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Immunosuppression Cure

Is the cure worse than the disease?

The only patient who has had a documented indefinite surcease of symptoms is a transplant patient who underwent full immunosuppression after a kidney transplant operation. This is a cure that is completely inappropriate for the rest of us, but it does suggest that the etiology is not active infection.

Unfortunately, anything short of full immunosuppression does not seem to help. Dr Shoskes has said: "Dr. Alexander at Maryland has tried steroids in chronic prostatitis with limited success and considerable side effects."

More recent supporting studies:

Short course oral prednisolone therapy in chronic abacterial prostatitis and prostatodynia: case reports of three responders and one non-responder


Variability of the symptoms of chronic abacterial prostatitis/chronic pelvic pain syndrome during intermittent therapy with rectal prednisolone foam for ulcerative colitis.

Palapattu GS, Shoskes DA. Resolution of the chronic pelvic pain syndrome after renal transplantation. J Urol. 2000 Jul;164(1):127.

From the Division of Urology, Harbor/UCLA Medical Center, Torrance, California

KEY WORDS: prostatitis, immunosuppression, transplants, kidney, prostate

Chronic nonbacterial prostatitis is a common condition with an unclear etiology. We report on a patient who had complete resolution of chronic prostatitis symptoms following full immunosuppression for a renal transplant.

CASE REPORT A 35-year-old black man with end stage renal disease secondary to focal segmental glomerulosclerosis presented elsewhere with a several month history of perineal and urethral sensitivity and pain. He produced only 3 ounces of urine per day with no dysuria. A few weeks earlier he had a single episode of painless white urethral discharge. He denied any recent sexual activity, or history of other urinary symptoms, urinary tract infections or sexually transmitted diseases. Genitourinary examination was normal except for discomfort on prostatic examination. Gonococcal and Chlamydia cultures were negative. Urine culture yielded greater than 100,000 colonies of Staphylococcus epidermidis. The patient was treated with metronidazole and norfloxacin for 7 days with partial resolution of symptoms. A month later he returned with persistent symptoms but no further discharge.Urine cultures were negative. However, the patient was treated with trovafloxacin for 2 weeks. Symptoms did not resolve and he was referred to us. Urine and expressed prostatic secretions were sterile but greater than 10 white blood cells per high power field were noted in the expressed prostatic secretions. Diagnosis was the chronic pelvic pain syndrome (National Institutes of Health category IIIa prostatitis). Symptoms did not improve with a course of norfloxacin. Before any other treatment regimen could be instituted, the patient underwent successful cadaveric renal transplantation with immediate renal function. Immunosuppression consisted of steroids, cyclosporine and mycophenolate mofetil. Postoperatively, perineal and urethral symptoms completely resolved. At 13-month followup the patient is symptom-free.

DISCUSSION The exact etiology of the chronic nonbacterial prostatitis/ chronic pelvic pain syndrome is unknown, although there is evidence of infectious, inflammatory and neuromuscular mechanisms. To our knowledge we report the first case of resolution of chronic prostatitis symptoms with the initiation of immunosuppression. If the symptoms of our patient had been due to chronic infection, a worsening of symptoms and recurrent episodes of urinary tract infection would have been expected. Acute exacerbations of prostatitis in immunosuppressed patients due to atypical uropathogens are well documented. Many patients with the chronic pelvic pain syndrome derive partial and/or temporary symptomatic relief with anti-biotics, despite the lack of positive cultures. While this result can indicate a true infection not detected by standard cultures, 1 studies have indicated that most antibiotics possess direct immunomodulatory activity independent of antimicrobial properties.2 Therefore, some of these patients may have an autoimmune or primary inflammatory disorder. The serious long-term side effects and complications of full immunosuppressive therapy preclude the use of these agents in non-transplant patients with chronic prostatitis. Nevertheless, resolution of symptoms in our patient suggests that therapy designed to suppress autoimmunity/inflammation, such as bioflavonoids 3 or monoclonal antibodies targeted to cytokines, may be a logical approach in men with the chronic pelvic pain syndrome.

REFERENCES

1.Tanner, M. A., Shoskes, D., Shahed, A. et al: Prevalence of corynebacterial 16S rRNA sequences in patients with bacterial and nonbacterial prostatitis. J Clin Microbiol, 37: 1863, 1999

2.Galley, H. F., Nelson, S. J., Dubbels, A. M. et al: Effect of ciprofloxacin on the accumulation of interleukin-6, interleukin-8, and nitrite from a human endothelial cell model of sepsis. Crit Care Med, 25: 1392, 1997 3.Shoskes, D. A., Zeitlin, S. I., Shahed, A. et al: Quercetin in men with category III chronic prostatitis: a preliminary prospec-tive, double-blind, placebo-controlled trial. Urology, 54: 960, 1999