Renal aspergilloma: an unusual cause of infection in a patient with the acquired immunodeficiency syndrome

Renal aspergillosis in a liver transplant patient: A case report and review of literature

BACKGROUND

Aspergillosis is a frequent invasive fungal infection in liver recipients (affecting 1%-9.2% of all patients), second only to candidiasis. Significant risk factors for invasive aspergillosis in liver recipients include corticosteroid therapy, neutropenia, T-cell dysfunction, renal failure and requirement for renal replacement therapy. Aspergillus infection usually affects the lungs of liver recipients, with hematogenous dissemination occurring in 50%-60% of cases. Renal involvement is rare and is considered to occur in 0.4% of all cases of invasive aspergillosis.

CASE SUMMARY

This paper describes a case of a liver recipient presenting with a newly formed renal mass a year after liver transplantation. The patient underwent liver transplantation due to alcoholic liver cirrhosis, with preoperative corticosteroid therapy and postoperative immunosuppressants (tacrolimus and mycophenolate mofetil). His 1-year follow-up was uneventful, with a satisfying graft function and lack of any symptoms. During a routine follow-up abdominal ultrasound, he was diagnosed with a renal tumor. The renal imaging findings were inconclusive (with a differential diagnosis to renal cell carcinoma), while the computed tomography (CT) of the chest showed scar tissue in the lungs suggestive of previous inflammation. The patient underwent radical nephrectomy, with histopathological analysis showing renal aspergilloma, yielding postoperative treatment with voriconazole. His follow up was uneventful, and the chest CT did not show any change in pulmonary lesions. This case illustrates the possibility of aspergillosis affecting the lungs of liver recipients, subsequently affecting the kidney and forming an aspergilloma.

CONCLUSION

Clinicians should be aware of aspergilloma mimicking solid organ tumors in organ recipients.

Multimodality Imaging Findings of a Renal Aspergilloma

BACKGROUND

Renal aspergillosis is a rare infection that usually occurs in persons with a predisposition for this condition. Its differential diagnosis includes primary and metastatic renal malignancies, pyelonephritis and secondary abscess formation, granulomatous disorders, and renal infarction. We aim to stress the role of multimodality imaging and percutaneous biopsy in the diagnosis of this condition.

CASE REPORT

We present diffusion weighted imaging (DWI) and positron emission tomography-computed tomography (PET-CT) findings in addition to conventional imaging modalities in a 55-year-old man with secondary renal aspergilloma.

CONCLUSION

Radiological imaging methods are an integral part of diagnostic workup for renal aspergillosis. A definitive diagnosis is made by histopathological and/or microbiological examination of the material obtained via percutaneous biopsy under guidance of imaging methods.

Unilateral ureteral obstruction caused by Aspergillus, subgenus Nidulantes in a patient on steroid therapy: a case report and review of the literature

Urinary tract obstructions caused by Aspergillus bezoars has been reported on rare occasions. We describe in this paper an unusual case caused by an isolate of the Aspergillus nidulantes subgenus, and review the literature on 13 additional cases of ureteral obstruction due to renoureteric aspergillosis so as to provide the characteristics of this disease entity. Our case presented with a unilateral ureteral obstruction and acute renal failure due to Aspergillus bezoars. The patient was immunocompromised having received corticosteroid therapy for chronic obstructive lung disease and bronchiectasis. She was treated successfully with antifungal chemotherapy, including amphotericin B followed by oral voriconazole for about two months and had a percutaneous nephrostomy for one month. The patient's renal function completely recovered after hemodialysis maintenance for six months.

