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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~ Conclusion
 ~  References
 ~  Article Figures

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  Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 36  |  Issue : 3  |  Page : 444-446
 

Fatal aspergillosis of the renal vasculature in a combined liver-kidney transplant recipient


1 Department of Infectious Diseases, Apollo Hospitals, Chennai, Tamil Nadu, India
2 Division of Infectious Diseases, Department of Medicine, Wayne State University, Detroit, Michigan, USA
3 Institute of Infectious Diseases, Apollo Hospitals, Chennai, Tamil Nadu, India
4 Department of Liver Transplant Surgery, Apollo Hospitals, Chennai, Tamil Nadu, India
5 Department of Infectious Diseases, Apollo Cancer Hospitals, Chennai, Tamil Nadu, India
6 Department of Microbiology, Apollo Hospitals, Chennai, Tamil Nadu, India
7 Department of Molecular Diagnostics Laboratory and Transplantation Immunology, Apollo Hospitals, Chennai, Tamil Nadu, India

Date of Web Publication14-Nov-2018

Correspondence Address:
Dr. Vasant Nagvekar
Department of Infectious Diseases, Apollo Hospital, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmm.IJMM_18_165

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 ~ Abstract 

Invasive aspergillosis remains a problem in solid organs and haematopoietic stem cell transplants. We report a case of 12-year-old female with primary hyperoxaluria with regular haemodialysis for the end-stage renal disease. She underwent a combined liver and renal transplantation which got infected by aspergillosis. In this case study, it is speculated that the most likely source of Aspergillus was contaminated preservative solution (perfusate), resulting in infection within the donor kidney and subsequent systemic infection in the recipient. This case study calls for critical analysis and needs for the routine culture of the preservative solution before transplantation, to detect any fungal contamination and manage it prophylactically.


Keywords: Aspergillosis, kidney transplantation, perfusate


How to cite this article:
Nagvekar V, Pranatharthi CH, Gopalakrishnan R, Anand R, Devarajan V, Thirunarayan M, Tarigopula A. Fatal aspergillosis of the renal vasculature in a combined liver-kidney transplant recipient. Indian J Med Microbiol 2018;36:444-6

How to cite this URL:
Nagvekar V, Pranatharthi CH, Gopalakrishnan R, Anand R, Devarajan V, Thirunarayan M, Tarigopula A. Fatal aspergillosis of the renal vasculature in a combined liver-kidney transplant recipient. Indian J Med Microbiol [serial online] 2018 [cited 2019 Aug 20];36:444-6. Available from: http://www.ijmm.org/text.asp?2018/36/3/444/245382



 ~ Introduction Top


Invasive aspergillosis remains a problem in solid organ and haematopoietic stem cell transplants. The incidence varies from 1% to 15% and carries a high mortality. Most of the infections occur in the setting of graft versus host disease or during use of steroids or intense immunosuppressant's to prevent rejection. Invasive aspergillosis in the immediate post-operative period after solid organ transplantation is commonly seen in the 1st 2 months with an attributable mortality of around 30%–100%.[1] We hereby describe a case of acquired aspergillosis, possibly due to contamination of perfusate solution of the donor kidney.


 ~ Case Report Top


A 12-year-old female with primary hyperoxaluria who had been on regular haemodialysis for end-stage renal disease underwent a combined liver and renal transplant (the usual protocol for this disease). The donor for both the liver and kidney was a patient who was brain dead patient following a road traffic accident and had developed Acinetobacter post-traumatic meningitis. He had a prolonged 30-day stay in the intensive care unit and had received broad-spectrum antibiotics but not steroids. Blood, urine and bronchoalveolar lavage cultures were sterile at the time of organ harvest. His other kidney was transplanted to a recipient in another hospital, who at 6 months was doing well and has had no untoward events.

The intraoperative time for this combined transplant procedure was 13 h. The recipient was on regular haemodialysis intra- and post-operatively to keep oxalate levels under control. She received methylprednisolone and basiliximab as an immune-suppressants. On post-operative day (POD) 3, the patient had pain in the right iliac fossa, and an ultrasound revealed a pelvic haematoma for which she was re-explored, and haematoma was evacuated. She was on broad-spectrum antibiotics (colistin and teicoplanin) for possible bacterial sepsis till POD 7.

On POD 8, she developed painful nodular swellings on the right thigh and low-grade fever. A biopsy was performed, and liposomal amphotericin was started on suspicion of a fungal infection. The biopsy revealed septate hyphae consistent with Aspergillus [Figure 1]. Voriconazole was added to liposomal amphotericin.
Figure 1: Septate hyphae consistent with Aspergillus in biopsy

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As she became anuric, she underwent a renal biopsy which was suggestive of acute cortical necrosis following which a transplant nephrectomy on POD 13 was carried out. Histopathological examination of the graft nephrectomy specimen showed extensive ischaemic necrosis with hilar vessels showing subacute inflammation and necrosis with fungal elements, consistent with invasive aspergillosis [Figure 2]. Cultures of the renal vessels, renal incision site and thigh tissue all grew Aspergillus fumigatus [Figure 3].
Figure 2: Graft nephrectomy specimen sowing extensive ischaemic necrosis with hilar vessels showing subacute inflammation and necrosis with fungal elements, consistent with invasive aspergillosis

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Figure 3: The presence of Aspergillus fumigatus in cultures of the renal vessels, renal incision site and thigh tissue

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She further underwent right leg fasciotomy due to compartment syndrome on POD 14 and finally underwent right leg above knee amputation on POD 16. Despite these measures, she continued to have a fever and spread of ischaemia above her waist to the opposite side. She subsequently became haemodynamically unstable and expired on POD 24. Hepatic function and hepatic vascular flow were intact throughout.


