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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2013  |  Volume : 24  |  Issue : 1  |  Page : 76-79
A fatal case of prostatic abscess in a post-renal transplant recipient caused by Cladophialophora carrionii


1 Department of Microbiology, Sri Ramachandra Medical College and Research Institute, Chennai, India
2 Department of Nephrology, Sri Ramachandra Medical College and Research Institute, Chennai, India
3 Department of Microbiology, Sri Ramachandra Medical College and Research Institute; Department of Nephrology, Madras Medical Mission, Chennai, India

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Date of Web Publication22-Jan-2013
 

   Abstract 

Fungal infection secondary to renal transplantation poses a significant threat to the life of the recipient with a high rate of morbidity and mortality. A high index of suspicion is necessary for early diagnosis of fungal infections in such patients. We herein report a fatal case of prostatic abscess in a post-renal transplant recipient.

How to cite this article:
Kindo AJ, Ramalakshmi S, Giri S, Abraham G. A fatal case of prostatic abscess in a post-renal transplant recipient caused by Cladophialophora carrionii. Saudi J Kidney Dis Transpl 2013;24:76-9

How to cite this URL:
Kindo AJ, Ramalakshmi S, Giri S, Abraham G. A fatal case of prostatic abscess in a post-renal transplant recipient caused by Cladophialophora carrionii. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2020 Jun 4];24:76-9. Available from: http://www.sjkdt.org/text.asp?2013/24/1/76/106249

   Introduction Top


Cladophialophora carrionii (synonym: Cladophialophora ajelloi) is one of the relatively common causative agents of chromoblastomycosis, a chronic mycosis of skin and subcutaneous tissue. The most common appearance of such lesions is as verrucous plaques or nodules. [1] This fungus is found in the arid areas of South America, Africa and Australia, [2] and was first described by Trejos in 1954 under the name Cladophialophora carrionii.[3] Recent taxonomic studies have moved the pathogenic species of the genus Cladosporium, including C. carrionii, to the genus Cladophialophora.[4] C. carrionii is considered to be the most important pathogenic species in this genus due to many cases of illness caused by this fungus worldwide. [4],[5],[6] But, to the best of our knowledge, prostatic abscess caused by this fungus in a renal transplant patient has not been reported.


   Case Report Top


In October 2008, a 22-year-old male came with a history of three to four episodes of diarrhea that was watery in consistency and not associated with abdominal pain. The patient also had nausea and chills. There was no history of fever or vomiting. The patient had undergone renal transplantation ten months ago. There was no history of hypertension or diabetes. On examination, the patient was conscious, oriented and afebrile. His blood pressure was 120/90 mmHg and pulse rate was 70/min. All other systems were found to be normal. The biochemical parameters showed an abnormal serum creatinine of 3.5 mg/dL. Na (128 mmol/L), K (3.9 mmol/L), chloride (96 mmol/L), uric acid (6.9 mg/dL) and calcium (8 mg/dL) were within normal range. Stool for occult blood was positive. Hanging drop of the stool sample was negative for darting motility. Stool culture did not reveal anything significant. Ultrasound of the abdomen was done, in which the prostate gland showed a size of 2.6 cm × 2.8 cm × 2.7 cm, and two irregular anechoic lesions of sizes 1 cm × 0.9 cm and 1.2 cm × 1 cm were noted [Figure 1]. The impression was of prostatic abscess. The advice given was transrectal ultrasound (TRUS) guided aspiration. The aspirated fluid was sent to the microbiology laboratory for culture.
Figure 1: Ultrasound picture of the prostate gland showing two anechoic lesions, suggestive of an abscess.

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The specimen was subjected to 10% KOH mount, which showed septate narrow pigmented hyphae [Figure 2]. The specimen was inoculated into Sabouraud's dextrose agar containing antibiotics in two sets and incubated at 37°C and 25°C. The growth was observed within three days as dark green color with slightly raised center; the reverse was black in color. Microscopic morphology showed septate hyphae and dark with lateral and terminal conidiophores of various sizes. The conidiophores produced long, branching chains of brown, smooth walled, oval, somewhat pointed conidia that were easily dispersed with handling. The conidia typically had relatively pale scars of attachment [Figure 3]. The pigmented fungus was identified to be C. carrionii.
Figure 2: 10% KOH showing thin septate hyphae.

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Figure 3: Microscopy showing brown, smooth walled, oval, somewhat pointed conidia; conidia typically had relatively pale scars of attachment (magnification 400×).

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The patient was started on voriconazole (6 mg/kg body weight IV every 12 hourly for two doses followed by maintenance doses of 4 mg/kg IV every 12 hourly and then 200 mg BD orally). Subsequently, partial prostatectomy was performed. The patient improved and was discharged.

The patient was admitted again on 13 October, 2009 with complaints of hematuria on and off and mild fever. There was no history of dysuria. The patient was conscious and mildly disoriented with pallor and bilateral pedal edema. Blood pressure was 130/90 mmHg and pulse rate 84/min. All other systems were found to be normal. The patient, on further evaluation with ultrasound, was found to have multiple prostatic abscesses. Therefore, he was planned for prostatic abscess drainage under ultrasound guidance. Meanwhile, the patient had a progressive increase in septicemia following which the patient's condition deteriorated. Then, the patient was taken up for prostatic abscess drainage on 20 October, but post-operatively he went in for septic shock followed by cardiorespiratory arrest. Resuscitation was done according to the Advanced Cardiac Life Support (ACLS) protocol, but the patient died.