Bilateral renal aspergillosis in a patient with AIDS: a case report and review of reported cases

Renal aspergillosis is an extremely uncommon complication in HIV-infected patients. In general, prognosis is poor and the need for nephrectomy is emphasized. We report the case of a 37-year-old patient with AIDS since April 2003 (CD4 count 10 cells/mm(3), a high viral load, Candida esophagitis, bilateral pneumonia, HIV encephalopathy). Treatment with zidovudine, lamivudine, nevirapine, and lopinavir/ritonavir was started. Adherence to this medication proved to be a problem, but after 18 weeks of HAART the CD4 count was 110 cells/mm(3) and viral load was undetectable. One year later, he presented with hematuria and flank pain. Computed tomography (CT) scan revealed multiple lesions in both kidneys. Cultures of the abscess aspirates yielded Aspergillus fumigatus. Our review of 18 reported cases shows that prognosis of renal aspergillosis is poor if nephrectomy is not performed. However, in the present case a conservative approach was chosen to avoid life-long dialysis. The patient was treated successfully with a combination of voriconazole, percutaneous drainage, and highly active antiretroviral therapy (HAART). Renal function was completely preserved. Reported cases from the literature of renal aspergillosis in HIV-infected patients are summarized in this paper.

Causative agents of nosocomial mycoses

In the last few years mycoses have been caused by fungi formerly considered to be harmless for humans. They cause diseases of plants and insects; some of them are also used in the industry. They are now usually called "emerging fungi". We investigated this flora with respect to their potential to cause infections in hospitals. These fungi are present in the air, on medical objects and instrumentation, in the respiratory tract and on the hands of hospital staff; other sources have been identified in the use of iatrogenic methods. Mycotic diseases, their risk factors, their clinical pictures, and spectra of agents were analyzed in 1990-2000; the results were compared with data in the literature. Transplantations were the most frequent risk factors, fungemia and abscess the most frequent clinical picture and filamentous fungi (genera Absidia, Acremonium, Alternaria, Apophysomyces, Aspergillus, Bipolaris, Cladophialophora, Cunninghamella, Exserohilum, Fusarium, Chaetomium, Chrysosporium, Lecythophora, Ochroconis, Paecilomyces, Pythium, Rhizopus, Scedosporium, Scopulariopsis) were the most frequent agents of nosocomial infections. These filamentous fungi and also some yeasts (genera Candida, Cryptococcus, Trichosporon) bring about different clinical syndromes in both immunocompromised and immunocompetent patients.

Laparoscopic retroperitoneal nephrectomy for Aspergillus-infected polycystic kidney

BACKGROUND AND PURPOSE

The management of polycystic kidney disease is mostly restricted to conservative measures. However, nephrectomy may be indicated in particular cases, especially when there are infective complications. To decrease the morbidity of the procedure, the laparoscopic approach has become appealing. We present a laparoscopic retroperitoneal approach to complicated polycystic kidney disease in a high-risk patient. CASERESPORT: We performed right retroperitoneal laparoscopic nephrectomy in a 39-year-old man who had autosomal polycystic kidney disease and had undergone heart transplantation. The immunosuppressed patient presented with severe flank pain, generalized signs of infection, and acute renal insufficiency. With the patient in the right lateral decubitus position, the retroperitoneal space was entered by the open technique, and the posterior pararenal space was developed with finger dissection. Five trocars were used. After the renal vessels had been secured and divided, the cysts were successively punctured, gradually shrinking the operative specimen. The kidney was placed in an Endo-catch and removed after morcellation, with no need to enlarge the 2-cm lumbotomy. The operating time was 80 minutes, and the hospital stay was 4 days. Histologic examination revealed a polycystic kidney with Aspergillus infection.

CONCLUSION

The laparoscopic approach is a less-invasive option for removing a polycystic kidney when nephrectomy is indicated. The retroperitoneal route has the advantage of minimizing infection risks because of the absence of peritoneal opening.

Isolated renoureteric aspergilloma due to Aspergillus flavus: case report and review of the literature

In this paper we describe a case in which acute renal colic was associated with elimination of multiple hyphal masses of Aspergillus flavus. Also, we reviewed the literature on similar cases and we found a similar pattern characterized by a marked male predominance, association with at least one underlying medical condition that predisposes to fungal infection, the presence of local symptoms resembling acute ureteral colic, and the absence of systemic manifestations. Moreover, our data suggest that Aspergillus balls must be suspected when a diabetic and intravenous drug user presents with acute renal colic and that non-obstructive renal aspergillosis may be initially treated with itraconazole.

