Medical Cases: renal transplantation, tetanus - Case Study Example

Case study F The patient in the case study F at the outset itself has a very poor prognosis as he had suffered in the past from end stage renal complications of such gravity that it needed a kidney transplant which although being practiced in order to save human lives, does not boast of a very high success rate. According to a University of Texas Medical Branch (UTMB) communiqué, “A living donor kidney will probably be functioning two years after the time of transplant 95% of the time. The chance of a cadaver transplant continuing to work one year after the transplant is about 85%, and 50% at five years.” There is cause for concern when such patients develop other complications depending upon their genetic predisposition, immune status and lifestyle. Patients with diabetes and cardiovascular disorders are more likely to succumb in such circumstances. The use of corticosteroids like prednisone for immunosuppression during organ transplants is normal practice as otherwise there is a great risk of the donor/cadaver-organ being rejected by the host’s immune system. According to Halloran Philip (NEJM, 2004) immunosuppressive agents are used for intense action during the first phase of allograph implants and then at a lowered dose for maintenance. In renal transplantation it is all the more necessary as the kidney has to play a pivotal role in human physiology and without it the person has to be hooked onto a dialysis system. A compromise has to be made in patients of end stage renal failure and undergoing a transplant to administer such immunosuppressive agents. However the immunosuppression exposes the patient to other risks and dangers which sometimes cannot be avoided as the patient has to go on with his normal profession and daily chores after attaining some semblance of a healthy status.This particular patient has been administered prednisone and other immunosuppressive drugs and as is obvious from the facts provided, resumed his normal life as a farmer after undergoing a successful renal transplant. His compliance/non compliance to a suggested lifestyle due to his susceptible medical status after the transplant as well as any recommended medications at home are not available in the facts of the case study provided. It is therefore logical to infer that he has not followed a protected lifestyle after the procedure. As an immunocompromised person, the patient is thus a prime case for opportunistic infections. Eight years post operation, the patient is again presented at the hospital with history of respiratory distress which although cited as moderate appears to be more grievous as the patient is able to speak only with a great effort on his part. Bilateral fluffy infiltrates are obvious in the X ray. Sputum samples are collected for culture examination which does not reveal any bacteria. The patient is however treated with various antibiotics which ultimately prove to be ineffective leading to the patient’s death. Confirmation of fungal infection of the lungs was there as colonies were found to grow on Sabouraud agar which is a selective medium for fungi. This is the most widely and highly effective medium for isolating fungi and yeasts (Collee J G, et al, Practical Medical Microbiology, 14th Edition).The patient’s locale & habitat in a farm is also highly suggestive of fungal infection where spores abound. Immunocompromised patients’ are even more susceptible to fungi like Candida, Aspergillus and Cryptococcus neoformans. (Nicod, L.P. et al, 2001, European Respiratory Journal) Effective therapy for fungal infections is practicable only if initiated at the early stages and is a long term process. In such a patient there would have been more likelihood of early detection if he had been advised regular monthly medical check ups after the surgery in which appropriate interventions and changes in lifestyle could have been suggested. The patient was presented at a very late stage when it was impossible to cure him with antibiotics. His normal physiological parameters like Haemoglobin, Blood Glucose level, Total and Differential leukocyte counts, SGOT/SGPT, creatinine clearance also should have been checked on presentation at the hospital and necessary hospitalization with intensive care if needed should have been recommended. Newer diagnostic techniques like computerised axial tomography of the thoracic region as well as some PCR (Polymerase Chain Reaction) techniques could have been used to confirm the nature of fungal infection more precisely. It is therefore logical to infer that if the infection had been detected at an early stage, effective anti fungal therapy with drugs like Amphotericin could have been initiated along with systemic fungicides. Case Study C This case refers to a 60 year old man whose main symptoms are difficulty in swallowing and muscle spasms with history of an injury one week earlier. From the given facts it is clear that the patient was not administered either the Anti Tetanus Serum or the Tetanus Toxoid after the injury. There is no evidence to suggest of pre existing immunity from any past vaccination records. As the patient is elderly, his past vaccination record should have been available to eliminate any doubts at the outset. As he is on beta blockers for treating hypertension, certain behavioural abnormalities can be attributed to their side effects. There is no history of any neurological disorder and the tests carried out confirm that. The increased muscle tone which is generalized all over is suggestive of a myoclonic disorder. Stiffness