission. Both medication ( Azithromcyin and Fluconazole ) can Rise up Prograf ( Tacrolimus ) level and causes Toxicity and AKI

HOW FEVER IN POST KIDNEY TRANSPLANT PATIENT IS APPROACHED

Infections post Kidney Transplant can be devided into

  • < 1month : Hosp. Aq infection , Donor Infections , Surgical Complications
  • 1 to 6 month: Reactivation / Opporunistic infections
  • > 6month : Community Aq, Opportunisitc , Malignancy

WHICH PATIENT AT HIGHER RISK FOR CMV ?

  • Donor was +ve ( highest risk )
  • Recipient was +ve ( intermediate risk )
  • Both -ve ( low risk )

REVIEW Q:

  • what are the ddx for Enlarged Tonsils ?
  • what is Centor Criteria ?
  • why Azithromycin and Fluconazole should be used with caution in this paitent. ?
  • what are the DDx for fever post-kidney transplant ?
  • how is at higher risk for CMV post kidney transplant ?