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.