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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2013  |  Volume : 24  |  Issue : 2  |  Page : 315-317
Candida lung abscesses in a renal transplant recipient


Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India

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Date of Web Publication26-Mar-2013
 

   Abstract 

We herein report a renal allograft recipient five years post transplant who had bilateral lung abscesses. The abscess grew Candida tropicalis on bronchoalveolar lavage. The patient was administered amphotericin B, but succumbed to massive hemoptysis. The case highlights a fungal complication in renal transplant and need for early suspicion and prompt therapy.

How to cite this article:
Gupta A, Bhowmik DM, Dogra PM, Mendonca S, Gupta A. Candida lung abscesses in a renal transplant recipient. Saudi J Kidney Dis Transpl 2013;24:315-7

How to cite this URL:
Gupta A, Bhowmik DM, Dogra PM, Mendonca S, Gupta A. Candida lung abscesses in a renal transplant recipient. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2019 Dec 14];24:315-7. Available from: http://www.sjkdt.org/text.asp?2013/24/2/315/109589

   Introduction Top


Solid organ transplantation leads to an immunocompromised state. These patients are prone to various opportunistic infections. We present a patient who developed bilateral lung abscesses five years after renal transplant.


   Case Report Top


A 45-year-old renal transplant recipient presented with fever and productive cough for five days. He had good baseline graft function with serum creatinine 1.3 mg/dL, on prednisolone 5 mg/day, cyclosporine 150 mg/ day, and azathioprine 125 mg/day, after five years of transplantation. He gave a past history of cryptococcal meningitis two years back. General physical examination revealed pallor and a temperature of 100.7°F. Chest examination showed left midscapular and infrascapular crackles. Cardiovascular, abdominal, and neurological examinations including fundus were normal. Investigations showed hemoglobin 8.5 g/dL, leukocyte count 3200/mm 3 (60% neutrophils), platelet 150,000/mm 3 , reticulocyte count 1%, and peripheral smear showing microcytic hypochromic picture. Biochemistry showed fasting plasma glucose as 88 mg/dL, blood urea 66 mg/dL, serum creatinine 2.3 mg/dL, bilirubin 0.9 mg/dL, alanine aminotransferase 17 U/L, and aspartate aminotransferase 15 U/L. HIV serology and cytomegalovirus (CMV) nucleic acid sequence based amplification (NASBA) were negative. Arterial blood gas showed pH 7.32, pCO 2 20 mmHg, SpO 2 97%, and HCO 3 11.2. Urine examination was normal. Chest X-ray revealed bilateral midzone cavities with air fluid levels [Figure 1]. Cyclosporine trough (C 0 ) level was 153 ng/mL. Blood cultures for bacteria and fungus were negative. Cultures for bacteria, fungus, and acid-fast bacilli were negative from the sputum. Patient was given intravenous levofloxacin 250 mg OD, piperacillin/tazobactum 2.25 g TID, and metronidazole 500 mg TID. Cyclosporine was reduced to 100 mg/day and azathioprine to 100 mg/day. High-resolution CT scan of chest revealed features suggestive of bilateral lung abscesses. No significant lymphadenopathy was seen. Bronchoscopic alveolar lavage (BAL) analysis showed isolated Candida tropicalis and was negative for bacteria, acid-fast bacilli, and CMV poly-merase chain reaction (PCR). BAL cytology showed neutrophils and macrophages. Injection conventional amphotericin B deoxycholate 0.7 mg/kg/day was started and followed under close supervision for renal toxicity. His condition improved clinically, but on day nine of therapy, he had massive hemoptysis, aspirated, and died.
Figure 1: Chest radiograph showing bilateral lung cavities with air fluid levels.

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   Discussion Top


Candidemia and invasive candidiasis are the most common causes of fungal infections, linked to a number of risk factors such as immunosuppressive therapy, intravenous catheters, and critical illness. [1] A particular problem with this group of patients is that they are difficult to distinguish clinically from patients with bacterial sepsis, at least early in infection. This often leads to an initial delay in instituting antifungal therapy, and furthermore the choice of initial empirical therapy may be inappropriate.

Various organisms have been isolated in lung abscesses of renal transplant recipients; but till date, according to our best knowledge, bilateral lung abscesses due to C. tropicalis have not been reported. Candida pneumonia seems to exist in two forms. Commonly, hematogenously disseminated candidiasis produces pulmonary lesions, along with involvement of multiple additional organs. Rarely, after aspiration of oropharyngeal material, primary pneumonia due to Candida may develop. [2]

Current Infectious Diseases Society of America (IDSA) guidelines for the empirical treatment of suspected candidemia or invasive Candida infection recommend that fluconazole may be used in clinically stable patients, and that caspofungin is an excellent alternative due to its wide spectrum of activity and low rate of adverse effects. [3] For clinically unstable patients, however, amphotericin B is preferred due to its greater spectrum of activity, although there is increasing evidence that echinocandins and voriconazole are as effective. [4] Though we suspected fungal infection, we did not empirically treat with fluconazole in our case as the organism or species may be resistant to fluconazole. Once Candida infection is confirmed, species level identification is in most cases an effective method for prediction of antifungal susceptibility. [5] In our case, C. tropicalis was the species isolated and amphotericin B deoxycholate was instituted. However, the patient succumbed to a fatal complication.

The case illustrates a rare cause of lung abscesses in a renal transplant recipient. A high index of suspicion for a fungal cause in such immunocompromised individuals is to be kept in mind. Adequate antifungal treatment is to be instituted early in such cases. Although the treatment duration has not been well defined, we feel that such patients should be treated with at least a total cumulative dose of 1.5 g of conventional amphotericin B deoxycholate and should be followed up closely. This case highlights the above mentioned facts which a renal physician in developing countries needs to be aware of.

 
   References Top

1.Pfaller MA, Diekema DJ. Epidemiology of invasive candidiasis: A persistent public health problem. Clin Microbiol Rev 2007;20:133-63.  Back to cited text no. 1
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2.Haron E, Vartivarian S, Anaissie E, Dekmezian R, Bodey GP. Primary Candida pneumonia. Medicine 1993;72:137-42.   Back to cited text no. 2
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3.Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis 2004;38:161-89.   Back to cited text no. 3
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4.Kuse ER, Chetchotisakd P, da Cunha CA, et al. Micafungin versus liposomal amphotericin B for candidaemia and invasive candidosis: A phase III randomised double-blind trial. Lancet 2007;369:1519-27.  Back to cited text no. 4
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5.Fleck R, Dietz A, Hof H. In vitro susceptibility of Candida species to five antifungal agents in a German university hospital assessed by the reference broth microdilution method and Etest. J Antimicrob Chemother 2007;59:767-71.  Back to cited text no. 5
[PUBMED]    

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Correspondence Address:
Ankur Gupta
Department of Nephrology, All India Institute of Medical Sciences, New Delhi
India
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DOI: 10.4103/1319-2442.109589

PMID: 23538356

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