Case presentation:
A 64 years old male patient who’s known to have uncontrolled diabeties,
hypertension, Ischemic heart disease and end stage renal disease;
underwent a non related renal transplant in August 2018 in Pakistan. Two
months post- transplant the patient developed oozing from his surgical
site and deterioration in his graft function for which he was admitted
for investigations. One day into admission, he complained of decrease
urine output with further rise in serum creatinine. Urgent ultrasound
was done which showed dilated pelvicalyceal system .Foleys catheter was
inserted which led to improve the urine output. Notably, whitish debris
was noticed in his urine .Upon patient ‘s wish Foley catheter was
removed subsequently he developed decrease urine output along with more
deterioration of renal function for which Foleys was reinserted but this
time renal functions did not improve which necessitated urgent
percutaneous nephrostomy on the same day. The patient underwent
cystoscopy which revealed whitish colored fluffy ball like structure
obstructing the urethra which was retrieved and sent for culture and
histopathology (Figure1). The Urine culture and PCR were positive for
Aspergillus species. The histopathology showed septated fungal hyphae
morphologically consistent with Aspergillus. Of note, serum
Galactomannan remained normal through the course ranging from 0.2 – 0.1
units. Immunosuppression was stopped, liposomal amphotericin was
initially started then switched to voriconazole IV after obtaining the
microbiological results. Further, nephrogram showed obstruction at mid
distal ureter downwards (figure 2). Cystoscopy showed fungal ball in
middle calyx and urinary bladder, which was subsequently washed out.
Despite starting the patient on voriconazole and decreasing his
immuno-suppression, his graft function took a long time to improve which
could be partly due to possible graft rejection. Patient was offered
graft nephrectomy which he declined. Patient was continued on oral
voriconazole 200 mg BID.
During in the hospital course his surgical site developed infection
secondary to coagulase negative staphylococci. Abdomen CT scan showed
thickening of the lower right anterior abdominal wall with subcutaneous
fat stranding and multiple air foci, with overlying skin defect.
Perinephric fat stranding noted around the transplanted kidney in the
right lower quadrant with extension along the transplant ureter. No
perinephric fluid collections.
Patient was started on antibiotics and continued on voriconazole until
he was discharged successfully .In the Outpatient department he was
subsequently started on Mycophenolic acid and tacrolimus .He continued
voriconazole for 9 months .Clinically he stayed well with no systemic
signs and symptoms ,his renal function returned to baseline of 80
microliter.