Concurrent Epstein-Barr Virus (EBV) Viremia, Non-Tuberculosis (TB) Mycobacterial Infection, and Acute T Cell-Mediated Rejection (TCMR) in Kidney Transplant (KT) Recipient

Introduction: Managing concurrent rejection and infection after KT is a therapeutic challenge. M. genavense is a rare, difficult-to-identify mycobacterial infection. We present a case of simultaneous EBV viremia, disseminated M. genavense infection, TCMR. Case Description: A 54yo man with ESKD due to HTN underwent deceased donor KT with thymoglobulin induction followed by tacrolimus dosed for goal trough 9-12 and mycophenolate mofetil (MMF) 1g BID. EBV IgG detectable in donor but not recipient. Initial post-KT course was uncomplicated (nadir Cr 1.19) until developing EBV viremia (1,992 cop/ml) and night sweats 6 months post-KT. MMF was stopped. PET-CT revealed 1.8cm FDG-avid posterior mediastinal node, diffuse increased marrow activity, and possible old granulomatous lung disease. Lymph node biopsy showed non-necrotizing granulomas with AFB. Quantiferon gold was negative. Low-grade EBV viremia, night sweats, chills, and fever continued with labs at 9 months post-KT showing elevated LFTs (Alk Phos 544, TB 3.9, AST 69, ALT 46). Empiric treatment initiated with azithromycin, rifabutin, moxifloxacin, and ethambutol. Liver biopsy revealed non-caseating granulomas consistent with disseminated mycobacterial infection, finally speciated 4 months later as M. genavense. 14 months post-KT, Cr rose from 1.29 to 2.34 with Banff grade 1B TCMR and interstitial non-caseating granulomas on allograft biopsy (Figure). IVIG 2g/kg every other month was initiated and Cr decreased to 1.34. 8 months later, he was asymptomatic and repeat renal biopsy showed no rejection. Antibiotics were discontinued after 12 months of treatment. On follow up 2 years post-KT, remains asymptomatic with Cr 1.34, undetectable EBV, and normalized LFTs. Discussion: Combination antibiotic treatment for 1 year, high-dose IVIG, and immunosuppression reduction effectively treated concurrent EBV viremia, disseminated M. genavense infection, and TCMR.