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LETTER TO EDITOR  
Year : 2014  |  Volume : 57  |  Issue : 4  |  Page : 643-645
Aspergillus fungal arteritis causing vascular anastomotic rupture and loss of commercially transplanted kidney


1 Department of Pathology, Mubarak Al-Kabeer Hospital, Minstry of Health, Jabriya, Kuwait
2 Department of Pathology, Faculty of Medicine, Kuwait University, Shamiyah, Kuwait City, Kuwait

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Date of Web Publication11-Oct-2014
 

How to cite this article:
George S, Al-Waheeb S. Aspergillus fungal arteritis causing vascular anastomotic rupture and loss of commercially transplanted kidney. Indian J Pathol Microbiol 2014;57:643-5

How to cite this URL:
George S, Al-Waheeb S. Aspergillus fungal arteritis causing vascular anastomotic rupture and loss of commercially transplanted kidney. Indian J Pathol Microbiol [serial online] 2014 [cited 2020 Sep 23];57:643-5. Available from: http://www.ijpmonline.org/text.asp?2014/57/4/643/142697


Sir,

We present a case of a 45-year-old female patient who underwent a live unrelated renal transplant in Pakistan. Her original kidney disease was unknown. She was admitted to our hospital on postoperative day (POD 9) with graft dysfunction and severe pallor. Her biochemical investigations were significant for a serum creatinine level of 3.31 mg/dl (293 μmol/L) and hemoglobin level of 6.2 g/dl (62 g/L). Routine bedside ultrasound examination showed well-perfused graft and minimal perigraft collection. Subsequently, patient developed sudden pain over the graft and progressed rapidly into shock. Immediate exploration showed active bleeding and ruptured arterial anastomotic site. Graft nephrectomy was inevitable as the upper pole of the kidney was infarcted. Hematoxylin and eosin [Figure 1]a stained sections of the ruptured arterial stump showed extensive fibrinoid necrosis of the arterial wall accompanied by neutrophilic infiltration and leukocytoclasia. The renal artery contained fibrin thrombi admixed with septate and dichotomously branching fungal hyphae [Figure 1]b highlighted by periodic acid-Schiff [Figure 1]c and Gomori methenamine silver [Figure 1]d stains. Light microscopic evaluation of the explanted renal graft showed extensive wedge-shaped areas of ischemic necrosis [Figure 2]. The viable cortex contained unremarkable glomeruli, none of which were globally sclerosed. Adjacent tubules showed severe acute tubular injury, but there were no features of tubulitis or viral cytopathic effects. There was no significant chronic tubulointerstitial damage in the viable foci. Extensive sampling of the graft kidney did not reveal any evidence of a fungal infection. C4d immunostain was negative in the peritubular capillaries of the graft kidney. A diagnosis of Aspergillus fungal arteritis and cortical ischemic necrosis of the graft kidney was rendered. However, there were no signs and symptoms of systemic fungal infection. Microbiological cultivations of the specimens of blood and urine were negative. The patient was treated with antifungals, amphotericin B and caspofungin acetate for 4 weeks. Postoperative period was eventful as the patient developed intravascular coagulopathy that necessitated re-exploration twice. This was further complicated by subcutaneous wound infections, treated by antibiotics. The patient is currently asymptomatic and on regular hemodialysis, 5 months after this episode.
Figure 1: (a) The vessel wall with fibrinoid necrosis and neutrophilic vasculitis (H and E). (b) The vessel lumen containing septate branching fungal hyphae admixed with fibrin (H and E, arrow). (c) Periodic acid-Schiff stain and (d) Gomori methenamine silver stain highlighting the fungal hyphae

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Figure 2: Wedge-shaped ischemic necrosis of the renal cortex (H and E)

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Infection is a frequent complication after organ transplantation among which fungal infections cause significant mortality and morbidity. Infection of an artery at or around the site of anastomosis is an ominous complication of renal transplantation, commonly presenting as an anastomotic leak or local dissolution of the arterial wall. [1],[2],[3] Mycotic aneurysms are another rare, but dangerous infectious complication following seeding and colonization of the arterial anastomotic site by the infectious agent. [4]

The clinical presentation of our case as hemorrhagic shock requiring emergency exploration was identical to the cases reported in the literature. [1],[2],[3] The interval between transplantation and arterial graft rupture averaged 24 days (range = 18-28 days). Our case presented on the POD 9, an early presentation similar to the experience of Zhan et al.

