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Please prepare and upload your E-Poster no later than March 14, 2026 11.59PM CET. After this date, you will no longer be able to prepare and upload your E-poster and it will not be displayed and accessible on the congress website.
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Nocardiosis is a rare and opportunistic infection after kidney transplantation. It was life-threatening especially in the disseminated nocardiosis patients. We reported a case of disseminated nocardiosis, involving the central nervous system, lungs, bloodstream, and subcutaneous tissue, in the third month after kidney transplantation. The case report empahsized the importance of metagenomic next-generation sequencing (mNGS) and timely targeted antimicrobial therapy.
A retrospective analysis was conducted on the clinical data of a Chinese patient with early nocardia infection after kidney transplantation in our hospital, and the relevant literature was reviewed.
1. Case description
A 61-year-old male was admitted due to disturbance of consciousness accompanied with fever. The patient had a history of diabetes for 25 years, combined with diabetic nephropathy, and underwent hemodialysis for half a year prior to receiving kidney transplantation. He took prednisone 16mg qd, MMF 540mg q12h and tacrolimus 2mg q12h for maintenance immunosuppression. Besides, the patient had a history of hypertension, coronary heart disease, pulmonary tuberculosis and thoracic vertebra tuberculosis. The initial vital signs were: body temperature: 36.2 ◦C; heart rate: 76 bpm; blood pressure: 137/80 mmHg. Lung auscultation revealed a rhonchi in both lungs. No obvious edema in both lower extremities. A local swelling was visible in the right upper arm, with a fluctuating sensation upon palpation. Clinical data on admission was observed in the Table 1. Chest CT: mild interstitial hyperplasia and fibrous cord shadows in both lungs, old pulmonary tuberculosis in both lungs, slightly enlarged lymph nodes in the mediastinum, no abnormalities in the transplanted kidney and vascular ultrasound. Superficial tissue ultrasound showed a cystic-solid mass in the right upper arm, approximately 62x32mm. Right tibial posterior vein and left calf intermuscular vein thrombosis were visible in the lower extremity ultrasound. The NGS of the pus fluid suggested nocardia farcinica and cytomegalovirus. The NGS of cerebrospinal fluid and peripheral blood showed nocardia farcinica and cytomegalovirus. The NGS of bronchoalveolar lavage fluid showed nocardia farcinica, acinetobacter baumannii, moraxella maltophilia, herpes simplex virus, cytomegalovirus and candida albicans.
Table 1. Clinical data on admission.
Blood
Urine
Cerebrospinal Fluid
White blood cells (/μL)
5.04
pH
7.0
Appearence
Transparent
Hemoglobin (g/L)
67
Specific gravity
1.015
Color
Colorless
Platelete (*103/μL)
230
Protein
2+
Protein (mg/L)
751
Total protein (g/L)
75.5
Occult blood
1+
Glucose (mmol/L)
8.06
Albumin (g/L)
39.4
White blood cell (/μL)
53.9
CL (mmol/L)
127.3
AST (g/L)
21.9
RBC (/μL)
3.0
4
ALT (g/L)
12.6
MN%
75
LDH (U/L)
343
0
Urea nitrogen (mmol/L)
9.8
pressure (mmH2O)
190
Creatinine (μmol/L)
172
eGFR (mL/min/1.73m2)
36.42
Uric acid (μmol/L)
339
Ca (mmol/L)
2.21
Na (mmol/L)
134.9
K (mmol/L)
4.42
Cl (mmol/L)
102.5
CHOL (mmol/L)
2.12
TRIG (mmol/L)
2.54
CRP (mg/L)
13.78
D-dimer (mg/LFEU)
4.23
Fibrinogen (g/L)
2.95
CD19+B lymphocyte
61.11
CD4+T lymphocyte
313.33
CD4/CD8
0.91
Tacrolimus concentration
(ng/mL)
6.49
AUC of Mycophenolate Mofetil (mg·h/L)
36.25
Review of the patient's medical records, the diagnosis of disseminated nocardia infection (the central nervous system, lungs, bloodstream, and subcutaneous tissue) was confirmed. In terms of treatment, right upper arm abscess puncture and drainage were performed. Subsequently, anti-infection treatment was given with trimethoprim-sulfamethoxazole (TMP-SMZ) , carbapenems, linezolid, moxifloxacin and minocycline. After 1 month, anti-fungal infection was added. Given the current patient's immunosuppressive state, the anti-rejection regimen was gradually adjusted to 8mg qd of prednisone, 360mg q12h of MMF, and 2mg/1.5mg oral tacrolimus. After 2 months, the symptoms of the patient have improved and the function of transplanted kidney returns to the baseline level. The inflammatory indicators was in the normal range and imaging follow-up has shown the involution of remaining lesions.
2. Literature review: The incidence of opportunistic infections in kidney transplant patients is significantly increased, especially within the first six months post-transplantion, when the risk of nocardiosis is elevated due to intensive immunosuppression. Among them, nocardia infection has a low incidence but a high mortality rate, especially in the disseminated nocardiosis patients. Prophylactic dosing of TMP-SMZ could decrease nocardia infection. Early recognition and prompt treatment of nocardiosis is necessary because nocardiosis progresses extremely rapidly when CNS involvement is present. For patients with nocardia infection after kidney transplantation, TMP-SMZ-based anti-infection treatment and adjustment of the immunosuppressive regimen are crucial.
Nocardia infection after kidney transplantation is relatively rare. The recommended treatment is a TMP-SMZ-based combined anti-infection therapy, while balancing the immune rejection reaction. Preventive antifungal treatment is also of great importance during the treatment process.
