Saudi Journal of Kidney Diseases and Transplantation

LETTER TO THE EDITOR
Year
: 2009  |  Volume : 20  |  Issue : 5  |  Page : 848--849

Primary cutaneous aspergillosis in renal transplant recipient


Ankur Gupta1, Ambar Khaira1, Suman Lata1, Alok Sharma2, Suresh C Tiwari1,  
1 epartment of Nephrology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Ankur Gupta
epartment of Nephrology, All India Institute of Medical Sciences, New Delhi
India




How to cite this article:
Gupta A, Khaira A, Lata S, Sharma A, Tiwari SC. Primary cutaneous aspergillosis in renal transplant recipient.Saudi J Kidney Dis Transpl 2009;20:848-849


How to cite this URL:
Gupta A, Khaira A, Lata S, Sharma A, Tiwari SC. Primary cutaneous aspergillosis in renal transplant recipient. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2020 Dec 4 ];20:848-849
Available from: https://www.sjkdt.org/text.asp?2009/20/5/848/55376


Full Text

To the Editor,

A 45 year-old renal transplant recipient pre­sented with nodular swelling over postero-lateral right calf for 10 days. He had good graft func­tion on prednisolone 7.5 mg/day, tacrolimus 2 mg/day and mycophenolate mofetil 1 g/day after 18 months of transplantation. Examina­tion showed tender and warm nodule 3 × 5 cm in size, along with a discharging sinus. No si­milar nodules were present elsewhere. Syste­mic examination was normal. Investigations showed normal absolute neutrophilic count, blood glucose and chest X-ray. Tacrolimus trough (T0) level was 12.80 ng/mL. Cultures for bacteria, fungus and acid fast bacilli were negative from the discharging sinus. Biopsy of the lesion revealed neutrophilic micro-abscesses with acute angle branching and slender septate fungal protoles compatible with Aspergillus species [Figure 1]. Tablet itraconazole 200 mg/day was started and tacrolimus was re­duced to 1.0 mg/day. Surgical excision was deferred since the lesion started to resolve and disappeared in 4 weeks. Repeat T0 level after 2 weeks was 5.08 ng/mL. The patient was given 12 weeks of itraconazole and followed under close supervision. There was no recu­rrence or new lesions.

Aspergillosis usually occurs in an immuno­compromised host. Commonly involved sites are lung, brain, heart, kidney, thyroid, intestines and skin in descending order of frequency. The literature is deplete with reports of primary cutaneous Aspergillosis. [1],[2] Biopsy and culture confirmation is needed to differentiate Asper­gillus species from other filamentous fungi. Cultures from the tissue were not done as fungus was not expected initially.

In cutaneous Aspergillosis, voriconazole is recommended as the first line agent and itra­conazole is an alternative agent; however the duration of treatment is not well defined. [3] We treated the patient with itraconazole due to financial constrains and obtained a gratifying response. A similar response was observed by Prasad et al in a case of cutaneous Asper­gillosis after one month therapy with itraco­nazole. [4] Since itraconazole is well concentra­ted in skin structures, and is cheap, it may be the drug of choice in skin limited cases. We reduced tacrolimus in view of high trough levels and its interaction with itraconazole. [5] Although the treatment duration has not been well defined, we feel that the patient should be treated for at least 3 months and followed up closely. This letter highlights the above men­tioned facts which a renal transplant physician in developing countries needs to be aware of.

References

1Thomas LM, Rand HK, Miller JL, Boyd AS. Primary cutaneous Aspergillosis in a patient with solid organ transplantation: case report and review of the literature. Cutis 2008;81: 127-30.
2Mallat SG, Aoun M, Moussalli A, Chelala D, Moukarzel M. Cutaneous aspergillosis in a renal transplant recipient. J Med Liban 2004; 52:111-4.
3Walsh TJ, Anaissie EJ, Denning DW, et al. Treatment of aspergillosis: Clinical practice guidelines of the infectious diseases society of America. Clin Infect Dis 2008;46:327-60.
4Prasad PV, Babu A, Kaviarasan PK, Anandhi C, Viswanathan P. Primary cutaneous aspergillosis. Indian J Dermatol Venereol Leprol 2005;71: 133-4.
5Ideura T, Muramatsu T, Higuchi M, Tachibana N, Hora K, Kiyosawa K. Tacrolimus/Itraco­nazole Interactions: A case report of ABO­incompatible living- related renal transplan­tation. Nephrol Dial Transplant 2000;15:1721-3.