Disseminated cryptococcosis and histoplasmosis in a renal transplant recipient
Abhishek Borle1, Pavan Wakhare1, Atul Sajgure1, Charan Bale1, Nilesh Shinde1, Vivek Biradar1, Akshay Kulkarni1, Abhijit Chavan1, Debapriya Saha1, Chetan Phadke1, Shreeharsh Godbole1, Anuja Makan1, Gaurav Singh1, Tushar Dighe1.
1Nephrology, Dr D Y Patil Medical College, Hospital & Research Centre, Pune, India
A 29-year-old female underwent renal transplant eight months ago with father being the donor. She was maintaining stable graft function on maintenance immunosuppression of Tacrolimus, Mycophenolate Sodium and Prednisolone. She presented with vesicular lesions over face and upper limbs, headache, and breathlessness for seven days. Initial blood investigations revealed azotaemia (Serum Urea: 167 mg/dL, Serum creatinine: 6.13 mg/dL) and leucocytosis (Total leucocyte count: 14,300 cells/ųL). Three days later, patient developed altered sensorium. CSF examination showed budding yeast cells with positivity for cryptococcal antigen. Subsequently, serum cryptococcal antigen and urinary histoplasma galactomannan also came out to be positive. Urine culture revealed growth of klebsiella pneumoniae with sensitivity present for Ceftazidime-Avibactam-Aztreonam. Treatment with Ceftazidime-Avibactam-Aztreonam, Liposomal Amphotericin B and Flucytosine was promptly initiated for the same. However, patient did not respond to treatment, developed septic shock, and succumbed to her illness. Although, co-infection with cryptococcus and histoplasma has been reported in immunocompromised individuals especially in HIV patients, it is not commonly seen in renal allograft recipients. This case highlights the spectrum of opportunistic infections which can infect immunocompromised patients after transplant. A high index of suspicion should be borne in mind for early diagnosis and to avoid morbidity and mortality in our patients.