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LETTER
Year : 2008  |  Volume : 54  |  Issue : 1  |  Page : 62-63

Aortic thrombus during invasive aspergillosis in a kidney transplant recipient


1 Department of Nephrology and Internal Medicine and Laboratory of Kidney Pathology 02, Charles Nicolle Hospital, Tunis, Tunisia
2 Department of Pneumology, Charles Nicolle Hospital, Tunis, Tunisia

Correspondence Address:
E Abderrahim
Department of Nephrology and Internal Medicine and Laboratory of Kidney Pathology 02, Charles Nicolle Hospital, Tunis
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.39205

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How to cite this article:
Abderrahim E, Ben AT, Aouina H, Ben MH, Kheder A. Aortic thrombus during invasive aspergillosis in a kidney transplant recipient. J Postgrad Med 2008;54:62-3

How to cite this URL:
Abderrahim E, Ben AT, Aouina H, Ben MH, Kheder A. Aortic thrombus during invasive aspergillosis in a kidney transplant recipient. J Postgrad Med [serial online] 2008 [cited 2019 Nov 21];54:62-3. Available from: http://www.jpgmonline.com/text.asp?2008/54/1/62/39205


Sir,

Involvement of the large vessels has been rarely described during invasive aspergillosis (IA), especially after solid organ transplantation. [1],[2],[3] It affects poorly the prognosis of this fungal infection and was often reported as a postmortem finding. [4],[5]

We report the case of a massive floating aortic thrombus diagnosed simultaneously with a pulmonary IA in a 54-year-old kidney transplant recipient. Kidney transplantation was performed in June 2003 with an uneventful early course. Maintenance immunosuppressive therapy consisted of prednisone, mycophenolate mofetil (MMF) and cyclosporine A (CsA). The occurrence of many complications, including extensive skin herpetic infection, cytomegalovirus (CMV) disease and post-transplantation diabetes mellitus (PTDM), resulted in prolonged hospital stay. In September 2003, two weeks after successful treatment of acute graft-rejection, the patient developed fever with a dull chest pain. Arterial gasometry revealed a moderate hypoxemia and hypocapnia. Chest X-ray showed pneumonic infiltration with right para-cardiac cavitations; angio-CT scan confirmed the pulmonary nodules [Figure - 1] and showed a massive floating thrombus of the ascending aorta [Figure - 2]. The diagnosis of IA was made in view of the isolation of Aspergillus fumigatus on the culture of the fluid of bronchoalveolar lavage. Electrocardiography, transoesophageal echocardiography and serum tests ruled out other predisposing factors for thrombosis, mainly endocarditis. Therapeutic regimen, associating reduction of the doses of MMF and CsA with initiation of Voriconazole, resulted in prolonged apyrexia with regression of the pulmonary radiological abnormalities. The substantial reduction in the size and mobility of the aortic thrombus, documented after the initiation of antifungal therapy, is an indirect argument in favor of the causative role of aspergillosis in the thrombotic process. However, this etiology is difficult to establish without microbiological or pathologic studies of the thrombotic material. Indeed, surgical removal of this thrombus was considered highly risky and our patient, who died suddenly five months later, did not have necropsy verification.

The mechanism of arterial obstruction during IA remains hypothetical. It was suggested that aggregation of the fungus cells in the intima stimulates endothelial cells to become prothrombotic by expressing thromboplastin that activates Factor II and initiates the extrinsic coagulation cascade. [6]

The vasculotropic character of aspergillus explains the disseminated forms of IA as was observed in our patient who developed adrenal insufficiency and multiple small areas of cerebral and splenic infarcts. All these disorders improved after initiation of antifungal therapy.

In our experience, this is the first case of IA among 330 renal transplantations performed since 1986. Of note, the diagnosis of IA was made during the same period of works of building renovation around our transplant unit. In addition, our patient had many of the reported predisposing factors to this fungal infection including prolonged hospitalization, PTDM, CMV infection and acute graft-rejection. [2]

This case is of clinical interest because of the unusual occurrence of aortic thrombus in a kidney transplant recipient with IA. Voriconazole was effective on fungal infection without substantial interference on graft function or CsA blood levels. Sudden fatal issue could be related to rupture or complete occlusion of the aorta. As a result, surgical removal of infective thrombi should be considered even in cases where the antimicrobial therapy seems to be effective.


 :: Acknowledgment Top


We thank Ms. N. Hajji for the manuscript preparation.

 
 :: References Top

1.Latge JP. Aspergillus fumigatus and aspergillosis. Clin Microbiol Rev 1999;12:310-50.  Back to cited text no. 1    
2.Paterson DL, Singh N. Invasive Aspergillosis in transplant recipients. Medicine 1999;78:123-38.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Ergin F, Arslan H, Azap A, Demirhan B, Karakayali H, Haberal M. Invasive Aspergillosis in solid-organ transplantation: Report of eight cases and review of litterature. Transplant Int 2003;16:280-6.  Back to cited text no. 3    
4.Vaideeswar P, Deshpande JR. Non-atherosclerotic aorto-arterial thrombosis: A study of 30 cases at autopsy. J Postgrad Med 2001;47:8-14.  Back to cited text no. 4    
5.Shintaku M, Sangawa A, Yonezawa A, Nasu K. Aortic lesions in aspergillosis: Histopatological study of two autopsy cases. Virchows Arch 2001;439:640-4.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Lopes Bezerra LM, Filler SG. Interactions of Aspergillus fumigatus with endothelial cells: Internalization, injury and stimulation of tissue factor activity. Blood 2004;103:2143-9.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]


    Figures

  [Figure - 1], [Figure - 2]

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2004 - Journal of Postgraduate Medicine
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