|Year : 2020 | Volume
| Issue : 5 | Page : 238-240
Renal aspergillosis in a patient with acquired immunodeficiency syndrome
Kevin Flores-Lovon1, Noris Lozano2, Nicolas Cuba3, Ericson L Gutierrez4
1 Faculty of Human Medicine, Universidad Nacional de San Agustín de Arequipa, Arequipa, Perú
2 Urology Service, Hospital II Ramón Castilla, Red Asistencial Almenara, Seguro Social de Salud EsSalud, Lima, Perú
3 Faculty of Human Medicine, Universidad de San Martin de Porres, Lima, Perú
4 Faculty of Human Medicine, Universidad de San Martin de Porres; Peruvian National Institute of Health, Lima, Perú
|Date of Submission||18-Feb-2020|
|Date of Decision||15-Apr-2020|
|Date of Acceptance||21-Apr-2020|
|Date of Web Publication||27-Oct-2020|
Ericson L Gutierrez
Facultad de Medicina Humana, Universidad de San Martin de Porres, Lima
Source of Support: None, Conflict of Interest: None
Renal aspergillosis is a fungal infection caused by Aspergillus, which develops in immunocompromised patients. We report the case of a patient with acquired immunodeficiency syndrome (AIDS), who developed renal aspergillosis. He underwent abdominal tomography (computerized tomography) which showed an abscess in his left kidney. A nephrectomy was performed, and pathology revealed Aspergillus conidia.
Keywords: Acquired immunodeficiency syndrome, aspergilosis, Perú
|How to cite this article:|
Flores-Lovon K, Lozano N, Cuba N, Gutierrez EL. Renal aspergillosis in a patient with acquired immunodeficiency syndrome. Urol Sci 2020;31:238-40
| Introduction|| |
Aspergillosis is a term used to reference a heterogeneous group of fungal infections. Aspergillusfumigatus cause the majority of cases of invasive aspergillosis. A.fumigatus is an airborne saprophytic fungus which is widespread in nature. It is the third leading cause of invasive mycosis in the world, with a global incidence of 300,000 cases per year, led by only Candida and Pneumocystis.
The most common presentation of A.fumigatus is chronic pulmonary aspergillosis, which affects patients not necessarily immunocompromised but patients with a previous pulmonary pathology such as tuberculosis, chronic obstructive pulmonary disease, and sarcoidosis. An aspergilloma or fungus ball is one of the manifestations of pulmonary aspergillosis. Invasive aspergillosis has been identified previously in immunocompromised patients.
In rare occasions, this pathogen can disseminate to other organs, such as the brain and kidneys. The mechanism of entry to the kidney has not yet been established, but the leading theory is hematogenous dissemination from the pulmonary aspergilloma. A timely diagnosis, including the identification of the pathogen, and an adequate antifungal therapy are essential to the treatment of this disease.
The objective of this case report is to report a new case of renal aspergillosis and its treatment.
| Case Report|| |
The case is a 35-year-old male, with an HIV infection diagnosed a year priorly, in treatment with highly active antiretroviral therapy (HAART). For a week before admission, the patient presented with respiratory distress, generalized weakness, and hypoxia associated with fever that improved with antipyretics. The patient did not present with lumbar pain or urinary distress.
Eight months before admission, the patient was diagnosed with Kaposi's sarcoma, optic neuritis, and ventriculitis due to a cytomegalovirus infection. A month before admission, the patient had a CD4 count of 414 cells/mm3.
During the physical examination, slight rhonchus is present in the base of both hemithoraces. On the left parasternal line, there is a 4 cm × 5 cm, nonpainful, ulcerative-suppurative lesion, which was attributed to the renal abscess. During the genitourinary examination, Murphy's punch sign was negative on the right side and positive on the left side.
Relevant laboratory findings included the following: hemoglobin – 9.2 mg/dl, leukocytes – 22270/mm3 with 3% band neutrophils, platelets – 811,000/mm3, creatinine – 0.8 mg/dl, urea – 22 mg/dl, and fasting glucose test – 94 mg/dl.
The urine culture, fecal culture, wound drainage culture, 2 blood cultures, and Acid fast bacilli (AFB) in urine were all negative.
The abdominal computerized tomography (CT) found a hypodense, heterogeneous, and septated lesion with defined borders in the left kidney [Figure 1]. A CT-guided drainage of the abscess was not attempted. The compromised kidney was no longer functioning due to the infection.
|Figure 1: (a) Hypodense and septated lesion in the left kidney. (b) Hypodense lesion in the left kidney, showing a thinning parenchyma|
Click here to view
Surgeons then performed a left nephrectomy. The extraction of the affected organ showed a hydronephrotic kidney with abundant purulent secretion [Figure 2]. Pathology confirmed the conidia of the aspergilloma. After the surgical intervention, the patient had a favorable evolution and was discharged home to continue with HAART.
|Figure 2: (a) Hydronephrotic left kidney. (b) Hydronephrotic pouch that contains conidia from the aspergilloma|
Click here to view
| Discussion|| |
This case report presents a male patient with acquired immunodeficiency syndrome (AIDS) presenting with renal aspergillosis. Internationally, there have been very few reported cases of a renal aspergillosis. A patient reported by Metta et al. presented with fever, difficulty of breathing, and weight loss. In that case, as in this one, the patient had an AIDS diagnosis. In another patient, reported by Araos, the main symptom was lumbar pain, but, in contrast to the previous cases, that patient did not present with a fever. Smolovic et al. in Montenegro reported an asymptomatic patient. The patients reported by Araos and Smolovic both had previously undergone a liver transplant.