Literature review showed 17 episodes of fungal arteritis among solid organ transplants recipients, and Candida was the cause in the majority of cases. [5] However the most common infections in commercial renal transplants are invasive aspergillosis and mucormycosis, which are predominantly disseminative in nature, isolated renal involvement as in this case is uncommon. Aspergillus is a ubiquitous saprophytic fungus with low virulence potential in normal human hosts but act as an opportunistic pathogen in patients with organ transplants, severe immunosuppression, diabetes, trauma, etc. They have a special affinity for blood vessels and angioinvasion is the hallmark of invasive aspergillosis, resulting in tissue ischemia and necrosis. Of all the Aspergillus species, Aspergillus fumigatus, Aspergillus flavus and Aspergillus niger account for virtually all the cases. The clinical syndromes associated with exposure to this fungus include hypersensitivity syndromes, colonization syndromes, allergic bronchopulmonary aspergillosis, invasive and semi invasive aspergillosis.

The causes of infections in the 1 st month of posttransplant are mainly untreated infections in the recipient that may be exacerbated by immunosuppression, infections related to contamination of the allograft, from an infection in the donor or during organ procurement or preservation. Opportunistic fungal infections are notably absent during the 1 st month after transplant however if such infection occurs, it is often due to excessive environmental exposures that occur within the community or in the hospital. Pertaining to this case, we presume that the invasive fungal infection at the vascular anastomosis site could be the disastrous complication of commercial transplant tourism. Possible routes of infection in this case include inhalation of aerosol laden with Aspergillus conidia, contaminated preservation fluid or an infected donor. Moreover, recipients of commercial transplants are more prone for invasive fungal infections due to postoperative complications, repeated bacterial infections and renal insufficiency.

Patient management includes both medical and surgical; Medical includes antifungal drugs. Surgically removal of not only of the graft, but also of the iliac artery involved by infection and an extra-anatomic reconstruction from an uninfected field is advisable.

A cautious selection of donors coupled with the adoption of stringent aseptic measures during organ transplant can reduce the incidence of these fungal infections. Donors who have craniocephalic trauma accompanied by abdominal injury and have spent prolonged periods in the Intensive Care Unit, harvesting of kidneys from nonheart beating donors, organ preservation and graft implantation with longer duration of surgery are risk factors for infectious complications in the posttransplant period. Susceptible recipients as described above should be under scrutiny for an early detection of any complications.

 
   References Top

1.
Zhan HX, Lv Y, Zhang Y, Liu C, Wang B, Jiang YY, et al. Hepatic and renal artery rupture due to Aspergillus and Mucor mixed infection after combined liver and kidney transplantation: a case report. Transplant Proc 2008;40:1771-3.  Back to cited text no. 1
    
2.
Yannam GR, Wrenshall L, Stevens RB. Loss of renal allografts secondary to Candida vascular complications in two recipients from the same donor. Case Rep Transplant 2012;2012:364735.  Back to cited text no. 2
    
3.
Fadhil RA, Al-Thani H, Al-Maslamani Y, Ali O. Trichosporon fungal arteritis causing rupture of vascular anastamosis after commercial kidney transplantation: a case report and review of literature. Transplant Proc 2011;43:657-9.  Back to cited text no. 3
    
4.
Fujikata S, Tanji N, Iseda T, Ohoka H, Yokoyama M. Mycotic aneurysm of the renal transplant artery. Int J Urol 2006;13:820-3.  Back to cited text no. 4
    
5.
Rubin RH. Fungal infections in the organ transplant recipient. In: Anaissie EJ, McGinnis MR, Pfaller MA, editors. Clinical Mycology. 2 nd ed. London: Churchill Livingstone; 2009.  Back to cited text no. 5
    

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Correspondence Address:
Dr. Salah Al-Waheeb
Faculty of Medicine, Kuwait University, P.O. Box 72, Code 71661, Shamiyah, Kuwait City
Kuwait
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.142697

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