Morganella morganii Graft Pyelonephritis in a Kidney Transplant Recipient: A Rare Case Report in a Failing Allograft

Dear Editors, Morganella morganii is a Gram-negative facultative anaerobe of Enterobacteriaceae group and is a rare organism to cause graft pyelonephritis.[1] There have been increasing reports of drug resistance in this organism.[2] As per our literature search in PubMed, EMBASE, and MEDLINE, we report the first case of imipenem-resistant-M. morganii causing acute pyelonephritis in a kidney transplant recipient. A 35-year-old gentleman received ABO incompatible kidney transplant with a marginal kidney from his father 5 months back. He had chronic graft dysfunction with 2 mg/dl. After 3 months, BK polyomavirus (BKpV) nephropathy (blood BKpV =107 and urine 108 copies/ml) was detected due to a creeping rise in serum creatinine. Intravenous immunoglobulin 5 g daily for 5 days was given. The immunosuppression (IS) was tailored by stopping mycophenolic acid and reducing tacrolimus to half. He presented with high-grade fever after 15 days of tailoring IS. Urinary tract infection (UTI) with Klebsiella pneumoniae was detected which was sensitive to carbapenems and was treated with meropenem 1 g loading dose, followed by 500 mg thrice daily as per sensitivity report done by minimum inhibitory concentration (MIC) automated detection. Graft screening showed no evidence of abscess. He received 21 days of therapy and was discharged in stable condition, and even though required 3 dialysis sessions, was discharged at serum creatinine of 3 mg/dl. The tacrolimus dose was restored as discharge. The patient was readmitted after 7 days with fever spike, early compensated shock, and anuria. The laboratory evidence was notable for neutrophil leukocytosis and high procalcitonin. BKpV was adequately controlled (blood not detected and urine BKpV =102 copies/ml). The patient required three sessions of slow effective hemodialysis. His tacrolimus was also withheld and was only on 5 mg of prednisolone. He was started empirically on meropenem and colistin in view of severe sepsis. Graft ultrasonography (USG) and noncontrast computed tomography abdomen showed a renal abscess [Figure 1] with a maximum size diameter of 3.5 cm. The abscess was aspirated real-time USG, which was thick and purulent, and cultures were sent. After 5 days, the blood culture revealed Morganella which was sensitive to ceftazidime, cefoperazone, and meropenem, but resistant to imipenem and ofloxacin. The pus culture showed the same organism and sensitivity pattern. As his fever was persisting despite 7 days of initial therapy, the antibiotic regimen was changed to ceftazidime. This report highlights the importance of diagnostic aspiration culture in abscess, in a nonimproving patient. USG-guided aspiration was performed thrice collecting 80 ml of pus. The previous published report of Morganella among kidney transplant patients was a UTI[3] The patient is now dialysis independent, stable, and is now managed for failing graft. A meticulous approach to balancing IS is needed in these cases, due to reports[4] of poor graft outcomes after recovery in acute pyelonephritis. As Morganella is a nosocomial infection, and the patient required hemodialysis in previous admission, the source of infection could be a possible dialysis catheter. This also calls for practicing strict aseptic precautions during and after dialysis. In summary, this report highlights the importance of balancing IS in infection, practicing antibiotic stewardship, and executing intensive workup in patients presenting with pyelonephritis in organ transplantation.Figure 1: Renal abscess multiple in graft kidneyDeclaration of patient consent The patient’s consent has been taken for participation in the study and for publication of clinical details and images. The patient understands that names and initials would not be published, and all standard protocols will be followed to conceal their identity. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.