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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#58;</span></p><p class="elsevierStylePara">Aspergillosis comprises a range of diseases caused by the fungus <span class="elsevierStyleItalic">Aspergillus</span>&#46;<span class="elsevierStyleSup">1&#44;2</span> In 20&#37; of cases&#44; it appears as disseminated invasive aspergillosis&#46;<span class="elsevierStyleSup">3</span> In the case of transplantation&#44; it is associated with high rates of morbidity&#44; mortality and extended hospitalisation&#46;<span class="elsevierStyleSup">1</span> Its incidence varies according to the organ and in kidney transplantation&#44; mortality reaches 70&#37;&#46;<span class="elsevierStyleSup">3&#44;4</span><span class="elsevierStyleItalic">Aspergillus</span> is the fungus that most commonly affects the thyroid gland and it is generally confirmed in the autopsy&#46;<span class="elsevierStyleSup">5-7</span> Reports of invasive aspergillosis that has disseminated to the thyroid gland&#44; diagnosed <span class="elsevierStyleItalic">ante mortem</span> and treated in renal transplant patients&#44; as in our case&#44; are extremely rare&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORT</span></p><p class="elsevierStylePara">A 49-year-old female received a deceased donor renal transplant&#46; Induction therapy&#58; anti-human thymocyte immunoglobulin&#44; 5 doses of 1&#46;5mg&#47;kg&#47;day&#46; She displayed delayed graft function and urinary fistula&#46; A biopsy revealed capillaritis with C4d-positive diffuse peritubular capillaries &#40;50&#37; positive&#41;&#44; treated with three pulses of 500mg methylprednisolone and 400mg&#47;kg&#47;day intravenous immunoglobulin for five days&#46; Immunosuppression&#58; tacrolimus 8mg&#47;day&#44; mycophenolate sodium 1440mg&#47;day and methylprednisolone 4mg&#47;day&#46; Prophylaxis for cytomegalovirus and pneumonia due to <span class="elsevierStyleItalic">Pneumocystis carinii</span>&#58; valganciclovir and trimethoprim-sulfamethoxazole&#46;</p><p class="elsevierStylePara">40 days after transplantation&#44; the patient developed urinary tract infections due to <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> and <span class="elsevierStyleItalic">Escherichia coli</span>&#46; Fifteen days later&#44; she was admitted with dyspnoea and fever&#46; A thoracic computerised tomography scan revealed bilateral pulmonary infiltrates&#44; and images of consolidation and cavitation in both lungs&#46; We performed bronchoalveolar lavage and a galactomannan antigen assay by ELISA &#40;Platelia<span class="elsevierStyleSup">&#174;</span> Aspergillus&#44; BioRad&#44; France&#41; with positive galactomannan of 1&#46;20 units&#46; Blood test&#58; haematocrit 27&#46;2&#37;&#44; haemoglobin 9&#46;6g&#47;dl&#44; platelets 149&#160;000&#47;mm<span class="elsevierStyleSup">3</span>&#44; leukocytes 691&#160;000&#47;mm<span class="elsevierStyleSup">3</span>&#44; blood sugar 103mg&#47;dl&#44; urea 56mg&#47;dl&#44; creatinine 1&#46;46mg&#47;dl&#46; The search for <span class="elsevierStyleItalic">Pneumocystis jiroveci </span>&#40;<span class="elsevierStyleItalic">P&#46; carinii</span>&#41; with Giemsa and Gram-Weigert stain and nested polymerase chain reaction &#40;PCR&#41; and for cytomegalovirus DNA by real time PCR was negative&#46; The wet mount microscopic examination with potassium hydroxide did not show intracellular yeasts or fungi compatible with histoplasma <span class="elsevierStyleItalic">capsulatum</span>&#46; We did not find Koch bacilli or methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#46;</p><p class="elsevierStylePara">With a presumptive diagnosis of invasive pulmonary aspergillosis&#44; voriconazole was introduced &#40;200mg twice a day&#41; and immunosuppression was discontinued&#46; Two days later&#44; enlarged thyroid gland and pain on compression were detected&#46; An ultrasound revealed moderate