Disseminated histoplasmosis in a kidney transplant patient
Histoplasmosis diseminada en un paciente trasplantado renal.
Hernán Trimarchia, Mariano Forrestera, Fernando Lombia, Vicente Campolo-Girarda, Pablo Youngb, Julio Bruetmanb, Jorge Finquelievichc, Roxana Jordanc, Ernesto Efronc, Iris Agoriod, Bárbara C. Finnb, Débora Pellegrinib
a Servicio de Nefrología, Hospital Británico de Buenos Aires, Buenos Aires, Buenos Aires, Argentina,
b Servicio de Clínica Médica, Hospital Británico de Buenos Aires, Buenos Aires, Buenos Aires, Argentina,
c Servicio de Infectología, Hospital Británico de Buenos Aires, Buenos Aires, Buenos Aires, Argentina,
d Servicio de Microbiología, Hospital Británico de Buenos Aires, Buenos Aires, Buenos Aires, Argentina,
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The immunosuppression<br></br>regimen consisted of methylprednisone 4  mg/day,  micophenolate  mofetil  2 g/day,  and  tacrolimus  2  mg/day.  She was  admitted  to  hospital  for  suspicion of  complicated  renal  cysts  and  was found  subcutaneous  nodules  that were biopsied and seen to be consistent with erythema  nodosum.  Nephrectomy  of the right native kidney was performed, but  fever persisted. Cultures were persistently  negative.  Patient  developed massive  ascites.  Magnetic  resonance imaging  showed  ascites  and  a  complicated liver cyst, that was marsupialized, and  two  liters of  ascites were drained. Peritoneum  was  normal  upon  inspection. After 22 days of  incubation, subcutaneous  nodules  developed  colonies of Histoplasma capsulatum. Fever persisted  despite  itraconazole  administration, and amphotericin B was therefore added. Subsequent blood, urine, and ascites  fluid  cultures  were  positive  for Histoplasma capsulatum. Fever and ascites resolved 29 days after hospital admission,  and  patient  was  discharged home. Two weeks later, fever and subcutaneous nodules in the arms recurred. Severe  pericardial  effusion with  ultrasonographic  signs  of  tamponade  was diagnosed. The patient died during  the procedure. <br></br><br></br>While early fungal infections are less commonly  reported  in  kidney  transplant  patients  than  in  other  transplant<br></br>patients,  their  mortality  is  high.2 These patients have a high risk of suffering  late  opportunistic  infections,<br></br>particularly  by  Listeria, Nocardia, Mycobacteria,  or  fungi,  associated  to use  of  venous  catheters,  antibiotics,<br></br>corticosteroids,  surgical procedures, and diabetes mellitus.<br></br><br></br>Approximately after 6 months since transplant, incidence of opportunistic fungal infections decreases, but an increase occurs in the incidence of systemic endemic fungal disease, of which histoplasmosis and coccidioidomycosis are the most significant. Histoplasmosis is  the most  common  endemic mycosis in  immunosuppressed  patients  in  Argentina,3,5 with  an  incidence  rate up  to 40%  in humid,  temperate areas.  In our country, the most common clinical presentations  in healthy  individuals  include the pulmonary variant and the chronic  disseminated  variant  associated  to mucocutaneous  lesions,  adenomegalies, hepatomegaly, and splenomegaly.6 In normal subjects, primary infection is  usually  asymptomatic  in more  than 90%  of  cases.  In  a  lower  proportion, clinical  signs  include  pericarditis, mediastinitis,  erythema  nodosum,  or  retinitis.7<br></br><br></br>Ascites is a complication of systemic histoplasmosis  not  previously  reported in the 48 cases of histoplasmosis in kidney  transplant.  It  should  be  noted  that surgeons  did  not  take  peritoneal  biopsies during abdominal  laparoscopy because  of  the  normal  characteristics  of the serosa. This could be due to the abnormal inflammation patterns in immunosuppressed  patients.  We  think  random  peritoneal  biopsies  should  be<br></br>performed  despite  absence  of  gross structural  changes  when  the  cause  of ascites has not been diagnosed.8<br></br><br></br>Patients  transplanted  solid  organs have an  increased  risk of suffering opportunistic  infections.  Systemic  histoplasmosis  is  a  rare  and  serious  condition  that  should  be  considered  as  a long-term  complication  in  transplant patients.