Renal allograft recipient with co-existing BK virus nephropathy and pulmonary histoplasmosis: report of a case

Abstract

Renal allograft recipients are prone to opportunistic infections, rarely multiple coexisting infections, due to the immunocompromised state. To the best of our knowledge, no case of a co-existing polyoma virus nephropathy and pulmonary histoplasmosis in a renal allograft recipient has been reported so far in the available literature. A 55-year-old male renal allograft recipient underwent graft biopsy for asymptomatic graft dysfunction. The graft biopsy showed features of polyoma virus nephropathy. Soon after, he developed fever with pulmonary nodules. Fine-needle aspiration from lung nodules showed intracellular yeast forms of histoplasma. The patient responded well to amphotericin B with subsidence of fever. The co-existence of renal allograft-limited infection like polyoma virus and systemic fungal infection such as histoplasmosis should be kept in mind in a transplant recipient with graft dysfunction and non-specific systemic symptoms. Prompt recognition of these infections permits the clinician to institute appropriate therapeutic modification and improved survival.

Clinical Characteristics and Outcomes of Endemic Mycoses After Solid Organ Transplantation: A Comprehensive Review

“…There were 172 cases of histoplasmosis described in 125 reports [ 66 , 69 , 72–87 , 90–99 , 101–182 , 194 , 196 , 197 , 199–206 , 208 , 241–243 ] ( Table 1 ). Half of recipients (74 of 144 [51.4%]) were on MMF [ 73 , 74 , 80 , 83–86 , 92–94 , 96 , 98 , 101–104 , 107–109 , 113–116 , 118–120 , 122 , 126 , 130 , 132–135 , 140 , 143 , 145 , 148–150 , 152 , 153 , 155 , 156 , 159 , 161–165 , 172–174 , 177 , 179 , 181 , 194 , 196 , 197 , 204 ]. T-cell–depleting induction was reported in 23 cases [ 78 , 104 , 107 , 108 , 110 , 113–115 , 118 , 125 , 133 , 146 , 154 , 163 ] while acute rejection occurred in 30 recipients within 1–3 months before symptom onset […”

Pulmonary histoplasmosis in a renal allograft recipient

“…[12] It is rare in renal transplantation, usually does not appear to be related to the intensity of immunosuppression and can occur at any time,[23] with the world's largest series reporting an attack rate of 0.6/1000 patient years over a 10 year follow-up period. [4] Immunosuppressed patients may develop disseminated disease,[35] which can progress to septic shock, disseminated intravascular coagulation, acute kidney injury and respiratory insufficiency[24] and carries a mortality of up to 23%.…”

“…[12] It is rare in renal transplantation, usually does not appear to be related to the intensity of immunosuppression and can occur at any time,[23] with the world's largest series reporting an attack rate of 0.6/1000 patient years over a 10 year follow-up period. [4] Immunosuppressed patients may develop disseminated disease,[35] which can progress to septic shock, disseminated intravascular coagulation, acute kidney injury and respiratory insufficiency[24] and carries a mortality of up to 23%. [6] The presenting clinical features, usually prolonged fever, malaise, weight loss, cough, dyspnea and an abnormal chest roentgenogram with diffuse nodular patchy or miliary infiltrates,[4] resemble tuberculosis, which is endemic in India and hence it has been empirically treated as such without definitive investigations.…”

“…Additional case reports from India specifically in renal allograft recipients have reported cutaneous,[6] pulmonary,[3] concomitant colonic and genitourinary histoplasmosis presenting as a prostatic abscess[7] and disseminated forms[2] at different time periods.…”

“…Histoplasmosis reported from the Gangetic plains in India,[12] is rare in renal transplantation,[23] and more common in human immunodeficiency virus (HIV) infected individuals. As the presenting clinical features are usually prolonged fever, malaise, weight loss, cough, dyspnea and an abnormal chest roentgenogram with diffuse nodular patchy or miliary infiltrates,[4] the condition may be misdiagnosed as tuberculosis and has been empirically treated as such without definitive investigations.…”