J Korean Soc Transplant.  2017 Mar;31(1):52-57. 10.4285/jkstn.2017.31.1.52.

Fatal Invasive Pulmonary Aspergillosis after Combined Induction with Rituximab and Antithymocyte Globulin for Kidney Transplantation in a Sensitized Recipient, and Early Rejection Therapy with Plasmapheresis and Low-dose Immunoglobulin

• Jeong DW
• Lee SH
• Moon JY
• Kim YG
• Lee YH
• Kim K
• Park H
• Joo SH

• KMID: 2375681
• DOI: http://doi.org/10.4285/jkstn.2017.31.1.52

Abstract

A high degree of sensitization to human leukocyte antigen requires more intensive induction therapy; however, this increases vulnerability to opportunistic infections following kidney transplantation. Although recent studies have suggested that combined induction therapy with antithymocyte globulin and rituximab would be more effective in highly sensitized kidney recipients, we experienced a case of near-fatal invasive pulmonary aspergillosis 2 months after combined induction and early rejection therapy for graft dysfunction. Fortunately, the patient recovered with intensive antifungal treatment and lung lobectomy for a necrotic cavity. Antifungal prophylaxis should be considered in cases undergoing intensive induction therapy.

Keyword

Invasive pulmonary aspergillosis; Combined desensitization induction; Kidney transplantation

MeSH Terms

Antilymphocyte Serum*
Humans
Immunoglobulins*
Invasive Pulmonary Aspergillosis*
Kidney Transplantation*
Kidney*
Leukocytes
Lung
Opportunistic Infections
Plasmapheresis*
Rituximab*
Transplants
Antilymphocyte Serum
Immunoglobulins
Rituximab

Figure

• 

  Fig. 1 (A) On hospital day (HD) 1, high-resolution computed tomography (CT) shows fibrotic consolidation and a peripheral ground glass opacity in the right lower lobe. (B, C) Follow-up enhanced chest CT on HD 82. (B) It shows increasing right loculated pleural effusion. (C) It shows a necrotic cavitary lesion at risk of developing a bronchopleural fistula.

• 

  Fig. 2 (A) On hospital day (HD) 39, percutaneous needle biopsy demonstrated Aspergillus (HE stain, ×400). Microscopic examination shows fungal hyphae with septated acute branching (45°). (B) On HD 101, right lower lung lobectomy demonstrated Aspergillus, too (periodic acid Schiff stain, ×400).

• 

  Fig. 3 The patient had improved allograft function with no further need for hemodialysis (HD), following recovery with intensive antifungal treatment and lung lobectomy for a necrotic cavity. This figure also shows the immunosuppressant schedule and tacrolimus levels.

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