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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 15  |  Issue : 4  |  Page : 368-370

Intracranial abscess due to disseminated aspergillosis in a renal transplant recipient - A case report


1 Department of Nephrology, Yashoda Hospital, Malakpet, Hyderabad, Telangana, India
2 Department of Urology, Yashoda Hospital, Malakpet, Hyderabad, Telangana, India
3 Department of Radiology, Yashoda Hospital, Malakpet, Hyderabad, Telangana, India
4 Department of Neurosurgery, Yashoda Hospital, Malakpet, Hyderabad, Telangana, India

Date of Submission29-Apr-2021
Date of Decision03-Aug-2021
Date of Acceptance01-Sep-2021
Date of Web Publication30-Dec-2021

Correspondence Address:
Dr. Sashi Kiran Annavarajula
Department of Nephrology, Yashoda Hospital, Malakpet, Hyderabad, Telangana-39
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_38_21

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  Abstract 

Fungal infections have devastating consequences in a renal transplant recipient. The risk of mortality is high despite early diagnosis and appropriate therapy. Here, we report the case of a 62-year-old male with multiple comorbidities who developed a deep-seated cerebellar abscess due to disseminated aspergillosis. Neuroimaging features and galactomannan features were critical in aiding the diagnosis as the abscess was difficult to access surgically. Early institution of appropriate antifungal therapy along with reduction in immunosuppressive medications helped in the successful treatment of a surgically difficult to access cerebellar abscess.

Keywords: Aspergillosis, cerebellar abscess, galactomannan assay, voriconazole


How to cite this article:
Annavarajula SK, Suryaprakash B, Ravikanth J, Reddy RS. Intracranial abscess due to disseminated aspergillosis in a renal transplant recipient - A case report. Indian J Transplant 2021;15:368-70

How to cite this URL:
Annavarajula SK, Suryaprakash B, Ravikanth J, Reddy RS. Intracranial abscess due to disseminated aspergillosis in a renal transplant recipient - A case report. Indian J Transplant [serial online] 2021 [cited 2022 Jan 26];15:368-70. Available from: https://www.ijtonline.in/text.asp?2021/15/4/368/334430




  Introduction Top


There can be only a few conditions more challenging than treating a solid organ transplant recipient with fungal infection. Treating clinicians often find themselves between the devil and deep sea in trying to save the patient along with the renal allograft. Here, we present one such challenging instance of a central nervous system (CNS) fungal infection in a renal transplant recipient.


  Case Report Top


A 62-year-old male, with Type II diabetes mellitus (with nephropathy, neuropathy, and retinopathy), hypertension, hypothyroidism, chronic pancreatitis, glaucoma, and end-stage renal disease on hemodialysis for the past 3 years was taken up for deceased donor renal transplantation. The deceased donor qualified to be an expanded criteria donor as he was 52 years old, had hypertension for about 6 years and suffered a catastrophic hemorrhagic stroke. Induction at the time of transplant comprised two doses of basiliximab along with methylprednisolone (MP) 500 mg once a day on the day of transplant and postoperative day (POD) 1 and 250 mg on POD2. He was also started on tacrolimus (0.07 mg/kg/day) and mycophenolate mofetil (MMF, 2 gm/day) from the time of transplant. From POD3, prednisolone (20 mg/day) was substituted for MP. He was also started on valgancyclovir, cotrimoxazole, and fluconazole at the same time. The patient was discharged from the hospital on the 8th POD with a serum creatinine of 2.3 mg/dl and a good urine output. At the end of 1 month following the transplant his serum creatinine had improved to 1.6 mg/dl; hence, the dose of prednisolone and MMF were reduced by 50%. He was followed up once a fortnight.

On the 62nd POD, he presented with fever, malaise, and ataxia which he was experiencing from the previous day. Evaluation revealed he a deep seated abscess in the right hemisphere of the cerebellum [Figure 1], multiple areas of consolidation in both the lungs [Figure 2] and abscesses over the chest and abdominal wall. Pus aspirated from the chest wall and bronchoalveolar lavage revealed Aspergillus fumigatus. Galactomannan assay performed on the cerebrospinal fluid (CSF) was positive. A diagnosis of disseminated aspegillosis was made. MMF was stopped, tacrolimus was reduced to maintain a trough level of 3 ng/ml and prednisolone was reduced to 5 mg once a day. He was also started on voriconazole and amphotericin B deoxycholate simultaneously. The option of neurosurgical intervention of the cerebellar abscess was abandoned after careful deliberation with the neurosurgical team. By the end of 1 week, with the above interventions, his fever had subsided, malaise had improved significantly and ataxia a little bit. His serum creatinine had increased to 3.5 mg/dl. Amphotericin B deoxycholate and voriconazole were continued for another 1 week with a close watch on his allograft kidney function. By the end of 2nd week of therapy, a repeat magnetic resonance imaging (MRI) scan of the brain showed the cerebellar abscess to have reduced a little in size along with a substantial reduction of the surrounding edema. His serum creatinine had increased to 5.2 mg/dl. Biopsy of the allograft kidney was performed, and it did not reveal rejection. The renal dysfunction was considered to be amphotericin B induced. Hence, amphotericin B was stopped, and voriconazole was continued. He remained on dual immunosuppression as mentioned above. By the 3rd week of therapy, his serum creatinine reached his previous baseline of 1.6 mg/dl. MRI scan of the brain performed 4 months after the diagnosis showed significant decrease in the size of the cerebellar abscess [Figure 3]. He was kept monitored closely, and a computed tomography scan of the brain performed after 1.5 years showed the cerebellar abscess to have resolved completely [Figure 4]. Voriconazole was stopped after 2 years.
Figure 1: Magnetic resonance imaging (MRI) brain at presentation. Axial T2 brain images (a and b) and GRE image (c) showing lobulated lesion in the left cerebellum with peripheral hypointense wall (arrows) showing blooming on GRE with central heterogeneous intermediate to bright contents. The lesion shows diffusion restriction in DWI and ADC map (d and e) more prominent in the wall of the lesion, with peripheral thin rim of enhancement (f)

