Year : 2005 | Volume
: 16 | Issue : 3 | Page : 330--333
Aspergillosis after Renal Transplantation
Mohammad Reza Ardalan1, Khalil Ansarin2, Esmail Hejazi2, Masood Nazemieh2, Javid Safa1,
1 Renal transplantation unit, Imam Hospital, Tabriz Medical University, Iran
2 Pulmonary disease Unit, Imam Hospital, Tabriz Medical University, Iran
Mohammad Reza Ardalan
Renal Transplantation unit, Imam Hospital, Tabriz Medical University, Tabriz
We report a case of a 32-year-old man who presented with invasive pulmonary aspergillosis and bronchial ulcerations that resulted in massive hemoptysis and concomitant thrombotic microangiopathy shortly after cadaveric renal transplantation. Despite vigorous antifungal therapy the patient succumbed due to apoplexy of brain fungal mass lesion.
|How to cite this article:|
Ardalan MR, Ansarin K, Hejazi E, Nazemieh M, Safa J. Aspergillosis after Renal Transplantation.Saudi J Kidney Dis Transpl 2005;16:330-333
|How to cite this URL:|
Ardalan MR, Ansarin K, Hejazi E, Nazemieh M, Safa J. Aspergillosis after Renal Transplantation. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2021 May 16 ];16:330-333
Available from: https://www.sjkdt.org/text.asp?2005/16/3/330/32863
Aspergillus is a soil-dwelling organism that causes a variety of clinical syndromes, ranging from aspergilloma with lung cavitations, bronchopulmonary aspergillosis in patients with asthma, to chronic necrotizing aspergillosis. Invasive pulmonary aspergillosis (IPA), which is common in immunocompromised patients, is a severe, life threatening disease and is usually unresponsive to therapy. Lower respiratory tract is almost always the primary focus of infection and results from the inhalation of airborne spores; it has predilection for the invasion of blood vessels. Outbreaks of aspergillosis have been associated with hospital reconstruction near medical units that had immunocompromised patients. 
We report a rare case of invasive pulmonary aspergillosis with massive hemoptysis due to multiple bronchial ulcerations after renal transplantation.
A 32 year old man with end-stage renal disease received a renal transplant from a cadaver donor. The initial immunosuppressive regimen included mycophenolate mofetil, antithymoglobulin (ATG) and prednisolone.
Following the implantation of the graft, the patient was anuric; his white cell count was 9.6x10 3/µl, platelets 169x10 3/µl and prothrombin time 13 sec. The Doppler ultrasound that was performed to evaluate the anuria revealed normal sized allograft with normal blood perfusion.
Two days post transplantation, re-exploration was performed because of massive periallograft blood collection. At that time, the platelets count was 50x10 3/µl. The allograft function remained non-functioning, so the patient was started on dialysis treatment. The platelets dropped further to 33x10 3/µl, till it reached a nadir of 14x10 3/µl, and the LDH was elevated to 2946 U/l.
Five days post transplantation fragmented red blood cells were detected on the blood smear [Figure 1]. Accordingly, the patient received four sessions of plasma exchange with fresh frozen plasma replacement; the platelet count increased again to 59x10 3/µl, while the LDH level decreased to 1890 U/l and the white cell count increased to 12x10 3/µl within three days of treatment.
However, suddenly massive hemoptysis occurred. Bronchoscopy was performed urgently which revealed two large subglottic tracheal ulcers, and several other intrabronchial ulcerative lesions with active hemorrhage. Direct smear of the broncho-alveolar washing was positive for aspergillus [Figure 2], and the culture was also positive. The radiograph of the chest showed completely opaque left lung. The patient was intubated and ventilated. Intravenously administered amphotericin B 1 mg/kg/day was initiated and all immunosuppressive medications were stopped.
Two days later, the bronchoscopy was repeated and showed multiple ulcerative nonbleeding lesions in the trachea as well as the carina. The left main bronchus was occluded with fungal mass and blood clot; removal of both lesions was attempted by bronchoscopy. Later bronchoscopic examinations revealed healing of the ulcerative lesions, but there was still an active area at the entrance of the left main bronchus. Serial chest radiographic studies revealed expansion of the left lung. The general condition of the patient improved and he was extubated; the platelets count increased to 150x10 3/µl. However, the patient's condition deteriorated suddenly, and his awareness changed to deep coma. The computerized tomography (CT) scan revealed a large round lesion in left frontal lobe of brain [Figure 3]. The patient expired three weeks after apoplexy.