of the jaw and difficulty in swallowing are the major markers which are highly suggestive of Tetanus to be the cause of exhibited symptoms. Clostridium tetani is normally occurs in cultivated soils and as a common saprophyte throughout the world. Infection usually occurs due to deep puncture wounds inflicted when injury occurs with dirty implements like nails, metallic objects, weapons, etc. When conditions are favourable in the body, the organism multiples and produces tetanospasmin which begins to act on the central nervous system between 7 to 10 days after infection. Tetanospasmin that is released by the maturing bacilli is distributed via the lymphatic and vascular circulations to the end plates of all nerves. Tetanospasmin then enters the nervous system peripherally at the myoneural junction and is transported centripetally into neurons of the central nervous system (CNS). Once the toxin becomes fixed to neurons, it cannot be neutralized with antitoxin. Recovery of nerve function from tetanus toxins requires sprouting of new nerve terminals and formation of new synapses. The toxin acts on the voluntary muscles and makes them hyper excitable, Muscle tone is increased just as displayed in the symptoms of this patient and there are exaggerated responses to trivial stimuli. This is confirmed by the increase in the deep tendon reflexes of the patient. The difficulty in swallowing is an early indicator of the condition called Lockjaw which is the common name of Tetanus typified by a sustained spasm of the neck muscles. As the disease progresses, mild stimuli may trigger generalized tetanic seizure-like activity, which contributes to serious complications and eventually death unless supportive treatment is given (WHO). However the disease is very uncommon nowadays due to active immunization campaigns all over the world. The situation demands an immediate confirmation of diagnosis by laboratory examination of smears from the patient’s samples from the wound by Gram staining. The organisms are strict anaerobes and are slender Gram positive rods which tend to be pleomorphic i.e. displaying variations in shape. Spores give a typical drumstick appearance. Imunoflourescence staining is also a recommended procedure in such cases. A clinical diagnostic test is the spatula test. This test involves touching the oropharynx with a spatula. It elicits a gag reflex, and the patient tries to expel the spatula (ie, a negative test result). If tetanus is present, the patient develops a reflex spasm of the masseter muscle and bites the spatula (ie, a positive test result). Confirmatory diagnosis can be made by inoculation of homogenized tissue or exudates into CMB (Cooked Meat Broth) and BA (Blood Agar) culture plates which are incubated anaerobically in the presence of 10% CO2 at 37ºC. (Collee J G, et al, Practical Medical Microbiology, 14th Edition) Plates are examined for the formation of typical diffused colonies of the organism and which can be sub cultured for further testing by advanced methods like toxicity testing and immunofluorescence. Confirmation by mouse inoculation from the pure cultures can also be done. Other advanced diagnostic techniques like direct staining with fluorochrome labelled antibody and by using Ellner’s/Duncan & Strong (1968)/Phillips (1986) medium can also be used. However one should not wait for confirmation as symptoms are pathognomic. Therapy can be initiated by administering Penicillin G or Vancomycin as the first line choice in antibiotics, Clindamycin as second choice and Doxycycline as the third option. Passive immunization with Tetanus immune globin is indicated when an individual is deficient in antibodies, there is inadequate time for active immunization or when the disease is actually present. (Goodman and Gilman, 2001). Administration by intra thecal route of the human antitetanus immunoglobulin has also been tried as an alternative therapy in a study by and patients showed better progression in recovery using this approach. (Miranda D B et al, 2004) References: 1. Bretagne S et al: Detection of Aspergillus species DNA in bronchoalveolar lavage samples by competitive PCR J Clin Microbiol. 1995 May ;33 (5):1164-8 7615723 Caillot D et al: Improved management of invasive pulmonary aspergillosis in neutropenic patients using early thoracic computed tomographic scan and surgery. J Clin Oncol. 1997 Jan ;15 (1):139-47 8996135 2. Collee J G, et al, Practical Medical Microbiology, 14th Edition, 1996, Churchill Livingstone, London 3. Duncan C L, Strong D H 1968 Improved medium for sporulation of Clostridium perfringens. Applied Microbiology 16:82-89 4. Ellner P D 1956 A medium promoting rapid quantitative sporulation in Clostridium perfringens. Journal of Bacteriology 71: 495-496 5. Goodman and Gilman’s Pharmacological Basis of Therapeutics, 10th Edition, 2001, The McGraw Hill Companies Inc., USA 6. Halloran Philip F: Immunosuppressive Drugs for Kidney Transplantation Volume 351:2715-2729 No 26 Dec 2004 The New England journal of Medicine 7. http://www.utmb.edu/renaltx/srate.htm 8. http://www.who.int/topics/tetanus/en/ 9. Nicod L.P., J-C. Pache and Howarth N. Fungal infections in transplant recipients European Respiratory Journal 17:133-140 (2001) 10. Miranda-Filho D B et al: Randomised controlled trial of tetanus treatment with antitetanus immunoglobulin by the intrathecal or intramuscular route BMJ  2004;328:615 (13 March), doi:10.1136/bmj.38027.560347.7C (published 5 March 2004) 11. Phillips K D 1986 A new sporulation medium for Clostridium perfringens. Letters in Applied Microbiology 3: 77-79 Read More