EARLY OCCURRENCE OF UNUSUAL FUNGAL INFECTIONS AFTER KIDNEY TRANSPLANT, A CASE REPORT

Introduction:

Infections are a cause of significant morbidity and mortality in the post kidney transplant population. Diagnosis is often delayed and difficult as presentation is atypical and  symptoms remain masked due to immunosuppression. 

Methods:

 59 year old /F, with type 2 diabetes for 15 years, underwent a deceased donor kidney transplant recipient with a discharge s. creatinine of 0.8 mg/dl ; presented within a month after transplant with reduced appetite and abdominal pain.Induction agents were IV methylprednisolone (1 gm over 3 days) and anti-thymocyte globulin( 3 mg/kg)  and maintenance immunosuppression was tacrolimus, mycophenolate sodium, and deflazacort .DJ stent was removed at three weeks. Esophagogastroduodenoscopy (OGD) revealed esophageal candidiasis, and she was treated with oral fluconazole.CT Abdomen (with oral & IV contrast) was unremarkable .Dose of mycophenolate sodium was reduced due to her GI symptoms. Three weeks later, she presented  with severe constipation, abdominal discomfort, hypotension, and respiratory distress, necessitating mechanical ventilation due to severe metabolic acidosis.Serum Lactate levels were high. Graft function remained stable throughout. Empirical antibiotics including ceftazidime-avibactam, aztreonam, teicoplanin, and anidulafungin were administered. CT imaging revealed multiple pulmonary nodules with reverse halo sign, pneumoperitoneum , perisplenic and anterior abdominal wall collections with airfoci (emphysematous splenic infection). Isuvaconazole was added to cover suspected mucor infection.

Results:

Urgent surgical exploration found a putrefied spleen, multiple air pockets and intra abdominal collections. Intra-operatively, a bronchoalveolar lavage (BAL) was performed. Postoperatively, the patient showed initial clinical improvement with reduced need for inotropes and declining lactate levels. However, on postoperative day 2 , she suffered a cardiac arrest and succumbed. Cultures from blood, BAL, and abdominal fluid later grew carbapenem-resistant Klebsiella pneumoniae, BAL grew Cunninghamella Bertholletiae (Mucor) and histopathology of the spleen indicating broad septate fungal hyphae consistent with Mucor. 

Conclusions:

Despite routine induction and maintenance immunosuppressive drug use in a low risk deceased donor kidney transplant , life threatening fungal infections can be a cause of morbidity and mortality in the early post transplant period .Routine antifungal prophylaxis is unlikely to be useful in such cases.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.