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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 3  |  Page : 260-262

Combined aspergillus and mucormycosis infection in a renal allograft recipient - a case report


1 Department of Nephrology, Father Muller Medical College, Mangalore, Karnataka, India
2 Department of Infectious Disease, Kasturba Medical College, Mangalore, Karnataka, India
3 Department of Pulmonolgy, Father Muller Medical College, Mangalore, Karnataka, India
4 Department of Pathology, Father Muller Medical College, Mangalore, Karnataka, India
5 Department of Radiology, Father Muller Medical College, Mangalore, Karnataka, India

Date of Submission11-Jul-2020
Date of Acceptance05-Aug-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Manjunath Jeevanna Kulkarni
Department of Nephrology, Father Muller Medical College, Mangalore - 575 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_75_20

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  Abstract 


We report a case of combined fungal infection with and aspergillus and mucormycosis in a kidney transplant recipient. Though fungal infections are common in solid organ transplant cases, combined infection with two fungi are not commonly reported. This case report describes one such infection in a kidney transplant patient, Awareness of such infections is essential in management of fungal infections in kidney transplant patients.

Keywords: Aspergillosis, fungal infection, kidney transplantation, mucormycosis


How to cite this article:
Kulkarni MJ, Dsouza A, Pramod G R, Fazal F, Mascarenhas DG, Bhat A, Dsouza LJ. Combined aspergillus and mucormycosis infection in a renal allograft recipient - a case report. Indian J Transplant 2020;14:260-2

How to cite this URL:
Kulkarni MJ, Dsouza A, Pramod G R, Fazal F, Mascarenhas DG, Bhat A, Dsouza LJ. Combined aspergillus and mucormycosis infection in a renal allograft recipient - a case report. Indian J Transplant [serial online] 2020 [cited 2020 Oct 20];14:260-2. Available from: https://www.ijtonline.in/text.asp?2020/14/3/260/296901




  Introduction Top


Infections are Achilles heel of solid organ transplant.[1] We describe a case of invasive fungal infection in a kidney transplant recipient due to aspergillosis and mucormycosis. This case demonstrates the challenges involved in diagnosis and management of the invasive fungal infection in a kidney transplant recipient.


  Case Report Top


A 42-year-old female patient was admitted with 1 day history of fever. She had undergone a living donor kidney transplant 2 months back for end-stage kidney disease due to IgA nephropathy. She was on hemodialysis for 1 year prior to the transplant.

During transplant, she received induction immunosuppression (IS) with antithymocyte globulin and methylprednisolone. Maintenance IS consisted of mycophenolate mofetil, tacrolimus, and prednisolone. She was on prophylaxis with trimethoprim/sulfamethoxazole and valganciclovir. Her immediate posttransplant course was complicated by  Escherichia More Details coli urinary tract infection and was treated with meropenem based on urine culture and sensitivity. She also developed New Onset Diabetes after Transplant. Her serum creatinine at the time of discharge was 0.9 mg/dl.

At the time of admission to the hospital, she had no history of cough or decreased urine output. On examination, she was hemodynamically stable. Physical examination was unremarkable.

Laboratory parameters showed: hemoglobin: 137 g/l, leukocyte count total: 19600/cumm, platelet count: 362000/cumm, serum creatinine: 120.25 μmol/l (1.36 mg/dl), glycoHb: 6.9%, serum Ast (Sgot): 94 IU/L, and serum Alt (Sgpt): 163 IU/L.

Chest X-ray showed a well-defined soft-tissue density lesion measuring 58 mm × 52 mm noted in the right upper zone and mid zone. Computed tomography (CT) scan was done which showed a similar picture with additional lesions in the left lung [Figure 1].
Figure 1: Chest computed tomography demonstrates computed tomography Halo sign (blue arrow) and the Reverse Halo and Bird's nest signs in left upper lobe (white arrow)

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Serum galactomannan test was inconclusive (result was 0.55). CMV DNA polymerase chain reaction was negative. Blood cultures showed no growth.

She was unable to produce sputum. In view of CT findings, she was subjected to bronchoscopy and alveolar lavage (BAL). The BAL cytology and microscopy did not show any evidence of bacteria, Pneumocystis jiroveci or fungal elements.

She was empirically started on meropenem, teicoplanin, and liposomal amphotericin B (Lip AMB). Since the suspicion of fungal infection was high we continued amphotericin as it is a broad spectrum antifungal.

The BAL sample culture grew Aspergillus Flavus. She fulfilled the criteria probable invasive pulmonary aspergillosis.

Lip AMB was stopped and she was shifted to voriconazole as it is the drug of choice for invasive aspergillosis. Doses of mycophenolate mofetil and tacrolimus were reduced to half and later stopped. Allograft dysfunction was observed during this period. Serum creatinine started to increase. The cause of graft dysfunction was multifactorial in origin. Factors contributing were worsening infection, drug interaction, and reduction in immunosuppressive drugs. However, the lung shadows showed gradual worsening. At this point, she was clinically worsening and the possible explanations were: Low serum voriconazole levels, new onset nosocomial infection or wrong diagnosis in terms of etiology. We could not check for voriconazole levels due to unavailability of this investigation. We added empirical IV polymyxin B to cover for multidrug resistant Gram-negative infection. After 10 days of admission, she became tachypnoeic, hypoxic and hypotensive and required ventilator support. Her condition worsened and she succumbed to illness after 14 days of admission.

