Abstract
Malignant (necrotizing) otitis externa is a severe, invasive infection of the external auditory canal and skull base, most commonly caused by
Pseudomonas aeruginosa
. It carries a high risk of morbidity in immunocompromised patients, particularly solid organ transplant. Management of immunosuppression in this case could be very challenging in view of balancing the life-threatening complications and prevention of rejection. We report a 46-year-old male with chronic kidney disease Stage 5 secondary to diabetic nephropathy, on hemodialysis for 2 years, who underwent deceased-donor kidney transplantation. He received antithymocyte globulin induction and maintenance immunosuppression with tacrolimus, prednisolone, and mycophenolate mofetil, achieving stable graft function with serum creatinine between 1.2 and 1.4 mg/dL and good glycemic control. One year posttransplant, he developed severe right otalgia and mucopurulent otorrhea persisting for 1 month, unresponsive to topical ciprofloxacin and oral amoxicillin prescribed by a physician elsewhere. Examination revealed granulation tissue and mucopurulent discharge; pus culture grew
P. aeruginosa
. Computed tomography temporal bone demonstrated osteomastoiditis with erosions of the postero-inferior wall of the middle ear cavity, petrous apex, and styloid process, confirming malignant otitis externa. He underwent a cortical mastoidectomy with excision of granulation tissue, and histopathology confirmed necrotizing inflammation. Mycophenolate was temporarily discontinued to reduce immunosuppression, and the patient received intravenous ceftazidime for 6 weeks, resulting in complete resolution of symptoms, preservation of hearing, and stable renal function (serum creatinine 1.2 mg/dL) at 6-month follow-up. This case underscores the importance of early recognition of malignant otitis externa in kidney transplant recipients, as delayed diagnosis and persistent symptoms warrant prompt imaging and aggressive management. Tailoring immunosuppression and initiating prolonged antipseudomonal therapy, combined with surgical debridement when indicated, can lead to favorable outcomes in this vulnerable population.