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Figure 2: High resolution computed tomography (HRCT) chest at presentation

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Figure 3: MRI brain 4 months later

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Figure 4: CT brain 1.5 years later

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Now 3 years following the transplant, the patient is healthy with a serum creatinine of 1.4 mg/dl and minimal cerebellar signs. He remains on minimal doses of dual immunosuppressive drugs.


  Discussion Top


Fungal brain abscesses in renal transplant recipients lead to a very high mortality despite neurosurgical intervention and the use of appropriate antifungal drugs.[1] There are only a few cases in literature where a successful outcome was achieved without a neurosurgical intervention. Instituting antifungal therapy alone as a treatment modality had a mortality risk close to 90% in prevoriconazole era.[2] Voriconazole with its superior CNS penetrating capacity provides a better survival chance over amphotericin B.[3]

We were faced with two difficulties in treating this patient. First was a deep-seated cerebellar abscess which was difficult and risky to approach surgically. The second was an absence of microbiological proof of the organism from the cerebellar abscess. We could circumvent these limitations by

  1. Relying on the MRI images of the cerebellar abscess which were suggestive of a fungal etiology [Figure 1]. The morphologic and apparent diffusion coefficient features on MRI helped us to differentiate the brain abscess to be of fungal etiology[4]
  2. Examining the CSF for aspergillus using galactomannan assay
  3. By isolating the fungus from the lungs and chest wall abscesses.


It is known that neuroaspergillosis can occur by hematogenous dissemination in patients with solid organ transplants.[5] Hence, we considered our patient to have a cerebellar abscess probably due to disseminated aspergillosis. This made us to treat him with Voriconazole and amphotericin B deoxycholate initially and later on with Voriconazole alone. Liposomal amphotericin and echinocandins could not be used due to financial constraints. Although survival benefit is suggested by a combination of surgery and antifungal therapy in small studies of prevoriconazole era, it is now known that voriconazole has a good CNS penetration obfuscating the need for surgical intervention.[6] The antifungal therapy is generally continued till 6 months after radiological stabilization and for this patient we continued it for 2 years. An attempt to shift him to posaconazole was made but was aborted as the patient developed persistent hypokalemia which was difficult to correct.


  Conclusion Top


We consider our case to be unique as it is one of the few cases where an intracranial abscess in a patient with disseminated aspergillosis was treated successfully without surgical intervention. Early diagnosis, institution of appropriate antifungal therapy coupled with an immediate reduction in immunosuppression, which included a complete withdrawal of antimetabolite, was instrumental in the successful outcome of this patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgments

The authors would like to thank Kashinatham D, Department of Urology.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ju MK, Joo DJ, Kim SJ, Chang HK, Kim MS, Kim SI, et al. Invasive pulmonary aspergillosis after solid organ transplantation: Diagnosis and treatment based on 28 years of transplantation experience. Transplant Proc 2009;41:375-8.  Back to cited text no. 1
    
2.
Lin SJ, Schranz J, Teutsch SM. Aspergillosis case-fatality rate: Systematic review of the literature. Clin Infect Dis 2001;32:358-66.  Back to cited text no. 2
    
3.
Walsh TJ, Pappas P, Winston DJ, Lazarus HM, Petersen F, Raffalli J, et al. Voriconazole compared with liposomal amphotericin B for empirical antifungal therapy in patients with neutropenia and persistent fever. N Engl J Med 2002;346:225-34.  Back to cited text no. 3
    
4.
Luthra G, Parihar A, Nath K, Jaiswal S, Prasad KN, Husain N, et al. Comparative evaluation of fungal, tubercular, and pyogenic brain abscesses with conventional and diffusion MR imaging and proton MR spectroscopy. AJNR Am J Neuroradiol 2007;28:1332-8.  Back to cited text no. 4
    
5.
Candoni A, Klimko N, Busca A, Di Blasi R, Shadrivova O, Cesaro S, et al. Fungal infections of the central nervous system and paranasal sinuses in onco-haematologic patients. Epidemiological study reporting the diagnostic-therapeutic approach and outcome in 89 cases. Mycoses 2019;62:252-60.  Back to cited text no. 5
    
6.
Patterson TF. Treatment and prevention of invasive aspergillosis. In: Ted W, editor. Uptodate Post. Waltham, MA: UpToDate; 2021.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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