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.