Tales of the unexpected

We present the case of a 33-year old Nigerian female with hypertensive renal disease and end-stage renal failure, since 1991. Her past medical history included a previous renal transplantation, Kaposi's sarcoma and β-thalassaemia. She had a repeat Cadaveric renal transplantation in December 2005, with an unremarkable post-operative course and a post-operative creatinine of 60 μmol/l. She presented on 20.02.06 complaining of a two day history of diarrhoea, fevers, sore throat and abdominal swelling. She had a soft, non-tender graft and ascities. Her creatinine levels had deteriorated to 1009 μmol/l and her CRP was 24 mg/l. Ultra sound excluded obstruction. After a renal biopsy on the 21.02.06, the patient was diagnosed and treated as an acute rejection episode. On 24.02.06 the patient suffered a cardio-respiratory arrest. Clinical examination revealed a distended tense abdomen and her haemoglobin was 4. Intra-operative findings included a large ruptured mycotic renal artery aneurysm. Broad spectrum antibiotics, meropenem and teicoplanin, were commenced, but the patient remained febrile. Following massive transfusion and arterial graft, a biopsy of the aneurysm was sent to the microbiology laboratory for microscopy and culture. Scanty growth of pin-point colonies was observed only on the anaerobic blood plate after three days incubation. The Gram stain showed an amorphous, Gram negative material that could not be identified by conventional techniques.