A post mortem USG-guided lung biopsy was done. Tissue was sent for bacterial/fungal culture and histopathology examination.

Postmortem examination of lung showed fungal elements made of broad nonseptate hyphae with wide angle branching suggestive of mucormycosis [Figure 2] and also bacterial culture grew vancomycin-resistant enterococci (VRE).
Figure 2: Hematoxylin and eosin stain: High power view of microscope showing fungal elements made of broad nonseptate hyphae with wide angle branching suggestive of mucormycosis (blue arrow)

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Final diagnosis was fungal pneumonia is an immunosuppressed host caused by Aspergillus and mucormycosis. She developed a superadded bacterial infection caused by Enterococci.


  Discussion Top


We describe a case of kidney transplant recipient who presented with pneumonia 2 months after kidney transplant surgery. Initial evaluation pointed towards “probable invasive Aspergillosis.” Despite treatment with voriconazole, she deteriorated and postmortem evaluation revealed mucormycosis and VRE. We believe that VRE was nosocomial/secondary bacterial infection which developed later in course of hospital stay. She received voriconazole as a drug for aspergillosis. The reason for her deterioration was probably due to additional infection with mucormycosis which went undetected.

Combined infection with Aspergillus and mucormycosis are described in nontransplant settings.[1],[2],[3],[4] Invasive pulmonary fungal infection due to Aspergillus and Mucormycosis in a kidney transplant recipient is relatively rare. There are case reports of combined infection in heart transplant recipient.[5] Extrapulmonary involvement in kidney transplant patient have been reported.[6]

A similar observation of initial diagnosis of Aspergillus and later Mucor was made in another case report by Vergara.[7]

The treatment involves surgical debridement of infected tissue, withdrawal of immunosuppressive drugs, and use of antifungals. AMB is corner stone of antifungal therapy in case of mucormycosis. Voriconazole is treatment for Aspergillus. It is crucial to be aware of the presence of simultaneous presence of other fungi as was observed in our case.

Fungal infections have high case fatality rate up to as high as 88% in aspergillosis.[8] One study reported 100% mortality in case of lung involvement due to mucormycosis.[9]

To conclude, the management of invasive fungal infection in an immunosuppressed patient is challenging and requires high degree of suspicion. Effort must be made to obtain accurate diagnosis including a tissue biopsy as early as possible. Possibility of a concurrent infection with another organism should be kept in mind. Continuing broad spectrum antifungals till we have ruled out a concomitant infection should be considered. Accurate diagnosis, identification of the organism, and prompt initiation of treatment will be essential for the management of Mucormycosis

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vaidya D and Shah P. Coinfection by Aspergillus and Zygomycetes species in a case of acute rhinosinusitis. Case Rep Otolaryngol 2011;2011:1-5.  Back to cited text no. 1
    
2.
Alfano C, Chiummariello S, Dessy LA, Bistoni G, Scuderi N. Combined mucormycosis and Aspergillosis of the rhinocerebral region. In Vivo. 2006;20 (2):311-315.  Back to cited text no. 2
    
3.
Rit K, Saha R, Dey R, Barik G. Rhino-oculo-cerebral Aspergillus and mucor co-infections in an immunocompromised patient with type 2 diabetes mellitus. Med J DY Patil Univ 2014;7:486-8.  Back to cited text no. 3
  [Full text]  
4.
Gupta V, Rajagopalan N, Patil M, Shivaprasad C. Aspergillus and mucormycosis presenting with normal chest X-ray in an immunocompromised host. BMJ Case Reports. 2014 Apr 9;2014:bcr2014204022.  Back to cited text no. 4
    
5.
Webb BJ, Blair JE, Kusne S, Scott RL, Steidley DE, Arabia FA, et al, Concurrent pulmonary Aspergillus fumigatus and mucor infection in a cardiac transplant recipient: A case report. Transplant Proc 2013;45:792-7.  Back to cited text no. 5
    
6.
Goswami S, Vohra R, Raju BM, Agarwal A. Case report concomitant mucormycosis and aspergillosis of rhinocerebral region in a renal transplant patient – Air cooler being the Culprit. Indian J Med Case Rep 2016;5:30-4.  Back to cited text no. 6
    
7.
Navarro Vergara DI, Barragán Pola G, Bonifaz A, Núñez Pérez-Redondo C, Choreño García O, Cicero Sabido R. Pulmonary mucormycosis in a patient with kidney transplant and uncontrolled haemoptysis. Rev Iberoam Micol 2017;34:233-6.  Back to cited text no. 7
    
8.
Lin SJ, Schranz J, Teutsch SM. Aspergillosis case-fatality rate: Systematic review of the literature. Clin Infect Dis 2001;32:358-66.  Back to cited text no. 8
    
9.
Einollahi B, Lessan-Pezeshki M, Aslani J, Nemati E, Rostami Z, Hosseini MJ, Ghadiani MH, Ahmadpour P, Shahbazian H, Pour-Reza-Gholi F, Ghanji MR, Miladipour AH, Nouri-Majalan N. Two decades of experience in mucormycosis after kidney transplantation. Ann Transplant. 2011 Jul-Sep; 16 (3):44-8. doi: 10.12659/aot. 881994. PMID: 21959509.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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