Concomitant renal and prostatic aspergillosis

Aspergillosis limited to the urinary tract is a rare disease seen most often in patients with altered immune status. Only 19 cases of renal aspergillosis including 3 with AIDS and 4 cases of isolated prostatic aspergillosis have been reported. We report the first case of concomitant renal and prostatic aspergillosis in a non-immunocompromised patient who presented with pyrexia of unknown origin and with dysuria. The diagnosis was based on the demonstration of characteristic hyphal elements on direct microscopy and isolation of the fungus in the culture of pus from the kidney. In view of obstructive prostatic enlargement and left non-functioning renal mass, transurethral resection of the prostate and left nephrectomy were performed in a single session with successful outcome. The aetiopathogenesis and brief review of the literature are discussed.

AIDS-related visceral aspergillosis: an underdiagnosed disease during life?

Five out of nine consecutive patients with HIV-related visceral aspergillosis observed by us since 1984 were diagnosed only at necropsy examination. The histopathological features of these five patients [two with isolated pneumonia, one with central nervous system (CNS) involvement, one with brain abscess and respiratory disease and one with pulmonary, pleural and kidney infection] have been evaluated according to epidemiological, clinical and radiological features. On the basis of our experience, life-threatening aspergillosis, which is often misdiagnosed or missed in the setting of HIV infection and AIDS, should be suspected in patients with far-advanced underlying disease and unexplained signs and symptoms, even in the absence of some presumed risk factors (i.e. neutropenia and prior steroid treatment). Plain chest radiography and bronchoscopy with broncholaveolar lavage may fail to reveal respiratory disease, CNS aspergillosis is not necessarily associated with suggestive neuroradiological features and disseminated disease may present with multiorgan failure. The unfavorable outcome of this emerging AIDS complication can be improved only by earlier diagnosis based on invasive techniques and appropriate and timely treatment.

Isolated bilateral renal aspergillosis: an unusual presentation in an immunocompetent host

A 35 year old apparently immunocompetent farmer developed isolated bilateral renal aspergillosis. He presented with acute renal failure due to granulomatous interstitial nephritis and had bilateral renal abscesses on CT scan. Diagnosis came from renal histology and was confirmed on serology. The patient responded quite satisfactorily to single agent antifungal chemotherapy with IV amphotericin B.

Fungal infections in patients with acquired immunodeficiency syndrome

The incidence and severity of fungal infections appear to increase with progression of HIV disease. Because of the significant morbidity and mortality associated with the mycoses discussed, knowledge of the clinical syndromes, early diagnosis, and prompt institution of therapy are crucial for a favorable outcome. For disseminated or invasive fungal infections, suppressive therapy must be continued to prevent relapse.

Genitourinary manifestations of the acquired immunodeficiency syndrome

As the number of HIV-1 infected individuals and AIDS patients continues to increase, more cases involving the genitourinary tract will be encountered. Often, genitourinary manifestations will be the initial presentation of AIDS. Proper diagnosis will require awareness and a high index of suspicion. In addition to routine cultures, opportunistic infections with unusual organisms will require staining for fungi and acid-fast bacilli. Repeat cultures of blood, urine, seminal fluid, and abscess cavities may be required to establish a diagnosis. Prolonged courses of antibiotic treatment for prophylaxis and for relapses are usually required. Clinical understaging and rapid progression of tumors distinguish HIV-1-associated malignancies involving the genitourinary tract. Treatment for these malignancies will depend on the stage of HIV-1 infection. Any concomitant drug therapy and evidence of malnutrition will be important factors in selecting the proper timing and mode of therapeutic intervention. Although AIDS predominantly affects individuals between 30 and 50 years of age, an increasing percentage of patients over 50 years of age are being diagnosed. Common risk factors for acquisition of HIV include homosexuality or bisexuality and transfusion of blood or blood products. For the urologist, it is important to recognize that older patients more frequently present with AIDS at the time of diagnosis of HIV infection. A more rapid course of deterioration and high mortality is noted in this population. Clearly, protocols including surveillance, dosing regimens, and surgical intervention will need to be established and clarified to treat an anticipated increasing number of affected patients. In addition, it appears that adequate adherence to universal precautions is far from being achieved. Close monitoring and active surveillance of infection control may be needed to improve compliance.