 ~ Discussion Top


Donor-transmitted aspergillosis is not uncommon with one case report where a donor infected with Aspergillus transmitted the organism to three recipients via three allografts (two kidneys and one heart).[2] In another case report, five recipients (two kidneys, one liver, one heart and one islet cell) received organs from a donor whose cause of death on autopsy was found to be invasive aspergillosis of the brain. The kidney recipient lost the renal graft due to invasive aspergillosis, the lung recipient died due to some unknown infection, and the others did well after the initiation of antifungals.[3]

In our case, it is unlikely that the donor had infected organs. The recipient of the other transplanted kidney was doing well with no evidence of fungal infection 6 months later. Airborne acquisition was also unlikely, as our patient had vascular invasion only of the transplanted kidney and no lung, sinus or neurological involvement.

Our patient developed vascular invasion of her transplanted kidney by A. fumigatus, and further developed arterial invasion along the right lower limb. We speculate that the most likely source of Aspergillus was contaminated preservative solution, resulting in infection within the donor kidney and subsequent systemic infection in the recipient.[4] Although a culture of the perfusate solution was not performed in our case, these are known to be an excellent media for the growth of microorganisms.[1] During harvesting, organs can become infected during transportation while hypothermic, while being continuously perfused or during the re-warming stage without perfusion. A prospective study between 2004 and 2008 demonstrated 21 samples out of 659 perfusate solutions were positive for yeasts.[5] Two cases of invasive aspergillosis in cadaveric renal transplants involving the vasculature (as in our case) were most likely due to contamination during preservation of the kidney. The transplanted liver and heart did not show any evidence of aspergillosis, suggesting that the source was preservation. Both these patients had involvement of their right lower limbs causing decreased arterial pulsations.[6]

Other factors such as use of methylprednisolone and basiliximab, intra- and post-operative haemodialysis and operative time more than 11 h (13 h) may have contributed to the fulminant course in this patient, despite antifungal therapy.[7],[8],[9] Recipients who are on haemodialysis are 15–25 times more at risk for invasive fungal infections.[10] Other risk factors recognised are CMV infection and use of large amounts of fresh frozen plasma.[11],[12]


 ~ Conclusion Top


We recommend that the perfusate should also be routinely cultured before transplantation, apart from the routine evaluation of donor so that if contamination is documented early, then the antifungal prophylaxis in the recipient can be initiated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 ~ References Top

1.
Paya C. Fungal infections in solid-organ transplantation. Clin Infect Dis 1993;16:677-88.  Back to cited text no. 1
    
2.
Keating M, Guerrero M, Daly R, Walker R, Davies S. Transmission of invasive aspergillosis from a sub clinically infected donor to three different organ transplant recipients. Chest 1996;109:1119-24.  Back to cited text no. 2
    
3.
Mueller N, Weisser M, Fehr T, Wuthrich R, Mullhaupt B, Lehmann R, et al. Donor derived aspergillosis from use of a solid organ recipient as a multi organ donor. Transpl Infect Dis 2010;12:54-9.  Back to cited text no. 3
    
4.
Maranes A, Portoles J, Blanco J, Torrente J, Herrero J, Coronel F, et al. Aspergillus infection of a renal allograft without evidence of a site of origin. Nephrol Dial Transplant 1996;11:1639-42.  Back to cited text no. 4
    
5.
Botterel F, Foulet F, Legrand P, Soria A, Farrugia C, Grimbert P. Yeast contamination of kidney, liver and cardiac preservation solutions before graft: Need for standardisation of microbial evaluation. J Hosp Infect 2010;76:52-5.  Back to cited text no. 5
    
6.
Garrido J, Lerma J, Heras M, Labrador P, Garcia P, Bondia A, et al. Pseudoaneurysm of the iliac artery secondary to Aspergillus infection in two recipients of kidney transplants from the same donor. Am J Kidney Dis 2003;41:488-92.  Back to cited text no. 6
    
7.
Monika R, Benjamin J, Park T, Chiller M. Donor-Derived Fungal Infections in Transplant Patients. Current Fungal Infect Reports 2010:4;219-28.  Back to cited text no. 7
    
8.
Singh N, Husain S. Invasive aspergillosis in solid organ transplant recipients. Am J Transplant 2009;9:S180-91.  Back to cited text no. 8
    
9.
Collins L, Samore M, Roberts MS, Luzzati R, Jenkins R, David Lewis W, et al. Risk factors for invasive fungal infections complicating orthotopic liver transplantation. J Infect Dis 1994;170:644-52.  Back to cited text no. 9
    
10.
Singh N, Avery R, Munoz P, Pruett T, Alexander B, Jacobs R, et al. Trends in risk profiles for and mortality associated with invasive aspergillosis among liver transplant recipients. Clin Infect Dis 2003;36:46-52.  Back to cited text no. 10
    
11.
Humar A, Snydman D. Cytomegalovirus in solid organ transplant recipients. Am J Transplant 2009;9:S78-86.  Back to cited text no. 11
    
12.
Briegel J, Forst H, Spill B, Haas A, Grabein B, Haller M, et al. Risk factors for systemic fungal infections in liver transplant recipients. Eur J Clin Microbiol Infect Dis 1995;14:375-82.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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