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T B, Subash KS, Anbuselvam BS, R P S, Joseph J. A Case of Aspergillus Fungal Ball in a Transplant Graft Kidney. Cureus 2024; 16:e64690. [PMID: 39156249 PMCID: PMC11327174 DOI: 10.7759/cureus.64690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2024] [Indexed: 08/20/2024] Open
Abstract
We report a case of an Aspergillus fungal ball in a transplant graft kidney presenting as obstructive nephropathy. This is a rare manifestation considering the usual presentations of Aspergillus infection, which are pulmonary, rhino-cerebral, and disseminated forms. Imaging showed hydronephrosis with an echogenic material in the transplant renal pelvis, which was further found to be the fungal ball. The patient underwent a graft nephrectomy due to severe sepsis, and following that, his condition improved.
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Affiliation(s)
| | | | | | | | - Jerry Joseph
- Nephrology, Government Kilpauk Medical College, Chennai, IND
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2
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Husain S, Camargo JF. Invasive Aspergillosis in solid-organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13544. [PMID: 30900296 DOI: 10.1111/ctr.13544] [Citation(s) in RCA: 144] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/18/2019] [Indexed: 12/13/2022]
Abstract
These updated AST-IDCOP guidelines provide information on epidemiology, diagnosis, and management of Aspergillus after organ transplantation. Aspergillus is the most common invasive mold infection in solid-organ transplant (SOT) recipients, and it is the most common invasive fungal infection among lung transplant recipients. Time from transplant to diagnosis of invasive aspergillosis (IA) is variable, but most cases present within the first year post-transplant, with shortest time to onset among liver and heart transplant recipients. The overall 12-week mortality of IA in SOT exceeds 20%; prognosis is worse among those with central nervous system involvement or disseminated disease. Bronchoalveolar lavage galactomannan is preferred for the diagnosis of IA in lung and non-lung transplant recipients, in combination with other diagnostic modalities (eg, chest CT scan, culture). Voriconazole remains the drug of choice to treat IA, with isavuconazole and lipid formulations of amphotericin B regarded as alternative agents. The role of combination antifungals for primary therapy of IA remains controversial. Either universal prophylaxis or preemptive therapy is recommended in lung transplant recipients, whereas targeted prophylaxis is favored in liver and heart transplant recipients. In these guidelines, we also discuss newer antifungals and diagnostic tests, antifungal susceptibility testing, and special patient populations.
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Affiliation(s)
- Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Unit, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jose F Camargo
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
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3
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Smolovic B, Vukcevic B, Muhovic D, Ratkovic M. Renal aspergillosis in a liver transplant patient: A case report and review of literature. World J Clin Cases 2018; 6:1155-1159. [PMID: 30613674 PMCID: PMC6306632 DOI: 10.12998/wjcc.v6.i16.1155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 11/10/2018] [Accepted: 11/24/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Aspergillosis is a frequent invasive fungal infection in liver recipients (affecting 1%-9.2% of all patients), second only to candidiasis. Significant risk factors for invasive aspergillosis in liver recipients include corticosteroid therapy, neutropenia, T-cell dysfunction, renal failure and requirement for renal replacement therapy. Aspergillus infection usually affects the lungs of liver recipients, with hematogenous dissemination occurring in 50%-60% of cases. Renal involvement is rare and is considered to occur in 0.4% of all cases of invasive aspergillosis.
CASE SUMMARY This paper describes a case of a liver recipient presenting with a newly formed renal mass a year after liver transplantation. The patient underwent liver transplantation due to alcoholic liver cirrhosis, with preoperative corticosteroid therapy and postoperative immunosuppressants (tacrolimus and mycophenolate mofetil). His 1-year follow-up was uneventful, with a satisfying graft function and lack of any symptoms. During a routine follow-up abdominal ultrasound, he was diagnosed with a renal tumor. The renal imaging findings were inconclusive (with a differential diagnosis to renal cell carcinoma), while the computed tomography (CT) of the chest showed scar tissue in the lungs suggestive of previous inflammation. The patient underwent radical nephrectomy, with histopathological analysis showing renal aspergilloma, yielding postoperative treatment with voriconazole. His follow up was uneventful, and the chest CT did not show any change in pulmonary lesions. This case illustrates the possibility of aspergillosis affecting the lungs of liver recipients, subsequently affecting the kidney and forming an aspergilloma.