Disseminated aspergillosis in the acquired immunodeficiency syndrome

The relationship of disseminated aspergillosis with human immunodeficiency virus (HIV) infection is unclear. In the initial case definition of acquired immunodeficiency syndrome (AIDS) developed by the Centres for Disease Control (CDC), Atlanta, aspergillosis was included as an AIDS-defining opportunistic infection. In view of the primary relationship of aspergillosis with neutropenia rather than with lymphocyte depletion, as well as the lack of aspergillar infections among reported AIDS cases, aspergillosis was later deleted from the CDC case definition of AIDS. We describe a case of disseminated aspergillosis in a patient with AIDS, with an extensive literature review of the subject.

Isolated kidney localization of invasive Aspergillosis in a patient with AIDS

Although the importance of Aspergillus in AIDS is now increasing, extra-pulmonary disease is still an unusual event, especially when a single localization occurs. A case of isolated renal aspergilloma in an AIDS patient is described. At onset, no recognized risk factors were present in our patient. An early surgical approach combined with antifungal chemotherapy (amphotericin B, Itraconazole) led to a good control of the disease, with no evidence of recrudescence at 8 months' follow-up.

Treatment of aspergillosis with itraconazole

OBJECTIVE

To review the role of itraconazole as oral therapy for the major infections caused by Aspergillus spp.: allergic bronchopulmonary aspergillosis, aspergilloma, and invasive aspergillosis.

DATA SOURCES

A MEDLINE search of articles published in the English language between 1986 and 1993 was used to identify relevant citations, including review articles. In addition, a search of the published abstracts of the past two Interscience Conferences on Antimicrobial Agents and Chemotherapy (ICAAC) was performed.

STUDY SELECTION

Clinical trials that evaluated itraconazole therapy in either allergic bronchopulmonary aspergillosis, aspergilloma, or invasive aspergillosis were critically reviewed. Trials were evaluated based upon entry criteria for the diagnosis of each type of aspergillosis, risk factors for the development of aspergillosis (neutropenia, transplant recipient, hematologic malignancy), prior antifungal chemotherapy, and dose and duration of itraconazole therapy.

DATA SYNTHESIS

Overall, the clinical trials of itraconazole therapy for aspergillosis are limited and of variable quality. In the treatment of allergic bronchopulmonary aspergillosis, itraconazole has been reported to prompt a reduction in corticosteroid dosage in selected patients. There have been no controlled trials of itraconazole as treatment for aspergilloma, but data from several open-label trials suggest that this agent may be of clinical benefit in aspergilloma, primarily as an alternative to surgery. The use of itraconazole for invasive aspergillosis has been evaluated in several trials, most often in patients who were intolerant to amphotericin B treatment. Response to oral itraconazole has generally been promising.

CONCLUSIONS

Although itraconazole offers promise for oral therapy against infections caused by Aspergillus spp., it should not presently be regarded as primary therapy for any of these diseases. Amphotericin B, in doses ranging from 1 to 1.5 mg/kg to a total dose of 1.5-4.0 g, should remain the treatment of choice in both aspergilloma and invasive aspergillosis. Itraconazole use should be restricted to patients who experience severe toxicity with amphotericin B therapy. Corticosteroids continue to be first-line therapy for allergic bronchopulmonary aspergillosis, with the use of itraconazole reserved for those patients who would benefit from a reduction in corticosteroid dose.