Nosocomial outbreaks of invasive aspergillus infection have been associated with hospital Reconstruction, which produces a burst of spores (as the building of our center renovation near the transplant unit was being performed). Aspergillus fumigatus is the most common species to infect the lung. Several types of immunosuppressants may predispose to aspergillosis. The patients mostly at risk of infection with this fungus are those with prolonged neutropenia and impaired lymphocyte function due to high-dose steroid therapy, chemotherapy, or acquired immunodeficiency syndrome (AIDS). 
It is estimated that IPA accounts for 7.5% of all the infections in neutropenic patients following induction immunosuppressive therapy for bone marrow transplantation (BMT). , The highest incidence of IPA is after lung transplantation and the lowest is in patients with renal transplants. The use of multiple anti-rejection drugs such as corticosteroids and cyclosporine or anti-graft-vs-host disease therapy may predispose the transplant patients to IPA.  This infection is one of the most common causes of hemoptysis in neutropenic patients. The aspergillus invades blood and progresses across tissue planes. A high index of suspicion is necessary in patients with risk factors for IPA. The chest radiograph often shows nonspecific changes; multiple pleural based lesions may be the early finding but pleural effusion is uncommon.  The diagnosis is best made by demonstrating the presence of closely septated acutely branching (45 degrees angles) hyphae that have smooth parallel walls in the lung tissue sample along with positive culture from the same site. 
Methenamine-silver and periodic acid-Schiff stains are the usual stains to demonstrate the characteristic hyphae. The specificity of a positive result of the examination of the bronchio-alveolar lavage (BAL) fluid is almost 97% but the sensitivity is 30-50%.  On the other hand, a sputum sample that is negative for the aspergillus does not exclude the diagnosis of IPA.
Trans-bronchial biopsies have not been shown to add much to the results of BAL and are associated with increased risk of bleeding. Aspergillus antibody detection is not useful, probably due to the poor immune response of patients with IPA and the rapidity with which the infection occurs, not giving enough time for an adequate antibody response. 
Brain is one of the final destinations for this organism, which can cause intracranial hemorrhage and epidural abscess. ,
The experience in our index patient suggests that we have to be aware of the preventive measures in this fatal disease because even early diagnosis and treatment could be ineffective.  The avoidance of overimmunosuppression cannot be overemphasized.
|1||George A. Sarosi, Scott F Davies Fungal disease of the lung, third edition, Lippncott William & Wilkins ,2000|
|2||Minamoto GY, Barlam TF, Vander Els NJ. Invasive aspergillosis in patients with AIDS. Clin Infect Dis 1992;14:66-74.|
|3||Wald A, Leisenring W, van Burik JA, Bowden RA. Epidemiology of Aspergillus infections in a large cohort of patients undergoing bone marrow transplantation. J Infect Dis 1997;175:1459-66.|
|4||McWhinney PH, Kibbler CC, Hamon MD, et al. Progress in the diagnosis and management of aspergillosis in bone marrow transplantation: 13 years' experience. Clin Infect Dis 1993;17:397-404.|
|5||Hibberd PL, Rubin RH. Clinical aspects of fungal infection in organ transplant recipients. Clin Infect Dis 1994;19 Suppl 1:S33-40.|
|6||Kahn FW, Jones JM, England DM. The role of bronchoalveolar lavage in the diagnosis of invasive pulmonary aspergillosis. Am J Clin Pathol 1986;86:518-23.|
|7||Tomee JF, Mannes GP, van der Bij W, et al. Serodiagnosis and monitoring of Aspergillus infections after lung transplantation. Ann Intern Med 1996;125:197-201.|
|8||Patterson TF, Kirkpatrick WR, White M, et al. Invasive aspergillosis disease spectrum, treatment practices, and outcomes; I3 Aspergillus Study Group. Medicine (Baltimore) 2000;79:250-60.|