Angioinvasive complications of Scedosporium infections are rare. We report two cases of mycotic aneurysm, following apparent localized infection, due to Scedosporium apiospermum and Pseudallescheria boydii. The thoracoabdominal aorta was affected in one patient, and cerebral vessels were affected in the other. Despite voriconazole therapy and surgical resection, the patients died. Previously reported cases are reviewed. CASE REPORTSPatient A. A 55-year-old male with diabetes mellitus who was the recipient of a kidney transplant from a living related donor presented in 2009 with a left index finger lesion, following a trivial gardening injury. Immunosuppressive treatment included mycophenolate mofetil (500 mg thrice daily), tacrolimus (3 mg twice daily), and prednisolone (10 mg daily), with a course of therapy with methylprednisolone (1 g daily for 3 days) in the preceding 6 months. A culture of material from the lesion grew Scedosporium apiospermum and Pseudallescheria boydii. The in vitro MIC of voriconazole was 1 g/ml (5). X rays of the hand showed no evidence of osteomyelitis, and there were no abnormalities upon chest X ray and cerebral computed tomography (CT) scanning. He received 3 months of oral voriconazole (200 mg twice daily after a loading dose of 6 mg/kg twice daily), with unchanged immunosuppression, with apparent complete clinical response.Nine months later, the patient developed progressive, severe flank and lower back pain. He was afebrile and his blood pressure was 190/100 mmHg. There was bilateral soft tissue tenderness of the mid-lumbar region but no vertebral or abdominal tenderness. A CT scan of the abdomen revealed nonspecific thickening of the aortic wall at the level of the third and fourth lumbar vertebra (LV3 to LV4). Magnetic resonance imaging (MRI) of the thoracolumbar-sacral vertebra showed destruction of LV4 without evidence of discitis between LV3 and LV4. A paravertebral abscess was observed extending from the 10th thoracic vertebra (TV) to the LV4 level (Fig. 1a), in addition to inflammatory aortitis with aneurysm formation of the aorta from the level of TV9 to LV4 (Fig. 1b).Empirical therapy with vancomycin, rifampin, and ciprofloxacin was commenced. Results from blood cultures were negative for bacteria and fungi. Drainage of the paravertebral abscess yielded 20 ml of purulent material; no organisms were seen on Gram or Ziehl-Nielsen staining. S. apiospermum and P. boydii were cultured after 14 days of incubation. A single, 1-by 2-cm subcutaneous nodule then appeared over the patient's right wrist. Histopathological examination (Gromori-Grocott and periodic acid-Schiff [PAS] staining) of the excised lesion revealed granulomatous inflammation and septate hyaline fungal hyphae; S. apiospermum and P. boydii were recovered after culturing. Treatment with voriconazole was reinitiated (6 mg/kg twice daily and then 4 mg/kg twice daily) in association with a reduction in the intensity of the immunosuppressive regimen. Voriconazole serum levels were checked regularly (trough levels w...

Following renal transplantation, hypercalcaemia is frequently caused by persisting hyperparathyroidism. Unregulated extrarenal 1,25-dihydroxyvitamin D (1,25(OH)(2)D) synthesis, which is well recognized as a cause of hypercalcaemia in granulomatous diseases, may also occur after kidney transplantation. This mechanism is also likely to be responsible for hypercalcaemia reported during treatment of cytomegalovirus and associated with acute symptomatic pneumocystis jivorecii pneumonia (PCP). Hypercalcaemia as a prodromal feature of indolent PCP has not been described. We report a renal transplant recipient who developed hypercalcaemia 30 months post-transplant due to extrarenal production of 1,25(OH)(2)D. Two months later, PCP was diagnosed and hypercalcaemia resolved after initiation of treatment.

Current practice guidelines recommend that 'low-risk' outpatients undergoing percutaneous native renal biopsy (PRB) are observed for 6-8 h to identify post-biopsy complications. We performed a retrospective review of 225 PRB procedures in low-risk outpatients who were observed for a 4-h period to determine the safety with regard to complication rate and timing. PRB was performed using a standardised protocol and under ultrasound guidance with a 16-or 18-gauge needle. Bleeding complications occurred in 7% (16/225) of patients, of which 88% (14/16) were detected within a 4-h period. The two undetected complications presented more than 72 h after the procedure. This suggests that a 4-h observation period may be safe and adequate in identifying the majority of patients who will experience significant complications in the first 24 h, with a potential saving of time and resources.