case 2 - kathrin glatz

• SGPath Slide Seminar 2015/11

Case 2

• Rosmarie Caduff, Institut für Klinische Pathologie, UniversitätsSpital Zürich

Clinics • 73-year old man

• 4 months before renal transplantation

• 1 month before mitral valve clipping

• Progressive malaise, respiratory distress

• Immunosupressive therapy

Clinics • 73-year old man

• 4 months before renal transplantation

• 1 month before mitral valve clipping

• Progressive malaise, respiratory stress

• Immunosupressive therapy

• 2 weeks before admission: skin lesions, histology unspecific inflammation

• Hospital admission: progressive renal graft dysfunction. Biventricular heart

failure. Fever.

• Blood cultures, urine examination, chest RX negative.

• Lung CT with opacity

Clinics • 73-year old man

• 4 months before renal transplantation

• 1 month before mitral valve clipping

• Progressive malaise, respiratory stress

• Immunosupressive therapy

• 2 weeks before admission: skin lesions

• Hospital admission: progressive renal graft dysfunction. Biventricular heart

failure. Fever.

• Blood cultures, urine examination, chest RX negative.

• Lung CT with opacity, lavage, detection of Trypanosoma cruzi

• Antiparasitic treatment

• Progression of hemodynamic instability, cardiogenic shock

Cortex Cortex

Medulla SV40

ptc

ptc

ptc

ptc

C4d negative in

peritubular capillaries

C4d positive in tubular

basement membranes

no microvascular

inflammation

Diagnoses

• Chagas myocarditis

• Renal cortical necrosis, chronic active vascular rejection.

Acute/floride polyomavirus nephropathy

Your diagnoses (heart) 62

• Myocarditis after reactivation of T.c. 2

• Chagas Disease 3

• Myocarditis with T.c. 9

• May be amastigote/T.c. in the heart? 6

• Myocarditis 29

• Ischemia/infarction/hypertrophy 9

• GvHD 3

• Plasmocytoma 1

•

Your diagnoses (kidney) 62

• Cortical necrosis, vascular rejection, BK 1

• Cortical necrosis or rejection or BK 10

• Ischemia/infarction/shock 26

• DIC 6

• Glomerulosclerosis, interstitial Nephritis, Tub.n 6

• Parasitosis, T.c., CMV 5

• No diagnosis for kidney pathology 8

•

Macroscopy (major findings)

• Heart/circulation: weight 568g (normal upper limit 368g), biventricular

hypertrophy and dilatation, scar left lateral. Sclerosis of the coronary arteries

without stenosis. Severe general arteriosclerosis. Thromboses of the right

atrium, right jugular veine, left iliacal veine.

Macroscopy (major findings) • Heart/circulation: weight 568g (normal upper limit 368g), biventricular

hypertrophy and dilatation, scar left lateral. Sclerosis of the coronary arteries

without stenosis. Severe general arteriosclerosis. Thromboses of the right

atrium, right jugular veine, left iliacal veine.

• Lungs: edeme, hemorrhages. Beginning of shock. Bilateral, paracentral,

organized and fresh pulmonary emboli with a wedge shaped hemorrhagic infarct

pleurabased in the right lower lobe. Bilateral pleural effusions.

• Shock necroses in the liver. Acute, abscess forming diverticulitis of the colon

descendens and sigmoideum.

• No metastases from prostate cancer diagnosed 2 years before death.

• Shrunken native kidneys. Necrotic transplant.

Carlos Chagas

Oswaldo Cruz

Trypanosoma cruzi, detected 1909 by Carlos Chagas

N Engl J Med. 2015

N Engl J Med. 2015

Trends Parasitol. 2015

DD Recurrence in our patient

Reactivation of latent disease under immunsuppression

Transmission by kidney transplantation

Transmission by blood transfusions