goiter of left lobe prevalence with parenchymal hypoechogenicity and heterogeneous structure&#44; changes in the left lobe&#58; solid-cystic heterogeneous nodular lesion 27 x 16 x 23mm&#44; thick peripheral hypoechoic halo without calcifications&#44; peripheral vascularisation&#44; solid hypoechoic lesions above nodule&#44; relatively defined margins and heterogenous structure without cystic foci or calcifications&#44; 14&#46;8 x 10&#46;8mm&#46; Right lobe&#44; 55 x 12 x 18mm&#44; dispersed cystic foci&#44; follicular colloid appearance&#44; the largest 3&#46;9mm&#46; Left lobe 59 x 23 x 25mm&#44; isthmus 6&#46;1mm&#46; The patient had no history of thyroid disease&#46; The thyroid enlargement was sudden&#46; Thyroid profile&#58; thyrotropin 0&#46;45&#956;IU&#47;ml&#44; ultrasensitive peroxidase 7&#46;6IU&#47;ml&#44; anti-thyroglobulin 10IU&#47;ml&#46;</p><p class="elsevierStylePara">The gland was punctured and purulent exudate was extracted with fungal filaments identified as <span class="elsevierStyleItalic">Aspergillus flavus</span>&#46; After 48 hours&#44; the fever and pain disappeared&#46; Voriconazole treatment lasted 20 weeks&#46; The patient made good progress and 45 days after diagnosis&#44; an ultrasound of the gland revealed normal shape&#44; size and structure&#46; Left lobe&#44; 48 x 17&#46;5 x 16mm cystic nodule with peripheral halo of 21 x 14 x 13mm&#44; denser&#44; without microcalcifications&#46; Right lobe&#44; 52 x 15 x 14mm&#44; colloid cysts&#44; the largest 4mm&#46; Isthmus 2&#46;4mm&#46; The galactomannan assay was repeated 60 days after the first assay with a result of 0&#46;10 units&#46; Plasma creatinine stabilised at 1&#46;02mg&#47;dl&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CONCLUSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The galactomannan assay can detect aspergillosis before symptoms appear&#44; but sensitivity and specificity in solid organ transplant patients are lower than in haematological patients&#46;<span class="elsevierStyleSup">8&#44;9</span> With the results of this test&#44; we suspended immunosuppression and administered voriconazole&#44; since it is recommended to start treatment when symptoms appear&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">Voriconazole&#44; the most used and most effective drug for treating invasive aspergillosis&#44;<span class="elsevierStyleSup">2&#44;8</span> inhibits the activity of cytochrome P450-3A4&#59; as such&#44; the tacrolimus dose should be adjusted to prevent nephrotoxicity&#46;<span class="elsevierStyleSup">4</span> We used the recommended dose&#44;<span class="elsevierStyleSup">10</span> which in adults increases exposure by a factor of 2&#46;5&#44; the area under the concentration-time curve&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">Differential diagnosis becomes more complicated because the pain may be due to viral infection&#44; but at the same time&#44; the gland is resistant to infection&#46;<span class="elsevierStyleSup">5&#44;6</span> In a similar case&#44; it was thought that a patient had fungal pneumonia and subacute thyroiditis and she was treated with prednisolone unsuccessfully&#59; aspergillosis was confirmed by puncture and voriconazole was administered with a positive result&#46;<span class="elsevierStyleSup">5</span> Another patient with acute myeloid leukaemia was diagnosed with <span class="elsevierStyleItalic">Aspergillus flavus</span> in the thyroid gland in the autopsy&#46;<span class="elsevierStyleSup">6</span> The diagnosis is only confirmed by aspiration<span class="elsevierStyleSup">5</span> and potential false positives should be considered in the galactomannans assay&#46;<span class="elsevierStyleSup">3&#44;8&#44;9</span> In our case&#44; the treatment lasted 20 weeks&#44; the disease was resolved and this allowed renal function to improve&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p>"
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