<br></br></p>" "pdfFichero" => "P-E-S-A377-EN.pdf" "tienePdf" => true "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "A los cuatro años de recibir un transplante renal vivo no relacionado por poliquistosis renal1, una paciente de 49 años comenzó con episodios de hipertermia. La inmunosupresión era metilprednisona 4 mg/día, micofenolato mofetil 2 g/día y tacrolimus 2 mg/día. Ingresó al hospital con la sospecha de quistes renales complicados y presentó nódulos subcutáneos que se biopsiaron y fueron consistentes con eritema nodoso. Se realizó una nefrectomía de un riñón nativo derecho pero persistió febril. Los cultivos fueron persistentemente negativos." ] "en" => array:1 [ "resumen" => "To the editor: Four years after receiving a kidney transplant from an unrelated living donor for polycystic kidney disease,1 a 49-year-old female patient started to experience episodes of hyperthermia. The immunosuppression regimen consisted of methylprednisone 4 mg/day, micophenolate mofetil 2 g/day, and tacrolimus 2 mg/day." ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Trimarchi H, Freixas E, Rabinovich O, Schropp J, Pereyra H, Bullorsky E. Cyclosporin-associated thrombotic microangiopathy during daclizumab induction. A suggested therapeutic approach. Nephron 87: 361-4, 2001. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11287781" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Jha V, Krishna S, Varma N, et al. Disseminated histoplasmosis 19 years after renal transplantation. Clin Nephrol 51: 373-8, 1999. <a href="http://www.ncbi.nlm.nih.gov/pubmed/10404698" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:1 [ "itemHostRev" => array:3 [ "pii" => "S0735109708014411" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Dictar M, Maiolo E, Alexander B, Jacob N, Veron MT. Mycosis in the transplant patient. Medical Mycology 38 Suppl I: 251-258, 2000." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Negroni R, Robles AM, Arechavala A, Bianchi M, Helou S. Histoplasmosis relacionada al SIDA, su estado actual en la Argentina. Prensa Médica Argentina 84: 696-700, 1997." 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"contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000002800000005/v0_201502091635/X2013251408004049/v0_201502091635/en/main.assets" "Apartado" => array:4 [ "identificador" => "35436" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000002800000005/v0_201502091635/X2013251408004049/v0_201502091635/en/P-E-S-A377-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408004049?idApp=UINPBA000064" ]
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| 2022 March | 30 | 66 | 96 |
| 2022 February | 41 | 46 | 87 |
| 2022 January | 44 | 32 | 76 |
| 2021 December | 44 | 49 | 93 |
| 2021 November | 33 | 27 | 60 |
| 2021 October | 40 | 45 | 85 |
| 2021 September | 25 | 38 | 63 |
| 2021 August | 21 | 27 | 48 |
| 2021 July | 39 | 40 | 79 |
| 2021 June | 25 | 22 | 47 |
| 2021 May | 32 | 43 | 75 |
| 2021 April | 56 | 31 | 87 |
| 2021 March | 37 | 26 | 63 |
| 2021 February | 29 | 23 | 52 |
| 2021 January | 26 | 14 | 40 |
| 2020 December | 27 | 11 | 38 |
| 2020 November | 34 | 20 | 54 |
| 2020 October | 22 | 16 | 38 |
| 2020 September | 29 | 18 | 47 |
| 2020 August | 40 | 13 | 53 |
| 2020 July | 39 | 5 | 44 |
| 2020 June | 17 | 15 | 32 |
| 2020 May | 34 | 11 | 45 |
| 2020 April | 29 | 22 | 51 |
| 2020 March | 26 | 14 | 40 |
| 2020 February | 31 | 18 | 49 |
| 2020 January | 39 | 14 | 53 |
| 2019 December | 38 | 17 | 55 |
| 2019 November | 32 | 15 | 47 |
| 2019 October | 11 | 13 | 24 |
| 2019 September | 22 | 25 | 47 |
| 2019 August | 13 | 12 | 25 |
| 2019 July | 23 | 25 | 48 |
| 2019 June | 16 | 18 | 34 |
| 2019 May | 22 | 29 | 51 |
| 2019 April | 29 | 36 | 65 |
| 2019 March | 20 | 16 | 36 |
| 2019 February | 20 | 11 | 31 |
| 2019 January | 20 | 16 | 36 |
| 2018 December | 83 | 34 | 117 |
| 2018 November | 97 | 14 | 111 |
| 2018 October | 70 | 22 | 92 |
| 2018 September | 57 | 12 | 69 |
| 2018 August | 37 | 16 | 53 |
| 2018 July | 49 | 18 | 67 |
| 2018 June | 32 | 14 | 46 |
| 2018 May | 46 | 19 | 65 |
| 2018 April | 49 | 6 | 55 |
| 2018 March | 44 | 11 | 55 |
| 2018 February | 48 | 8 | 56 |
| 2018 January | 30 | 7 | 37 |
| 2017 December | 52 | 11 | 63 |
| 2017 November | 22 | 9 | 31 |
| 2017 October | 28 | 10 | 38 |
| 2017 September | 31 | 7 | 38 |
| 2017 August | 23 | 9 | 32 |
| 2017 July | 42 | 16 | 58 |
| 2017 June | 26 | 8 | 34 |
| 2017 May | 53 | 11 | 64 |
| 2017 April | 26 | 7 | 33 |
| 2017 March | 22 | 6 | 28 |
| 2017 February | 20 | 8 | 28 |
| 2017 January | 12 | 7 | 19 |
| 2016 December | 51 | 13 | 64 |
| 2016 November | 43 | 11 | 54 |
| 2016 October | 63 | 11 | 74 |
| 2016 September | 60 | 4 | 64 |
| 2016 August | 157 | 2 | 159 |
| 2016 July | 118 | 3 | 121 |
| 2016 June | 101 | 0 | 101 |
| 2016 May | 130 | 0 | 130 |
| 2016 April | 58 | 0 | 58 |
| 2016 March | 71 | 0 | 71 |
| 2016 February | 68 | 0 | 68 |
| 2016 January | 91 | 0 | 91 |
| 2015 December | 78 | 0 | 78 |
| 2015 November | 73 | 0 | 73 |
| 2015 October | 66 | 0 | 66 |
| 2015 September | 43 | 0 | 43 |
| 2015 August | 64 | 0 | 64 |
| 2015 July | 44 | 0 | 44 |
| 2015 June | 36 | 0 | 36 |
| 2015 May | 52 | 0 | 52 |
| 2015 April | 6 | 0 | 6 |
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