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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 4  |  Page : 360-362

A case report of central nervous system mucormycosis and aspergillus pneumopericardium in a renal transplant recipient


Department of Nephrology, Medanta Kidney and Urology Institute, Medanta - The Medicity, Gurgaon, Haryana, India

Date of Submission09-Jan-2020
Date of Acceptance22-Nov-2020
Date of Web Publication30-Dec-2020

Correspondence Address:
Dr. Arushi Nautiyal
Department of Nephrology, Medanta Kidney and Urology Institute, Medanta - The Medicity, Sector 38, Gurgaon - 122 018, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_2_20

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  Abstract 


Renal transplant recipients are at high risk of opportunistic infections. The occurrence of infections is influenced by the intensity of immunosuppression, microbial exposures and other environmental and systemic factors. We present a case of a postrenal transplant recipient who developed polymicrobial infections, including bacterial and invasive fungal infections involving the cerebrum (Mucormycosis) and lung (Aspergillosis) complicated by extension into the pericardial cavity. Despite treatment with intravenous antibiotics and antifungals along with surgical debridement of infective focus, the patient succumbed to the illness. Fungal infections in posttransplant population can have myriad presentations and many pathogens can become locally and systemically invasive unless detected and controlled in a timely manner. Risk factors such as hyperglycemia and high immunosuppression should be appropriately addressed for the prevention of high-grade infections.

Keywords: Fungal, infection, renal transplant


How to cite this article:
Nautiyal A, Gadde A, Mahapatra AK, Bansal SB. A case report of central nervous system mucormycosis and aspergillus pneumopericardium in a renal transplant recipient. Indian J Transplant 2020;14:360-2

How to cite this URL:
Nautiyal A, Gadde A, Mahapatra AK, Bansal SB. A case report of central nervous system mucormycosis and aspergillus pneumopericardium in a renal transplant recipient. Indian J Transplant [serial online] 2020 [cited 2021 Apr 10];14:360-2. Available from: https://www.ijtonline.in/text.asp?2020/14/4/360/305424




  Introduction Top


Infections in renal allograft recipients are often associated with significant morbidity and mortality, accounting for the second-most common cause of death in this population.[1] The type and severity of infections to which patients are most prone are influenced by factors such as time since transplant, immunosuppression, episodes of rejections, azotemia, hyperglycemia, and environmental exposures.[1] Although bacterial and viral pathogens comprise the bulk of postrenal transplant infections, fungal infections contribute significantly to overall morbidity as they are often difficult to diagnose and treat. However, multiple and multifocal invasive fungal infections are distinctly uncommon. We present a case of a renal allograft recipient who developed multifocal bacterial as well as multiple fungal infections leading to a fatal outcome.


  Case Report Top


A 53-year-old male, resident of Punjab, India, known diabetic (20 years) and hypertensive, underwent a renal transplant in December 2017 with his wife as donor at a center in Punjab; he received thymoglobulin as induction and was on triple immunosuppression (Tacrolimus, MMF, steroid). He had poor glycemic control in the posttransplant period. After 3 months, he developed fever and chest pain of 3 days duration and was admitted at an outside facility for the same, wherein he was detected to have bilateral pneumonia and underwent bronchoscopy and bronchoalveolar lavage, which showed growth of Burkholderia cepacia, Escherichia coli, and septate fungal hyphae on the smear. He was started on sensitive antibiotics and antifungals (Voriconazole later changed to liposomal Amphotericin). However, his condition deteriorated and he was shifted to our center for further evaluation and management.

He was received in a state of severe respiratory distress and was intubated and put on ventilatory support in emergency room. He was continued on Carbapenem antibiotics, started a day prior, according to sensitivity and Liposomal Amphotericin B in view of severe sepsis. Investigations showed - serum creatinine - 1.1 mg/dl, total leucocyte count - 9550/cumm and Tacrolimus level - 12 ng/ml, cytomegalovirus (CMV) DNA polymerase chain reaction - 270 copies/ml. High-resolution computed tomography (CT) chest [Figure 1] showed a large area of consolidation in the anterior segment of the right upper lobe, multifocal nodular lesions in bilateral lungs, few showing cavitation.
Figure 1: X-ray and high-resolution computed tomography chest at presentation