CONCLUSION Clinicians should be aware of aspergilloma mimicking solid organ tumors in organ recipients.
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Affiliation(s)
- Brigita Smolovic
- Faculty of Medicine, University of Montenegro, Podgorica 20000, Montenegro
- Department of Gastroenterohepatology, Clinical Center of Montenegro, Podgorica 20000, Montenegro
| | - Batric Vukcevic
- Faculty of Medicine, University of Montenegro, Podgorica 20000, Montenegro
| | - Damir Muhovic
- Department of Gastroenterohepatology, Clinical Center of Montenegro, Podgorica 20000, Montenegro
| | - Marina Ratkovic
- Faculty of Medicine, University of Montenegro, Podgorica 20000, Montenegro
- Department of Nephrology and Hemodialysis, Clinical Center of Montenegro, Podgorica 20000, Montenegro
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Kamal M, Apewokin S, Anand M, Abu Jawdeh BG, Govil A, Sheikh MM, Shah S. Late-Onset Allograft Aspergillosis in an HIV-Positive Renal Transplant Recipient: A Case Report. Transplant Proc 2018; 49:1570-1573. [PMID: 28838442 DOI: 10.1016/j.transproceed.2017.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 05/13/2017] [Indexed: 01/11/2023]
Abstract
Aspergillus infection of the allograft in renal transplant patients is rare and associated with a high mortality. We report a case of a 21-year-old, human immunodeficiency virus-positive, deceased-donor kidney recipient who presented 1 year after transplant with oliguric kidney injury. A nuclear medicine renal scan revealed absence of flow to the transplanted kidney, and a urine fungal culture was positive for Aspergillus flavus. The diagnosis was confirmed with the presence of fungal hyphae along with thrombosis in the vascular structures in renal allograft pathology. We found no evidence of disseminated aspergillosis or involvement of any other organ in the patient. To our knowledge, this case is the first reported in the literature of late-onset non-disseminated renal-limited aspergillosis in a human immunodeficiency virus-positive renal transplant patient.
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Affiliation(s)
- M Kamal
- Nephrology and Hypertension, University of Cincinnati, Cincinnati, Ohio.
| | - S Apewokin
- Infectious Disease, University of Cincinnati, Cincinnati, Ohio
| | - M Anand
- Nephrology and Hypertension, University of Cincinnati, Cincinnati, Ohio
| | - B G Abu Jawdeh
- Nephrology and Hypertension, University of Cincinnati, Cincinnati, Ohio
| | - A Govil
- Nephrology and Hypertension, University of Cincinnati, Cincinnati, Ohio
| | - M M Sheikh
- Pulmonary and Critical Care Medicine, University of Cincinnati, Cincinnati, Ohio
| | - S Shah
- Nephrology and Hypertension, University of Cincinnati, Cincinnati, Ohio
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Cikova A, Vavrincova-Yaghi D, Vavrinec P, Dobisova A, Gebhardtova A, Flassikova Z, Seelen MA, Henning RH, Yaghi A. Gastrointestinal tuberculosis following renal transplantation accompanied with septic shock and acute respiratory distress syndrome: a survival case presentation. BMC Gastroenterol 2017; 17:131. [PMID: 29179699 PMCID: PMC5704353 DOI: 10.1186/s12876-017-0695-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/20/2017] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Post-transplant tuberculosis (PTTB) is a serious opportunistic infection in renal graft recipients with a 30-70 fold higher incidence compared to the general population. PTTB occurs most frequently within the first years after transplantation, manifesting as pulmonary or disseminated TB. Gastrointestinal TB (GITB) is a rare and potentially lethal manifestation of PTTB and may show delayed onset in renal transplant recipients due to the use of lower doses of immunosuppressants. Further, non-specificity of symptoms and the common occurrence of GI disorders in transplant recipients may delay diagnosis of GITB. CASE PRESENTATION Here we report a rare survival case of isolated GITB in a renal transplant recipient, occurring seven years after transplantation. The patient's condition was complicated by severe sepsis with positive blood culture Staphylococcus haemolyticus, septic shock, multiple organ failure including acute respiratory distress syndrome (ARDS) and acute renal failure, requiring mechanical ventilation, vasopressor circulatory support and intermittent hemodialysis. Furthermore, nosocomial infections such as invasive aspergillosis and Pseudomonas aeruginosa occurred during hospitalization. Antituberculosis therapy (rifampicin, isoniazid, ethambutol and pyrazinamide) was initiated upon Mycobacterium confirmation. Moreover, treatment with voriconazole due to the Aspergillus flavus and meropenem due to the Pseudomonas aeruginosa was initiated, the former necessitating discontinuation of rifampicin. After 34 days, the patient was weaned from mechanical ventilation and was discharged to the pulmonary ward, followed by complete recovery. CONCLUSION This case offers a guideline for the clinical management towards survival of GITB in transplant patients, complicated by septic shock and multiple organ failure, including acute renal injury and ARDS.
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Affiliation(s)
- Andrea Cikova
- University Hospital Bratislava, Nemocnica Ruzinov, ICU, KAIM, Clinic of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Diana Vavrincova-Yaghi
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Odbojarov 10, 832 32 Bratislava, Slovakia
| | - Peter Vavrinec
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Odbojarov 10, 832 32 Bratislava, Slovakia
| | - Anna Dobisova
- University Hospital Bratislava, Nemocnica Ruzinov, ICU, KAIM, Clinic of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Andrea Gebhardtova
- University Hospital Bratislava, Nemocnica Ruzinov, ICU, KAIM, Clinic of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Zora Flassikova
- University Hospital Bratislava, Nemocnica Ruzinov, ICU, KAIM, Clinic of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
| | - Mark A. Seelen
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert H. Henning
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Aktham Yaghi
- University Hospital Bratislava, Nemocnica Ruzinov, ICU, KAIM, Clinic of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
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Zhou L, Zhao H, Chen Z, Zhu L. Urinary tract aspergillosis in a patient with chronic kidney disease. BMJ Case Rep 2017; 2017:bcr-2017-221638. [PMID: 29102972 PMCID: PMC5747772 DOI: 10.1136/bcr-2017-221638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Invasive aspergillosis is a life-threatening fungal infection, especially in immunocompromised patients. Pulmonary aspergillosis is the most common type of the infection, while urinary tract infection is relatively rare. Here, we describe a case of a 46-year-old man with chronic renal disease presenting with intermittent abdominal pain. The diagnosis of aspergillosis was established by pathological findings of the fungal ball in the bladder. The patient underwent multiple antimicrobial treatments and surgical interventions and was finally cured by posaconazole.
