A kidney transplant patient with fevers 5 months post-transplant underwent a lung CT scan. What is the diagnosis?

Quiz: 5 Months Post Kidney Transplant With Fever And This Lung CT Scan

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56-year-old woman is 5 months post kidney transplant. She has had a fever and cough for 4 days and has received antibiotics. 

The cause of the recipient’s end-stage kidney disease is diabetic nephropathy. The patient had delayed graft function. Both the kidney donor and the recipient were cytomegalovirus seropositive. Blood studies are ordered. The CT scan of the chest is offered above to help provide the diagnosis. Pulmonary nodules with surrounding low attenuation are noted.

Please answer the following questions:

What is the most probable infectious agent responsible for this patient’s fever?
* Aspergillus
* Pneumocystis jirovecii
* Cytomegalovirus
* Rhizopus arrhizus

What is one of the major risk factors for invasive aspergillosis in renal transplant recipients?
A
Older age
B
Regular exercise
C
High blood pressure
D
Low levels

Which type of infection is the most common in invasive aspergillosis cases?
A
Urinary tract infection
B
Skin infection
C
Parenchymal pulmonary infection
D
Ear infection

When do about 50% of invasive aspergillosis cases occur after renal transplantation?
A
1 year
B
2 years
C
First 6 months
D
5 years

What is one of the fastest means of establishing the diagnosis of invasive aspergillosis?
A
Urinalysis
B
Blood culture
C
Serum Aspergillus antigen test
D
X-ray imaging

Which medication is NOT recommended as standard therapy for invasive aspergillosis?
A
Isavuconazole
B
Liposomal amphotericin B
C
Voriconazole
D
Posaconazole

Discussion:

Invasive Aspergillosis in Kidney Transplant Recipients

Invasive aspergillosis can affect kidney transplant recipients, with approximately 50% of cases occurring within the first 6 months post-transplantation. The median time of onset is 3 years.

Risk Factors

  • Major risk factors for invasive aspergillosis include older age, diabetes mellitus (especially with prior diabetic nephropathy), delayed graft function, acute graft rejection, chronic obstructive pulmonary disease, cytomegalovirus disease, and neutropenia.
  • Hospital construction, demolition activities, and residential restorations can increase the risk of infections.

Clinical Presentation and Radiological Features

Parenchymal pulmonary infection is the most common presentation (up to 75%). Typical lung features include fever, dyspnea, cough, and hemoptysis, while 20% of patients may present with non-specific general symptoms. Non-specific infiltrates and pulmonary nodules are common radiological findings, with bilateral disease suggesting a worse prognosis.

Diagnosis and Prognosis

  • Bronchoscopy for direct microscopy, fungal culture, and Aspergillus antigen testing are the fastest ways to establish a diagnosis.
  • A positive serum Aspergillus antigen indicates a worse outcome.
  • The CT scan shows pulmonary nodules with a “halo sign,” revealing aspergillosis infection.

Treatment

  • Standard therapy includes voriconazole (preferred), isavuconazole, or posaconazole, watching for potential drug interactions with immunosuppression.
  • Liposomal amphotericin B and echinocandins (such as anidulafungin, caspofungin, or micafungin) are less effective treatment options.
  • Reducing or stopping immunosuppression should be considered, as continuing corticosteroids post-diagnosis increases mortality by up to 2.5 times.
  • Surgical resection or the addition of gamma interferon may also be considered in treatment plans.

Inspiration: Invasive Aspergillosis after Renal Transplantation, National Library of Medicine

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