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He underwent repeat bronchoscopy and bronchoalveolar lavage, which showed growth of Acinetobacter baumanii and positive galactomannan antigen. His immunosuppressive medications (Tacrolimus and MMF) were stopped in view of overwhelming sepsis; however, steroids were continued. In view of poor sensorium, he underwent noncontrast head CT head which showed left frontal intracranial space-occupying lesion, for confirmation of nature of the lesion, he underwent magnetic resonance imaging brain with contrast [Figure 2] which showed an SOL in left frontal periventricular and gangliocapsular regions suggestive of the cerebral abscess with midline shift of 5.5 mm; imaging did not show any involvement of sinuses. He underwent surgical drainage of the same, KOH smear [Figure 3] showed aseptate fungal hyphae suggestive of Mucor, Posaconazole was added. Poor sensorium persisted despite drainage of the cerebral lesion.
Figure 2: Magnetic resonance imaging brain showing cerebral abscess

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Figure 3: Mucor hyphae seen on KOH smear and histopathology slides from cerebral abscess

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He remained on ventilator support and progressive radiographs of the chest [Figure 4] showed the development of lung cavitation with suspicious pneumopericardium. Contrast enhanced CT scan showed the development of cavitation in the previous consolidation in the right lung lobe communicating with pericardium-Hydro-pneumo-pericardium. The thoracic surgery team was consulted, as the patient was hemodynamically stable and repeated echocardiograms did not show any features of cardiac compromise; the hydropneumopericardium was managed conservatively in view of his high risk for surgery. He remained in a serious condition, requiring ventilator support. His graft function remained well, with adequate urine output, serum creatinine - 1 mg/dl. He developed cardiac arrest on the 19th day of admission and could not be revived following cardiopulmonary resuscitation. Fungal culture of bronchoalveolar lavage later showed growth of Aspergillus species, acid-fast bacilli did not grow on culture. Aerobic/fungal/mycobacterial culture of drained cerebral abscess did not show any growth.
Figure 4: Pneumopericardium as detected on chest X-ray and computed tomography chest

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  Discussion Top


Our patient was detected to have polymicrobial infections and despite high-grade antibiotics, antifungals, and surgical debridement, he succumbed to his illness.

Chugh et al. in 1992, reported fungal infections in 19 out of 310 renal transplant patients (6.1%). Cryptococcus was the most common infecting organism. Only one patient had multiple fungal pathogens with mixed Cryptococcal and Aspergillus infection. Bacterial coinfection was more common, seen in 10 patients. CMV was not detected in any patient.[2] Whereas, Patel et al. more recently found fungal infections to occur in 30 out of 1900 renal transplants (1.5%), Candida and Aspergillus being most common. All patients had received Thymoglobulin induction, 10 patients also had concomitant CMV infection. The mortality rate was 30.7%.[3] Thus changing patterns of fungal infections can be seen. Previously, hygiene and environmental exposures were major determinants, whereas the intensity of immunosuppression, especially with more widespread use of induction agents, is perhaps a more prominent factor lately as evidenced by increased CMV co-infection.[2],[3]

The occurrence of multiple, simultaneous fungal infections as in the present patient is rare. Eswarappa et al., described an unusual case of a renal transplant recipient developing esophageal candidiasis with cryptococcal involvement of graft.[4] Meyers , reported a 100% mortality rate for bone marrow transplant recipients with mixed Candida and Aspergillus infections.[5] Aspergillus and Mucor spores are ubiquitous in the environment; however, persons with diabetes, immunosuppression are particularly susceptible.[6],[7] Factors which possibly contributed to our patient's morbid state included a history of uncontrolled hyperglycemia, high maintenance immunosuppression, thymoglobulin induction, and long hospital stay. The patient had undergone kidney transplant and follow-up at another center, his records of ATG induction dose, HLA matching and Tacrolimus levels in posttransplant period were not available. However, on admission, his Tacrolimus levels were high (12 ng/ml at 3 months posttransplant) and attendants gave a history of poor glycemic control posttransplant.

He developed pneumopericardium due to the extension of Aspergillus infection from the chest cavity. Pneumopericardium has most commonly been reported following trauma, following pericardiocentesis, as a complication of positive pressure ventilation and extension from surrounding organ inflammatory or infectious lesions. Amongst infectious causes, it is most commonly seen following pulmonary tuberculosis.[8] Khan et al. detail a case of pneumopericardium following a pulmonary mucor lesion. Pulmonary lesions with invasive organisms can cause erosion of alveoli; air may then track along mediastinum and enter around the reflections of the pericardium.[9] A small pneumopericardium which is not symptomatic can be managed conservatively; however, a lesion causing hemodynamic compromise by cardiac tamponade requires decompression.[8] Aspergillosis led to the development of cavitatory consolidation in our patient. Due to its angio-invasive nature, it can lead to thrombi and infarction of involved tissues causing necrosis. Extension of the cavity leads to air entry into the contiguous pericardium, complicating the clinical course.