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Affiliation(s)
- Linghong Zhou
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Huazhen Zhao
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhongqing Chen
- Pathology Department, Huashan Hospital, Fudan University, Shanghai, China
| | - Liping Zhu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
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Jeong DW, Lee SH, Moon JY, Kim YG, Lee YH, Kim K, Park H, Joo SH. Fatal Invasive Pulmonary Aspergillosis after Combined Induction with Rituximab and Antithymocyte Globulin for Kidney Transplantation in a Sensitized Recipient, and Early Rejection Therapy with Plasmapheresis and Low-dose Immunoglobulin. KOREAN JOURNAL OF TRANSPLANTATION 2017. [DOI: 10.4285/jkstn.2017.31.1.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Da Wun Jeong
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sang-Ho Lee
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Ju-Young Moon
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Yang-Gyun Kim
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Yu Ho Lee
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Kipyo Kim
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hochul Park
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sun Hyung Joo
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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Renal Allograft Aspergillus Infection Presenting With Obstructive Uropathy: A Case Report. Transplant Proc 2017; 49:193-197. [PMID: 28104135 DOI: 10.1016/j.transproceed.2016.11.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 11/16/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND Isolated renal allograft aspergillosis is rare and usually presents with fever and decreased glomerular filtration rate. Presentation with obstructive uropathy caused by aspergillus fungal balls is much less common. We report a young male patient who presented with obstructive uropathy secondary to isolated renal allograft aspergillus infection 6 weeks after transplant. He was treated with nephrectomy and antifungal medications. CASE PRESENTATION A 29-year-old Saudi male patient had a recent living non-related kidney transplantation in Pakistan. Early Post-transplant course was complicated by acute cellular rejection (Banff Class IB) which was managed successfully with pulse steroid and anti-thymocyte globulin. The patient presented again to our emergency room on fortieth day post-transplant with a complaint of decreased urine output and passing white particles in his urine. This presentation was three Three weeks after treatment for cellular rejection, the urine fungal culture showed growth of Aspergillus fumigatus, and ultrasound imaging of the allograft kidney revealed mild to moderate hydronephrosis with echogenic materials within the renal pelvis. Biopsy of the transplanted kidney showed severe necrotizing granulomatous inflammation and fungal elements consistent with aspergillus species. The patient was given voriconazole as an antifungal agent and was weaned from immunosuppressive medication. The patient eventually required intermittent hemodialysis and underwent surgical allograft nephrectomy. CONCLUSION Suboptimal environmental and infection prevention and control precautions can explain this type of infection. It is important for clinicians to have a high index of suspicion and to investigate for fungal infection as a rare cause of obstructive uropathy in high-risk patients.
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9
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Shannon EM, Reid MJA, Chin-Hong P. Late aspergilloma of a renal allograft without need for operative management: a case report and review of the literature. Transpl Infect Dis 2016; 18:261-5. [PMID: 26751414 DOI: 10.1111/tid.12495] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/13/2015] [Accepted: 11/01/2015] [Indexed: 01/16/2023]
Abstract
Aspergillus infection localized to the renal allograft is a rare and potentially life-threatening infection and typically requires a combination of operative and medical management. We report the case of a renal allograft aspergilloma in a renal transplant patient presenting 2 years post transplant, successfully managed non-surgically. To our knowledge, this is the first report of a patient presenting with an allograft aspergilloma so long after transplantation and being successfully managed with antifungal therapy alone.
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Affiliation(s)
- E M Shannon
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - M J A Reid
- Division of Infectious Disease, Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, California, USA
| | - P Chin-Hong
- Division of Infectious Disease, Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, California, USA
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Donor-derived filamentous fungal infections in solid organ transplant recipients. Curr Opin Infect Dis 2013; 26:309-16. [DOI: 10.1097/qco.0b013e3283630e4d] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Singh N, Huprikar S, Burdette SD, Morris MI, Blair JE, Wheat LJ. Donor-derived fungal infections in organ transplant recipients: guidelines of the American Society of Transplantation, infectious diseases community of practice. Am J Transplant 2012; 12:2414-28. [PMID: 22694672 DOI: 10.1111/j.1600-6143.2012.04100.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Donor-derived fungal infections can be associated with serious complications in transplant recipients. Most cases of donor-derived candidiasis have occurred in kidney transplant recipients in whom contaminated preservation fluid is a commonly proposed source. Donors with cryptococcal disease, including those with unrecognized cryptococcal meningoencephalitis may transmit the infection with the allograft. Active histoplasmosis or undiagnosed and presumably asymptomatic infection in the donor that had not resolved by the time of death can result in donor-derived histoplasmosis in the recipient. Potential donors from an endemic area with either active or occult infection can also transmit coccidioidomycosis. Rare instances of aspergillosis and other mycoses, including agents of mucormycosis may also be transmitted from infected donors. Appropriate diagnostic evaluation and prompt initiation of appropriate antifungal therapy are warranted if donor-derived fungal infections are a consideration. This document discusses the characteristics, evaluation and approach to the management of donor-derived fungal infections in organ transplant recipients.
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Affiliation(s)
- N Singh
- University of Pittsburgh, PA, USA.
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