Discussion:
This patient had presented with clinical feature consistent with obstructive uropathy and acute deterioration of renal profile secondary to renal pelvis aspergillus ball as it was evident by the culture and the PCR. Owing to his early presentation after transplantation and the lack of the donor records, we believe it is a donor driven fungal infection. Isolated renal aspergillus has been described after renal transplant with unfavorable graft prognosis specially if it is an early presentation which mostly lead to allograft nephrectomy1. Clinically they presented with fever and decrease in the urine output2-5. Yet, our patient mainly had decrease in the urine output and increase in the renal profile. More than one possibility could have led to acquire aspergillus as reported previously either from the donor source, contaminated procedures or from the urinary tract infections. The rarity and the high fatality rate of the disease has resulted in a limited medical option for the cure. Thus, the majority consider surgical intervention as an urgent and lifesaving treatment modality owing to the high rate of medical treatment failure and to the angioinvasion with occasional aneurysmal formation2,6. Some of the medical treatment which was used amphotericin or liposomal amphotericin itraconazole and voriconazole as a combination or monotherapy2-5,7. Fortunately, Our patient has improved on nephrostomy drainage and antifungal liposomal amphotericin followed by voriconazole for a total duration of one year with a good clinical and radiological response. H. Vuruskan etl had reported Similar case of distal ureteric obstruction secondary to aspergilloma which was treated with nephrostomy drainage and antifungal However, the patient died after forty days of transplantation due to acute circulatory failure6. On the other hand, there are reported cases which were treated by nephrostomy drainage and anti-fungal with a good preserved allograft functions8,9. Another report from Shannon et al of late presentation of renal allograft aspergilloma which have been successfully treated medically10. Indefinite antifungal therapy would be the preferable approach in non-surgically managed patients as the recurrence pseudoaneurysm was reported with two weeks course of itraconazole but not with three months duration8,10,11. Sadagah etl from Saudi Arabia has reported renal allograft aspergilloma who failed the antifungal therapy and ended by nephrectomy12.