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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 1  |  Page : 133-134
Pulmonary aspergilloma in a patient on hemodialysis


1 NMC Specialty Hospital, Dubai, United Arab Emirates
2 Al-Qasimi General Hospital, Sharjah, United Arab Emirates

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How to cite this article:
Jabur WL, Saeed HM. Pulmonary aspergilloma in a patient on hemodialysis. Saudi J Kidney Dis Transpl 2009;20:133-4

How to cite this URL:
Jabur WL, Saeed HM. Pulmonary aspergilloma in a patient on hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2019 Nov 14];20:133-4. Available from: http://www.sjkdt.org/text.asp?2009/20/1/133/44723
To the Editor,

We report on a 24-year-old male patient, a known case of chronic renal failure (CRF) secondary to obstructive nephropathy, who was on hemodialysis (HD) at the New Medical Center Specialty Hospital, Dubai. Based on the measured KT/V, the patient was scheduled to receive three sessions of four hourly HD per week. During his stay on HD he was scheduled for kidney transplantation, after improving his general condition and finding a suitable donor.

One month after being on HD, the patient developed dyspnea, cough with expectoration of large amount of watery brownish sputum with floating dark particles. The clinical examination was unremarkable, and an x-ray of the chest showed a ring shadow with a regular outlined wall. Repeated examination of the sputum was unremarkable.

A primary radiological diagnosis of ruptured pulmonary hydatid cyst was made and the patient improved gradually on supportive measures and broad spectrum antibiotic therapy. Follow-up of the patient with frequent chest x-rays showed regression of the ring shadow.

One month after the event, the patient remained asymptomatic without any problem related to his chest. However, two months later during routine pre-transplant check up, chest x-ray revealed a small ring shadow partially filled with a non­homogenous material.

CT scan and MRI of the chest confirmed the presence of an intra-cavitary solid mass secluded from the surrounding lung tissue and bronchi [Figure 1] and [Figure 2]. A bronchoscopy was performed with bronchoalveolar lavage, which was negative for any pathogen. Two months later, in view of persisting cough, the patient underwent a lobec­tomy. Histopathology of the resected spcimen showed hyphae of Aspergillus Fumigatus em­bedded in mucoid material, fibrocytes, and macrophages.

The patient underwent kidney transplantation a few months later, and he is doing well at last follow-up.


   Pulmonary Aspergilloma Top


Aspergilloma refers to the disease caused by a ball of fungal mycelia which occurs within a cavity, usually within the parenchyma of the lung or other organs such as the brain and the kidneys. [1] It is generally thought that the pre­sence of Aspergillus fumigatus in pulmonary cavity reflects saprophytic colonization and not actual tissue invasion. [2] The commonest under­lying diseases are tuberculosis, bronchiectasis, and lung abscess. The lesion may be solitary or multiple and appear as a typical solid mass surrounded by a radiolucent crescent, what is called the MONOD sign. [3] Radiological investi­gations are highly suggestive of the diagnosis; sputum examination is positive in more than 50% of cases especially if the cavity is connected to the bronchi. [4]

In immunocompromised patients, the risk of spread of the fungal infection is high; a fact that would relegate the option for kidney transplan­tation in a patient with chronic renal failure. [1] Our case highlights many features:

  1. the short time for a pulmonary cavity to be colonized by fungal species, particularly in immunocompromised patient,
  2. the difficulty in diagnosing such an infection,
  3. the priority of establishing the diagnosis in a transplant candidate,
  4. lobectomy is the optimal treatment for a potential kidney transplant candidate, both to prove the diagnosis and to avoid potential devastating complications (i.e. fungal metas­tases to other organs).
  5. antifungal therapy is useless in cavitary fungal infection, although there are reports of successful treatment with itraconazole 100-200 mg orally, and topical treatment of mycetoma with amphotericin gel in unfitpatients or patients with multiple lesions. [4]


 
   References Top

1.Addrizzo-Harris D, Harkin T, Mcguinness G, Naidich DP, Rom WN. Pulmonary aspergilloma and AIDS: a comparison of HIV-infected and HIV negative individuals. Chest 1997;111:612-8.  Back to cited text no. 1    
2.Tsubura E. Multicenter clinical trial of itraconazole in the treatment of pulmonary aspergilloma: Pulmonary Aspergilloma Study Group. Kekkaku 1997;72(10):557-64.  Back to cited text no. 2    
3.Akbari JG, Varma PK, Neema PK, Menon MU, Neelakandhan KS. Clinical profile and surgical outcome for pulmonary aspergilloma: a single center experience. Ann Thorac Surg 2005;80 (3):1067-72.  Back to cited text no. 3    
4.Kurul IC, Demircan S, Yazici U, Altinok T, Topcu S, Unlu M. Surgical management of pulmonary aspergilloma. Asian Cardiovasc Thorac Ann 2004;12(4):320-3.  Back to cited text no. 4    

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Correspondence Address:
Wael L Jabur
NMC Specialty Hospital, Dubai
United Arab Emirates
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PMID: 19112235

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  [Figure 1], [Figure 2]



 

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