Malakoplakia is an unusual chronic inflammatory disease related to prior
urinary tract infection. It is characterized by the presence of macrophages with foamy cytoplasm exhibiting larger PAS positive inclusions that
stain for
calcium and
iron.
Malakoplakia affects renal allograft and is associated with severe morbidity. Herein, the authors report a new case of renal graft
malakoplakia in a 23-year-old female patient. The patient received a living-related donor
renal transplantation with a high immunological risk.
Plasmapheresis and
intravenous immunoglobulin (i.v. Ig) treatment, pre- and post-transplant, and induction with rabbit
anti-thymocyte globulins were used due to presence of donor specific
antibodies and positive B cross match by flow cytometry. The patient had an early
urinary tract infection with a good outcome. On Day 36 post-transplant (PO), the patient returned to the clinic with
fever, graft
pain and acute renal dysfunction leading to
hemodialysis. Escherichia coli (E. coli) was present in the blood and urine culture. At the time, the renal biopsy revealed numerous sheets of macrophages with foamy, eosinophilic cytoplasm showing several PAS positive granules and large inclusions that stained strongly with
hematoxylin,
calcium (von Kossa method) and
iron (
Prussian blue). The patient was diagnosed with
malakoplakia related to a kidney transplant. Despite prolonged treatment with
antibiotics, determined by a susceptibility test, the patient did not recover renal function and remained on dialysis.