The patient's prognosis was further altered by the detection of the cerebral abscess. Despite surgical debridement, he did not show any neurological improvement. Mucor rarely leads to isolated cerebral involvement; most cerebral lesions occur as an extension from infected sinuses. Hematogenous spread of infection has been described in cases of solitary mucor lesions, most commonly reported in intravenous drug abusers, though immunosuppression and diabetes are also risk factors.[10] When surgical drainage is not possible or has not been consented to, neuroimaging can sometimes help in delineating possible pathogens causing the cerebral abscess. Luthra et al., described in a retrospective analysis that appearance of heterointensity on T2 weighted images of the cerebral abscess was often a feature of fungal etiology along with irregular walls and intracavitary projections as opposed to smooth walls and hyperintensity on T2 films in pyogenic or tubercular lesions. Differences in ADC and metabolite composition on magnetic resonance spectroscopy were also seen.[11] However, no such distinguishing features were discernible for our patient.

Management of postrenal transplant recipients is limited by the requirement of frequent visitations and therapeutic drug monitoring, which have financial implications. Diligent blood sugar monitoring and optimization of immunosuppressants, which adversely affect glycemic control is required.


  Conclusion Top


This case report highlights the increased infection risk in renal transplant recipients with hyperglycemia and high immunosuppression. Thus, the adoption of practices that mitigate such risk factors is essential.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Karuthu S, Blumberg EA. Common infections in kidney transplant recipients. Clin J Am Soc Nephrol 2012;7:2058-70.  Back to cited text no. 1
    
2.
Chugh KS, Sakhuja V, Jain S, Singh V, Tarafdar A, Joshi K, et al. Fungal infections in renal allograft recipients. Transplant Proc 1992;24:1940-2.  Back to cited text no. 2
    
3.
Patel MH, Patel RD, Vanikar AV, Kanodia KV, Suthar KS, Nigam LK, et al. Invasive fungal infections in renal transplant patients: A single center study. Ren Fail 2017;39:294-8.  Back to cited text no. 3
    
4.
Eswarappa M, Varma PV, Madhyastha R, Reddy S, Gireesh MS, Gurudev KC, et al. Unusual fungal infections in renal transplant recipients. Case Rep Transplant 2015;2015:292307.  Back to cited text no. 4
    
5.
Meyers JD. Fungal infections in bone marrow transplant patients. Semin Oncol 1990;17:10-3.  Back to cited text no. 5
    
6.
Kousha M, Tadi R, Soubani AO. Pulmonary aspergillosis: A clinical review. Eur Respir Rev 2011;20:156-74.  Back to cited text no. 6
    
7.
Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP. Epidemiology and clinical manifestations of mucormycosis. Clin Infect Dis 2012;54 Suppl 1:S23-34.  Back to cited text no. 7
    
8.
Muller NL, Miller RR, Ostrow DN, Nelems B, Linda M, Vickars LM. Tension pneumopericardium: An unusual manifestation of invasive pulmonary aspergillosis. AJR Am J Roentgenol 1987;148:678-80.  Back to cited text no. 8
    
9.
Khan S, Waqar Elahi M, Ullah W, Abdullah HMA, Ahmad E, Al Mohajer M, et al. Invasive mucormycosis induced pneumopericardium: A rare cause of pneumopericardium in an immunocompromised patient. Case Rep Infect Dis 2017;2017:1-5.  Back to cited text no. 9
    
10.
Malik AN, Bi WL, McCray B, Abedalthagafi M, Vaitkevicius H, Dunn IF. Isolated cerebral mucormycosis of the basal ganglia. Clin Neurol Neurosurg 2014;124:102-5.  Back to cited text no. 10
    
11.
Luthra G, Parihar A, Nath K, Jaiswal S, Prasad KN, Husain N, et al. Comparative evaluation of fungal, tubercular, and pyogenic brain abscesses with conventional and diffusion MR imaging and proton MR spectroscopy. AJNR Am J Neuroradiol 2007;28:1332-8.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


This article has been cited by
1 Immunosuppressants
Reactions Weekly. 2021; 1846(1): 175
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