The development of aspergillosis depends on the number and virulence of the invasive organisms, as well as the immunologic state of the host. The urinary symptoms of renal aspergillosis tend to be non-specific. The laboratory results could show hematuria, pyuria, bacteriuria, and positive leukocyte esterase.
The low frequency of infections by Aspergillus in patients with HIV infection is probably related to the preserved function of the phagocytes until the advanced stages of AIDS, which is why the isolated renal aspergillosis is a rare complication of advanced AIDS.
The imaging complemented the diagnosis of the renal aspergilloma. In the ultrasonography, the renal abscess appears as a hypoechoic or anechoic lesion. The CT shows hypodense and well-defined lesions, like the ones the patient presented.
Guided fine-needle aspiration is the method of choice to diagnose renal aspergillosis. The diagnosis is then confirmed through histopathological evidence of the invasion of hyphae in the renal tissue or the presence of hyphae seen through direct microscopy. The auxiliary microbiologic methods are the quantification of the antigen galactomannan, polymerase chain reaction, and a culture which presents low sensibility.
For the treatment of this disease, the American Society of Infectious Diseases suggests that the obstruction of one or both ureters should be managed with decompression if possible, in addition to applying local amphotericin B deoxycholate because it allows high local concentrations. This method is not absorbed into the bloodstream and is not nephrotoxic. Therefore, it can be useful in aspergillosis of the renal pelvis but has no use in the treatment of parenchymal disease. The method of decompression and local instillation of amphotericin B deoxycholate, could only be successful if the abscesses would be small, but the treatment of bigger abscesses requires surgical intervention.
Microwave ablation has been used successfully as a complement to antimycotic therapy in one patient not considered to be a surgical candidate. The use of voriconazole, posaconazole, itraconazole, amphotericin B, and echinocandins shows low urinary concentration. Nephrectomies should be performed only as the last option, as was shown in this case.
In conclusion, the case presented is of renal aspergillosis in a patient with AIDS. The relevance of this case report is how infrequent it is to see renal aspergillosis. This case report contributes to the accumulating knowledge of symptoms and treatment of renal aspergillosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gregg KS, Kauffman CA. Invasive aspergillosis: Epidemiology, clinical aspects, and treatment. Semin Respir Crit Care Med 2015;36:662-72.
Quindos G. Epidemiology of invasive mycoses: A landscape in continuous change. Rev Iberoam Micol 2018;35:171-8.
Kosmidis C, Denning DW. The clinical spectrum of pulmonary aspergillosis. Thorax 2015;70:270-7.
Torales M, Martínez F, Bagattini J. Bilateral lung aspergilloma. Arch Med Int 2010;32:53-6.
Fortún J, Meije Y, Fresco G, Moreno S. Aspergillosis. Clinical forms and treatment. Enferm Infecc Microbiol Clin 2012;30:201-8.
Mehmood T, Chua MJ, Khasawneh FA. A 52-year-old HIV-positive man with abdominal pain. Can J Infect Dis Med Microbiol 2015;26:97-9.
Bulakçı M, Kartal MG, Çelenk E, Tunçer S, Kılıçaslan I. Multimodality Imaging Findings of a Renal Aspergilloma. Balkan Med J 2016;33:701-5.
Sugui JA, Kwon-Chung KJ, Juvvadi PR, Latgé JP, Steinbach WJ. Aspergillusfumigatus
and related species. Cold Spring Harb Perspect Med 2014;5:a019786.
Metta H, Corti M, Redini L, Bruggesser F, Arechavala A, Negroni R, et al
. Renal abscess due to Aspergillusfumigatus
as the only sign of disseminated aspergillosis in a patient with AIDS. Rev Iberoam Micol 2010;27:136-9.
Araos-Baeriswyl E, Moll-Manzur C. Renal aspergillosis after liver transplant: Report of an unusual case. Gastroenterol Hepatol 2018;41:30-2,
Smolovic B, Vukcevic B, Muhovic D, Ratkovic M. Renal aspergillosis in a liver transplant patient: A case report and review of literature. World J Clin Cases 2018;6:1155-9.
Das S, More AR, Iyadurai R. Bilateral renal aspergilosis in an immunocompetent host. Family Med Prim Care 2017;6:873-5.
Garcia-Vidal C, Alastruey-Izquierdo A, Aguilar-Guisado M, Carratalà J, Castro C, Fernández-Ruiz M, et al
. Executive summary of clinical practice guideline for the management of invasive diseases caused by Aspergillus
: 2018 Update by the GEMICOMED-SEIMC/REIPI. Enferm Infecc Microbiol Clin 2019;37:535-41.
Patterson T, Thompson G, Denning D, Hadley S, Herbrecht R, Kontoyiannis D, et al
. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis 2016;63:e1-60.
Waller S, Raglow Z, Lemons S, Johnson P, Eid A, Schmitt T, et al
. Microwave ablation of a large renal aspergilloma. Transpl Infect Dis 2014;16:496-500.
Kauffman CA. Diagnosis and management of fungal urinary tract infection. Infect Dis Clin North Am 2014;28:61-74.
[Figure 1], [Figure 2]