Presentation on theme: "Perils of medical tourism"— Presentation transcript:
1Perils of medical tourism Dr Theo GouliourisMicrobiology and Infectious Diseases StRAddenbrooke’s Hospital, Cambridge
2Case history 55 year old man, Pakistani origin ESRD secondary to hypertensive nephrosclerosis2007 Haemodialysis via AV fistula2009 Transplant waiting list
3Case history Summer 2010 Travelled to Pakistan August 2010 HCV antibody and PCR positiveRemoved from transplant waiting list pending antiviral therapySeptember 2010 commenced on ribavirin 200 mg dailyOctober 2010 travelled to Pakistan against medical advice
4Acute presentation May 2011 Presented to Addenbrooke’s unwell Living-related kidney transplant in Pakistan Nov 2010Donor and HLA match unclearRecipient CMV positiveComplicationsARDS, ventilated in ICU for 4 daysWound dehiscence and infected perinephric haematoma, treated with imipenem and colistinPoor graft function: creatinine 477 mol/LMedications: Prednisolone 10mg od, Tacrolimus 3mg/4mg, Mycophenolic acid 720mg bdLetter said wound healed. Patient believes kidney working well.
5Examination Vomiting Febrile T 38.9°C Tachycardia Widespread vesicular rash consistent with shinglesOpen wound in right iliac fossa, packed, discharging pusCommenced on empirical piperacillin-tazobactam and aciclovirBarrier nursed
7CT abdomen and pelvisCT abdomen showed an intraparenchymal abscess lower pole of kidney communicating with perinephric abscess. Multiple intramuscular abscesses R flank and R abdominal muscle.
8Management and progress Ultrasound-guided drainage of 3 largest collectionsClinical deteriorationOngoing feverProductive coughCXR pulmonary infiltratesMetabolic acidosisDiarrhoeaMycophenolate and tacrolimus stoppedTransplant nephrectomy 12 days post-admission
9Microbiology / virology results Skin vesicles: VZV DNA detectedBlood: Low-grade CMV viraemiaStool: Norovirus detectedWound swabs:Multidrug-resistant ESBL-producing Klebsiella pneumoniae and E. colivancomycin-resistant Enterococcus faeciumPeri-nephric abscess aspiratesFilamentous mould - Aspergillus terreus (amphotericin B resistant)Meropenem-resistant Klebsiella pneumoniae
11Real-time PCR detection of New Delhi metallo- beta-lactamase Purple - control NDM positive extract DNAGreen - clinical isolate extract DNABlack/blue - PCR negative control isolatesCourtesy of R. Swayne and M.Ellington, Cambridge HPA
12Histopathology results Numerous branching septal hyphae invading vessel walls and in necrotic parenchyma. Balls of fungal hyphae.
13GII.4 – Most prevalent norovirus in humans GIV ClusterGII.4 – Most prevalent norovirus in humansGI ClusterPartial sequencing of capsid encoding region - genogroup 1 genotype 4GII ClusterAdapted from Glass et al. Norovirus Gastroenteritis. N Engl J Med 2009;361:1776Courtesy of M. Curran, Cambridge HPA
14Further management Recurrent collections requiring drainage procedures Antimicrobial therapy complex – renal impairment, drug interactions and toxicity, multiple MDR organisms, need for prolonged treatmentLong courses of tigecycline (63d), amikacin (45d) and voriconazole
15Transplant tourism Common 5 to 10% of kidney transplants performed worldwidePakistan 2006: 2/3 of 2000 transplants for foreign recipients1Ethical issuesOrgan traffickingTransplant commercialismDeclaration of Istanbul on Organ Trafficking and Transplant Tourism, 2008Ethical issues: equity, justice, respect for human dignitySummit meeting of 150 representatives of scientific and medical bodies from around the world, govt officials, social scientists and ethicists1. Naqvi et al, Transpl Int 2007; 20: 934
16Literature review of outcomes 21 case series between 1990 and 2012Total no. of patients 1331 (range 5 – 515)Countries: India (62%), Pakistan (13%), China (12%), Philippines (3%), Egypt (3%), IranGraft 1-yr survival rate 86.9% (range %)Patient 1-yr survival rate 91.9% (range %)Acute rejection common 23.4% (range 10-50%)
17Infective complications Infections common, esp. CMV, wound infectionsSignificant risk of BBV acquisitionHIV 0.8%HBV 4%HCV 16%Risk of TB 3%Malaria reported (1.8%)Little emphasis on resistant organisms (mainly ESBL producing Enterobacteriaceae, one panresistant Acinetobacter baumannii)
18Aspergillus infections in renal transplants 1.3% one-year cumulative incidence of invasive fungal infections in renal transplants114% of IFI caused by Aspergillus spp. (<5% A. terreus)Usually pulmonary or disseminated infectionRecognised association with transplant tourism217 cases identifiedInfection in transplanted graft 35%Graft loss or death 76%TRANSNET 1500 patient American cohortPappas et al, CID 2010; 50: 1101Shoham et al, Transplant ID 2010; 12: 371
19Outcome Discharged from hospital on day 82 Last clinical review: wound completely healed, incisional herniaHCV RNA negative
20ConclusionsTransplant tourism is associated with significant morbidity and mortality, particularly related to infectionNDM-1 producers, pose a significant risk to patients who travel to the Indian subcontinent for medical treatmentPatients returning following hospitalisation in endemic countries should be screened for the presence of resistant bacteria and isolatedRapid molecular detection methods for antimicrobial resistance facilitate prompt diagnosis
21AcknowledgmentsDr S.H. Aliyu, Dr S. Ojha, Prof S. J. Peacock, Dr M.E. TörökRenal Transplant teamMicrobiology and Infectious Diseases colleaguesDr Matthew Ellington, Dr Rosie Swayne (Cambridge HPA)Dr Martin Curran (Cambridge HPA)Dr Verena Broecker (Histopathology Department)Dr Winterbottom (Radiology Department)