Burkholderia Cenocepacia Pyelonephritis in a Post-Kidney Transplant Patient

Dear Editor, We report a case of graft pyelonephritis with multidrug-resistant (MDR) Burkholderia cenocepacia in a renal transplant recipient. This organism belongs to the Burkholderia cepacia complex, and is often associated with infections in immunocompromised patients.[1] A 37-year-old gentleman with no history of diabetes underwent deceased donor renal transplantation. The induction agent was antithymocyte globulin (ATG). The immediate posttransplant period was uneventful, and he was discharged on the 10th day with a serum creatinine of 0.9 mg/dL and good urine output. He was on triple immunosuppression with tacrolimus, mycophenolate mofetil (MMF), and prednisolone. Two weeks after discharge, he was found to have high blood sugars. His C0 tacrolimus level was 10 ng/mL, and the renal function was stable. He was initiated on insulin, and glycemic control was achieved. DJ stent was removed after 6 weeks. Two months later, he presented with high-grade fever, abdominal pain, and dysuria. He was febrile, pulse rate – 110/min, blood pressure – 150/100 mmHg. Graft tenderness was present. On evaluation, TC – 4500 cells/mm3, DC – P90 L6 M4, platelet – 1.43 lakhs/cu mm, erythrocyte sedimentation rate – 20 mm/1st hour, Random blood sugar (RBS) – 180 mg/dL, S. creatinine-0.9 mg/dL, C-reactive protein was 81 mg/dL. Blood culture was negative. Urine culture showed Burkholderia cenocepacia >100,000 colony-forming unit/ml, sensitive to meropenem, ceftazidime, and minocycline. Computed tomography (CT) abdomen showed a 1.7 cm × 2.4 cm collection in the lower pole of the transplant kidney with perinephric fat stranding. Ultrasound sonography-guided aspiration from the collection was done, and culture showed Burkholderia cenocepacia. He was initiated on injection meropenem 1g BD and was continued for 3 weeks. His fever subsided within 2 days. In view of acute infection, tablet MMF was stopped. A repeat CT abdomen was done after 3 weeks, which showed a decrease in the size of the collection. Repeat urine culture done after 3 weeks was negative. He was discharged with stable renal function. Two weeks later, he was again initiated on MMF. The risk factors for MDR urinary tract infection following renal transplantation include female gender, prolonged Foley’s catheterization, diabetes mellitus, and the use of ATG.[2]Escherichia coli was the most frequent MDR uropathogen associated with UTI in postrenal transplant.[2] Burkholderia cenocepacia is found in the rhizosphere of plants and water-based environments.[3] They also survive in various sterile (intravenous solutions, drugs) and nonsterile pharmaceuticals (mouthwash, hand sanitizers, preoperative skin solutions, and nasal sprays).[3] The factors for multidrug resistance of Burkholderia include: (a) efflux pumps, (b) presence of class A beta-lactamases, (c) change in the outer membrane protein of the lipopolysaccharide structure of the organism, making them resistant to polymyxins and other cationic antimicrobial peptides.[4] In a case report of posttransplant Burkholderia UTI published by Li et al., the patient was resistant to antibiotic therapy, and finally, graft nephrectomy was done.[5] Since our patient has responded with antibiotic therapy and had stable renal function, the situation was manageable. However, long-term follow-up is necessary to assess the effect of acute pyelonephritis on graft survival. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.