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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2016  |  Volume : 27  |  Issue : 1  |  Page : 174-176
Severe forms of aspergillosis in patients on hemodialysis


1 Nephrology and Kidney Transplantation, Medical University Hospital, University Caddi Ayad, Marrakech, Morocco
2 Department of Otolaryngology-Head and Neck Surgery, Medical University Hospital, University Caddi Ayad, Marrakech, Morocco

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Date of Web Publication15-Jan-2016
 

How to cite this article:
Jabrane M, Skandour D, Rochdi Y, Nouri H, Aderdour L, Raji A, Alaoui C, Fadili W, Laouad I. Severe forms of aspergillosis in patients on hemodialysis. Saudi J Kidney Dis Transpl 2016;27:174-6

How to cite this URL:
Jabrane M, Skandour D, Rochdi Y, Nouri H, Aderdour L, Raji A, Alaoui C, Fadili W, Laouad I. Severe forms of aspergillosis in patients on hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2019 Nov 15];27:174-6. Available from: http://www.sjkdt.org/text.asp?2016/27/1/174/174208
To the Editor,

Aspergillosis is the most common opportunistic respiratory mycotic infection and often carries a fatal prognosis. [1] The primary infection is mainly pulmonary due to inhalation of spores. It also causes various other clinical presentations depending on local and general risk factors of the host. The prevalence of this infection is high in immune-suppressed individuals. We report our observations of multifactorial predisposing situations resulting in severe laryngeal and systemic aspergillosis.

A 34-year-old male patient with type 1 diabetes mellitus for 10 years had been treated for pulmonary tuberculosis 17 years earlier. The patient had multiple complications such as diabetic retinopathy, arterial hypertension and endstage renal disease (ESRD). He presented with gradually worsening dyspnea, productive cough and signs of acute pulmonary edema without dysphonia or dysphagia. Chest radiography showed an image corresponding to aspergillosis in a right apical tuberculous cavity [Figure 1]. The patient was treated with corticosteroids and epinephrine nebulization twice daily. Intensive hemodialysis was administered without significant respiratory improvement. Naso-fibroscopy showed a left laryngeal sub-glottic tumor with a curled and edematous epiglottis. A tracheostomy was performed because of the persistence of dyspnea. Laboratory tests showed anemia of 7.8 g/dL, leukocytosis of 24,000/mm 3 , predominantly neutrophils, C-reactive protein (CRP) of 164 mg/L and hyponatremia of 120 mmol/L. A biopsy of the tumor under laryngoscopic guidance was suggestive of aspergillosis with no signs of malignancy or granuloma. Congo red staining was negative [Figure 2] and [Figure 3]. A computerized tomographic (CT) scan of the neck showed a laryngeal sub-glottic tissue mass (30 m × 20 mm) involving the epiglottic fold and bilateral pyriform sinuses [Figure 4].
Figure 1: Picture of aspergillosis in a tuberculous cavity (red arrow).

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Figure 2: Congo red stain showing hyphae of aspergillosis grouped in clusters (PAS +).

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Figure 3: Illustration of typical branching hyphae characteristic of aspergillus.

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Figure 4: Computerized tomography scan of the neck showing laryngeal tissue mass (red arrow).

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The patient was treated with antifungal therapy voriconazole 6 mg/kg/12 h intravenously. The patient died two days later and his chest Xray showed non-homogenous infiltrates in the left middle and lower lobes [Figure 5], probably secondary to invasive pulmonary aspergillosis (IPA).
Figure 5: X-ray of the chest showing nonhomogenous infiltrates in the right middle and lower lobes.

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The second case is a 54-year-old female patient with type 2 diabetes treated with insulin, on hemodialysis for ESRD since 11 years. She developed purulent rhinitis complicated by severe sepsis requiring admission to the intensive care unit. A CT scan of the face showed fungal pan-sinusitis with extension to the subcutaneous soft tissues, the right infra-temporal fossa, infiltration of the right orbit and muscle collection next to the inner wall of the right orbit. Laboratory examination showed leukocytosis of 14,800/mm 3 , blood glucose of 4.4 g/L and high CRP of 354 mg/L. The evolution was marked by appearance of nasal necrosis and early vascular necrosis of the right hemi-palate, evoking a diagnosis of invasive aspergillus rhino-sinusitis. Endo-nasal biopsy confirmed the suspected diagnosis. The patient was initiated on anti-fungal treatment with surgical drainage of the collection.

Aspergillosis of the upper airway remains common in immune-compromised patients, but laryngeal localization is exceptional and can mimic neoplasia. [2],[3],[4] Only one case of pulmonary localization in a hemodialysis patient has been described in the literature from Dubai. [5] Our observations are the first cases described in hemodialysis patients with severe laryngeal and sinusal localizations. Most cases of aspergillosis in ESRD patients have been described in relation to peritoneal dialysis [6] or after renal transplantation, with a predominantly pulmonary disease. [7],[8] IPA has a bad prognosis. [9]

Conflict of Interest: None

 
   References Top

1.
Gallo A, Manciocco V, Simonelli M, et al. Clinical findings of laryngeal aspergillosis. Otolaryngol Head Neck Surg 2000;123(5):661-2.  Back to cited text no. 1
    
2.
Florent M, Ajchenbaum-Cymbalista F, Amy C, et al. Dysphonia and dysphagia as primary manifestations of invasive aspergillosis. Eur J Clin Microbiol Infect Dis 2001;20:441-2.  Back to cited text no. 2
    
3.
Kingdom TT, Lee KC. Invasive aspergillosis of the larynx in AIDS. Otolaryngol Head Neck Surg 1996;115:135-7.  Back to cited text no. 3
    
4.
Benson-Mitchell R, Tolley N, Croft CB, Gallimore A. Aspergillosis of the larynx. J Laryngol Otol 1994;108:883-5.  Back to cited text no. 4
    
5.
Jabur WL, Saeed HM. Pulmonary aspergilloma in a patient on hemodialysis. Saudi J Kidney Dis Transpl 2009;20:133-4.  Back to cited text no. 5
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6.
Kazancioglu R, Kirikci G, Albaz M, Dolgun R, Ekiz S. Fungal peritonitis among the peritoneal dialysis patients of four Turkish centres. J Ren Care 2010;36:186-90.  Back to cited text no. 6
    
7.
Nasim A, Baqi S, Zeeshan SM, Aziz T. Chronic necrotizing pulmonary aspergillosis in a renal transplant recipient. J Pak Med Assoc 2011;61: 1242-4.  Back to cited text no. 7
    
8.
Badiee P, Alborzi A. Invasive fungal infections in renal transplant recipients. Exp Clin Transplant 2011;9:355-62.  Back to cited text no. 8
    
9.
Williams MS, Ali N, Nonaka D, Bloor AJ, Somervaille TC. Fatal invasive aspergillosis of the larynx. Eur J Haematol 2013;90:354.  Back to cited text no. 9
    

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Correspondence Address:
Dr. M Jabrane
Nephrology and Kidney Transplantation, Medical University Hospital, University Caddi Ayad, Marrakech
Morocco
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DOI: 10.4103/1319-2442.174208

PMID: 26787591

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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