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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2015  |  Volume : 26  |  Issue : 6  |  Page : 1253-1256
Scedosporium apiospermum causing brain abscess in a renal allograft recipient


1 Department of Nephrology, Institute of Renal Sciences, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India

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Date of Web Publication30-Oct-2015
 

   Abstract 

Scedosporium apiospermum is the asexual form of a rare fungus Pseudallescheria boydii that is usually present in the soil, sewage and dirty water. In immunocompromised patients, it is a rare infection involving multiple organs. We present a case of renal allograft recipient who developed fever two weeks post renal transplant. He was initially found to have dengue fever. After five days, he became drowsy and developed right-sided hemiparesis. Magnetic resonance imaging of the brain revealed multiple irregular masses with associated edema consistent with fungal brain abscesses. Left parietal abscess was drained and he was started on voriconazole. His cyclosporine was stopped. Drained pus revealed fungal hyphae on potassium hydroxide stain and Scedosporium apiospermum on culture. Unfortunately, the patient died after five days. Scedosporium infections should be kept as a possibility in transplant recipients with disseminated infections, especially with a brain abscess. Despite antifungal therapy and surgical drainage, mortality rates are high.

How to cite this article:
Sharma A, Singh D. Scedosporium apiospermum causing brain abscess in a renal allograft recipient. Saudi J Kidney Dis Transpl 2015;26:1253-6

How to cite this URL:
Sharma A, Singh D. Scedosporium apiospermum causing brain abscess in a renal allograft recipient. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2019 Oct 14];26:1253-6. Available from: http://www.sjkdt.org/text.asp?2015/26/6/1253/168664

   Introduction Top


Scedosporium apiospermum is the asexual form of a rare fungus Pseudallescheria boydii. It is usually present in soil, sewage and dirty water in ditches, ponds, etc. It commonly leads to skin infections, but in immunocompromised patients it can present with disseminated organ involvement, commonly in brain, lung and bones. The clinical presentation varies from bone and joint involvement in immunocompetent persons to disseminated infection in immunosuppressed individuals. [1] Cerebral abscess due to P. boydii is usually seen in immunosuppressed organ transplant recipients. [2] These account for approximately 25% of all non-Aspergillus fungal infections in patients who received organ transplant. [3] These infections are associated with high mortality rates ranging from 50% to more than 70%. [1],[4]


   Case Report Top


A 40-year-old male with chronic kidney disease with basic disease chronic glomerulonephritis with hypertension and cardiomyopathy on maintenance hemodialysis for one year duration underwent renal transplantation in November 2011, with the donor being his mother. Both the donor and the recipient were cytomegalovirus (CMV) seropositive. They had 3/6 human leukocyte antigen (HLA) mismatch. Induction was given in the form of antithymocyte globulin and immunosuppression in the form of cyclosporine, mycophenolate mofetil and steroids was started. The graft function was good and the patient was having good urine output. On post-operative Day 13, the patient had fever that was moderate to high grade, associated with chills and rigor. The patient was evaluated and found to have positive dengue IgM and NS1-based assay. Rest of his fever workup was negative. The patient was managed conservatively using antipyretics and adequate hydration. But, the patient's fever persisted and on post-operative Day 17 he became drowsy. On examination, he was found to have right-sided hemiparesis. Non-contrast computed tomography (CT) head showed multiple patchy hypodensities in bilateral cerebral hemispheres with midline shift to the right [Figure 1]. Magnetic resonance imaging (MRI) of the brain revealed multiple irregular masses having a shaggy T2 hypointense rim with associated edema. These lesions were markedly hypointense on gradient images suggesting the presence of paramagnetic substance [Figure 2]. The radiological findings were consistent with fungal abscesses in the setting of immunocompromised status of the patient. Neurosurgery consultation was taken and left frontoparietal craniotomy was performed and left parietal abscess was drained. The patient was started on voriconazole. His cyclosporine and mycophenolate mofetil were stopped. Drained pus revealed fungal hyphae on potassium hydroxide stain and on culture revealed S. apiospermum. The patient was continued on voriconazole. Progressively, his condition deteriorated and unfortunately the patient died after five days.
Figure 1: Axial non-contrast CT image showing multiple areas of white matter edema in bilateral cerebral hemispheres causing mass effect with midline shift toward the right.

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Figure 2: Axial MRI images. T2 and FLAIR images (A, B) showing multiple heterogeneous hyperintense lesions with shaggy iso-to-hypo intense rim in bilateral cerebral hemispheres. Gradient image (C) shows blooming in all the lesions. Post-contrast image (D) shows peripheral rim enhancement in these lesions.

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   Discussion Top


P. boydii/S. apiospermum infections have been seen more commonly in patients with organ transplant and receiving corticosteroids, thereby being immunosuppressed. [1] They constitute approximately 0.05% of severe infections in renal allograft recipients. [4] Affected patients may present with a wide spectrum, with majority being disseminated (46%), pulmonary (43%), skin (31%) and central nervous system (CNS) (29%) involvement. Sinusitis, osteomyelitis, peritonitis, liver abscess, endocarditis, endophthalmitis, etc. have also been reported. [1] Majority of the affected patients die, especially if the infection is disseminated or involves CNS. Risk factors for CNS infection of S. apiospermum include immunosuppressive therapy, near-drowning, road traffic accident, cytotoxic chemotherapy, diabetes mellitus, direct inoculation (orbital trauma, lumbar puncture) or human immunodeficiency virus infection. [5] Pseudallescheriasis is frequently seen in temperate regions, but has also been reported from Southeast Asia. [6],[7]