The aspirated fluid from the prostatic abscess was sent to the microbiology laboratory for culture and the organism in the aspirated fluid was again found to be C. carrionii.


   Discussion Top


Recipients of solid organ transplants have a 6-10% incidence of opportunistic infections in the Indian subcontinent as against 1.4-9.4% in the western countries. The mortality rate in the Indian subcontinent is also very high, ranging from 70% to 100%. [7] This is because of intense immunosuppression, delay in diagnosis and treatment and overcrowded environment.

Fungal pathogens most often responsible for infection in solid organ transplant recipients are Candida spp., Aspergillus spp. and Cryptococcus neoformans, although other fungi may also cause infection in these patients. [8] Overall, Candida species are the most common cause of fungal infections in solid organ transplant recipients. The high mortality rate associated with fungal infections in solid organ transplant recipients is due to a number of factors. First, fungal infections in these patients are frequently advanced at the time of diagnosis, and are rapidly progressive. Second, difficulties abound in establishing the early diagnosis needed for successful therapy. Immunosuppression impairs the inflammatory responses that normally signal fungal invasion, thereby diminishing clinical and/or radiologic signs associated with inflammation, often allowing the infection to progress prior to clinical presentation. Third, the modest efficacy of currently available therapeutic agents and the difficulty in utilizing these drugs to their fullest advantage due to inherent toxicity and interactions with concurrently administered immunosuppressive or other drugs also contribute to the high mortality rates.

Infections due to dematiaceous (pigmented) fungi are being seen more frequently, although still rarely, in solid organ transplant recipients. [9] These infections tend to occur late in the posttransplant course, with a median posttransplant interval of two years. Most pheohyphomycoses are indolent skin and soft tissue infections, with Exophiala spp. being the most common offenders. These often present as subcutaneous tissue or muscle nodules, and should be biopsied to exclude squamous cell carcinoma.

Infections caused by C. carrionii are chronic and appear as spreading mycoses of the skin, subcutaneous tissues and nail. [1],[4] Bronchitis in response to the allergic mechanism of this fungus has also been reported. [10]

Surgical excision is the most effective mode of therapy, regardless of whether the infection is of the subcutaneous or deeply invasive type. Itraconazole and some of the newer generation azoles, such as voriconazole, have activity against these pathogens and appear to be more effective. [10] Still then, the mortality rate due to fungal infections in solid organ transplant recipients remains high. Prompt diagnosis, aggressive surgical intervention and medical treatment are necessary to have a favorable outcome. And, finally, it is very important to keep the fungal etiology in mind in any immunosuppressed patient.

 
   References Top

1.Kwon-Chung KJ, Bennett JE, eds. Chromoblastomycosis. In: Medical Mycology. Philadelphia London: Lea & Febiger ; 1992. p. 337-55.  Back to cited text no. 1
    
2.Lavelle P. Chromoblastomycosis. Proceedings of the 7th International Conference on Mycoses held at Mexico. 1980. Pan American Health organization, Washington D.C. 1980. p. 235-47.  Back to cited text no. 2
    
3.Trejos A. Cladophialophora carrionii n. sp. and the problem of Cladosporia isolated from chromoblastomycosis. Rev Biol Trop 1954;39: 103-6.  Back to cited text no. 3
    
4.Barde AK, Singh SM. Cladophialophora carrionii Trejos 1954 infection of human nail. Mykosen 1984;27:366-69.  Back to cited text no. 4
    
5.Goh KS, Padhye AA, Ajello L. A Samoan case of Chromoblastomycosis caused by Cladophialophora ajelloi. Sabouraudia 1982;20:1-5.  Back to cited text no. 5
    
6.Jacyk WK. Chromomycosis due to Cladophialophora carrionii treated with 5-fluorocytosine: A case report from northern Nigeria. Cutis 1979;23:649-50.  Back to cited text no. 6
    
7.Gandhi BV, Bahadur MM, Dodeja H, Aggarwal V, Thamba A, Mali M. Systemic fungal infections in renal disease. J Postgrad Med 2005;51: 30-6.  Back to cited text no. 7
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8.Hibberd PL, Rubin RH. Clinical aspects of fungal infection in organ transplant recipients. Clin Infect Dis 1994;19:S33-40.  Back to cited text no. 8
    
9.Singh N, Chang FY, Gayowski T, Marino IR. Infections due to dematiaceous fungi in organ transplant recipients: A case report and review. Clin Infect Dis 1997;24:369-74.  Back to cited text no. 9
    
10.Bergan T. Bronchitis caused by the fungus Cladophialophora carrionii usually considered apathogenic, possibly by an allergic mechanism. Mykosen 1983;26:547-50.  Back to cited text no. 10
    

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Correspondence Address:
Anupma Jyoti Kindo
Department of Microbiology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai
India
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DOI: 10.4103/1319-2442.106249

PMID: 23354196

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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