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
epartment of Nephrology, All India Institute of Medical Sciences, New Delhi
|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
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. , 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.  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.  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.  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.
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