The histological diagnosis for P. boydii is not easy in view of its similarity to other filamentous fungi and hence a positive culture is essential for definitive diagnosis. But, the culture takes a long time to give a positive report. Real-time polymerase chain reaction-based assays allow for quick, specific and quantitative detection of scedosporiosis from clinical samples like blood, serum, etc. [8],[9] Early identification helps in prompt treatment as P. boydii is resistant to amphotericin B and its treatment of choice is extended spectrum triazoles like voriconazole. [10],[11],[12] Even with prompt treatment with azoles and surgical drainage of the abscess, the overall mortality is more than 50%. [13],[14]

To summarize, Scedosporium infections should be kept as a possibility in transplant recipients with disseminated/invasive infections, especially with a brain abscess. It is important to be aware of such an entity as it masquerades as other fungi only and can be easily missed if not specifically looked for. A positive culture is a must for diagnosis, and voriconazole is the antifungal of choice for its treatment due to resistance to amphotericin B. In spite of antifungal therapy and surgical drainage, this infection is associated with a high mortality.

Conflict of interest: None declared.

 
   References Top

1.
Husain S, Muñoz P, Forrest G, et al. Infections due to Scedosporium apiospermum and Scedosporium prolificans in transplant recipients: Clinical characteristics and impact of antifungal agent therapy on outcome. Clin Infect Dis 2005; 40:89-99.  Back to cited text no. 1
    
2.
Berenguer J, Diaz-Mediavilla J, Urra D, Muñoz P. Central nervous system infection caused by Pseudallescheria boydii: Case report and review. Rev Infect Dis 1989;11:890-6.  Back to cited text no. 2
    
3.
Husain S, Alexander BD, Munoz P, et al. Opportunistic mycelial fungal infections in organ transplant recipients: Emerging importance of non-Aspergillus mycelial fungi. Clin Infect Dis 2003;37:221-9.  Back to cited text no. 3
    
4.
Castiglioni B, Sutton DA, Rinaldi MG, Fung J, Kusne S. Pseudallescheria boydii (Anamorph Scedosporium apiospermum). Infection in solid organ transplant recipients in a tertiary medical center and review of the literature. Medicine (Baltimore) 2002;81:333-48.  Back to cited text no. 4
    
5.
Nesky MA, McDougal EC, Peacock Jr JE. Pseudallescheria boydii brain abscess successfully treated with voriconazole and surgical drainage: Case report and literature review of central nervous system pseudallescheriasis. Clin Infect Dis 2000;31:673-7.  Back to cited text no. 5
    
6.
Patterson TF, Andriole VT, Zervos MJ, Therasse D, Kauffman CA. The epidemiology of pseudallescheriasis complicating transplantation: Nosocomial and community-acquired infection. Mycoses 1990;33:297-302.  Back to cited text no. 6
    
7.
Satirapoj B, Ruangkanchanasetr P, Treewatchareekorn S, Supasyndh O, Luesutthiviboon L, Supaporn T. Pseudallescheria boydii brain abscess in a renal transplant recipient: First case report in Southeast Asia. Transplant Proc 2008; 40:2425-7.  Back to cited text no. 7
    
8.
Wedde M, Müller D, Tintelnot K, De Hoog GS, Stahl U. PCR-based identification of clinically relevant Pseudallescheria/Scedosporium strains. Med Mycol 1998;36:61-7.  Back to cited text no. 8
    
9.
Castelli MV, Buitrago MJ, Bernal-Martinez L, Gomez-Lopez A, Rodriguez-Tudela JL, CuencaEstrella M. Development and validation of a quantitative PCR assay for diagnosis of scedosporiosis. J Clin Microbiol 2008;46:3412-6.  Back to cited text no. 9
    
10.
Girmenia C, Luzi G, Monaco M, Martino P. Use of voriconazole in treatment of Scedosporium apiospermum infection: Case report. J Clin Microbiol 1998;36:1436-8.  Back to cited text no. 10
    
11.
Rogasi PG, Zanazzi M, Nocentini J, et al. Disseminated Scedosporium apiospermum infection in renal transplant recipient: Long-term successful treatment with voriconazole: A case report. Transplant Proc 2007;39:2033-5.  Back to cited text no. 11
    
12.
Kubak BM, Huprikar SS; AST Infectious Diseases Community of Practice. Emerging & rare fungal infections in solid organ transplant recipients. Am J Transplant 2009;9 Suppl 4: S208-26.  Back to cited text no. 12
    
13.
Montejo M, Muñiz ML, Zárraga S, et al. Case Reports. Infection due to Scedosporium apiospermum in renal transplant recipients: A report of two cases and literature review of central nervous system and cutaneous infections by Pseudallescheria boydii/ Sc. apiospermum. Mycoses 2002;45:418-27.  Back to cited text no. 13
    
14.
Campagnaro EL, Woodside KJ, Early MG, et al. Disseminated Pseudallescheria boydii (Scedosporium apiospermum) infection in a renal transplant patient. Transpl Infect Dis 2002;4: 207-11.  Back to cited text no. 14
    

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Correspondence Address:
Amit Sharma
Department of Nephrology, Institute of Renal Sciences, Sir Ganga Ram Hospital, New Delhi-110 060
India
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DOI: 10.4103/1319-2442.168664

PMID: 26586067

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