A case of invasive pulmonary aspergillosis in renal failure

Sir,

A 55-year-old ex-community care assistant was admitted with a 2 day history of increasing shortness of breath and productive cough. She suffered with chronic kidney impairment secondary to reflux nephropathy, and had undergone a nephrectomy 1 year previously. After gradually worsening uraemic symptoms, a peritoneal dialysis catheter had been inserted uneventfully 1 month prior to her admission. She was due to start training for peritoneal dialysis within the next few days (GFR 7 ml/min, serum urea 32 mmol/l, creatinine 536 µmol/l). An ultrasonogram had showed the remaining kidney to be of normal size, and serum immunoglobulin levels were normal. She was a smoker of 20 cigarettes per day, but there were no medical antecedents of note. Her medications reflected uraemia, and the biochemistry otherwise had been unremarkable.

On admission, she was tachypnoeic (30 respirations per minute) and hypotensive at 108/60 mmHg. The right lung was clear on auscultation, but there was wheeze at the left base. Oxygen saturation on air was 86%, and an arterial blood gas analysis showed profound metabolic acidosis. The chest X-ray was normal, but there was a slight leukocytosis (12.7 x 109/l), and the biochemistry showed end-stage renal failure (urea 49 mmol/l, creatinine 1319 µmol/l). She was managed with broad-spectrum antibiotics (intravenous ceftazidime 1 g OD) and haemodialysis via a femoral central catheter. Repeated arterial blood gases showed a normalized pH and base excess, but the hypoxia and clinical air hunger persisted. She was transferred to the High-Dependency Unit for non-invasive ventilatory support and was given inotropic drugs and amiodarone for increasing cardiovascular instability. Respiratory failure led to intubation and transfer to the Intensive Therapy Unit, but severe bronchospasm rendered ventilation very difficult. Serial chest X-rays showed rapid development of dense perihilar infiltrates, and sputum cultures from admission grew Aspergillus fumigatus. Despite treatment with liposomal amphotericin B from admission day 3, death ensued within hours. The autopsy confirmed extensive Aspergillus infection, coating the tracheo-bronchial tree and invading bronchial walls and vasculature (Figure 1).



View larger version (143K):
[in this window]
[in a new window]
 
Fig. 1. Histology view of bronchial tree. H/E section view (a) shows carpet of fungal organisms coating luminal surface. Silver stains (b) highlight fungal hyphae of Aspergillus. Scales: larger, 0.4 mm for (a); smaller, 0.1 mm for (b).

 
Infections cause considerable morbidity and mortality in chronic kidney failure [1], and mycoses are seen in dialysis-dependency [2], as well as in non-dialysing uraemia [3,4]. Invasive pulmonary aspergillosis is probably the most aggressive fungal infection known to man. It occurs mainly in severely immunocompromised patients, and has not previously been reported in a non-dialysing uraemic patient. Cigarette smoking has been associated with airway colonization by Aspergillus [5], but it unclear whether this predisposes to invasive disease.

The increasing seniority of our uraemic population, as well as their frequently diabetic background [6,7], contribute to further immune dysfunction. This report emphasizes the message that renal physicians should keep a low threshold for diagnosing opportunistic infection in their patients.

Conflict of interest statement. There are no conflicts of interest associated with the publication of this case report.

Anders O. Sahlén1, S. Kim Suvarna2 and Martin E. Wilkie1

1 Sheffield Kidney Institute2 Department of Histopathology The Northern General Hospital Herries Road Sheffield S5 7AU UK

References

  1. USRDS. United States Renal Data System: The 2003 Annual Data Report. Available at www.usrds.org
  2. Abbott KC, Hypolite I, Tveit DJ, Hshieh P, Cruess D, Agodoa LY. Hospitalizations for fungal infections after initiation of chronic dialysis in the United States. Nephron 2001; 89: 426–432[CrossRef][ISI][Medline]
  3. Lim SK, Verly GP, Jacob DF. Fatal cryptococcosis in a patient with chronic renal failure: a case report. J Natl Med Assoc 1980; 72: 374–376[Medline]
  4. Gupta KL, Radotra BD, Sakhuja V, Banerjee AK, Chugh KS. Mucormycosis in patients with renal failure. Ren Fail 1989–1990; 11: 195–199[ISI][Medline]
  5. Verweij PE, Meis JFGM, Van den Hurk P, De Pauw BE, Hoogkamp-Korstanje JAA, Melchers WJG. Polymerase chain reaction as a diagnostic tool for invasive aspergillosis: evaluation in bronchoalveolar lavage fluid from low risk patients. Serodiagn Immunother Infect Dis 1994; 6: 203–208[CrossRef]
  6. Sims RJA, Cassidy MJD, Masud T. The increasing number of older patients with renal disease: trainees should enhance their skills in geriatrics. Br Med J 2003; 327: 463–464[Free Full Text]
  7. Ritz E, Miltenberger-Miltenyi G, Rychlik I, Fliser D. Endstage renal failure in diabetes type II—a silent epidemic. Nephrology 1998; 4: 299–300[ISI]




This Article
Extract
FREE Full Text (PDF)
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Disclaimer
Request Permissions
Google Scholar
Articles by Sahlén, A. O.
Articles by Wilkie, M. E.
PubMed
PubMed Citation
Articles by Sahlén, A. O.
Articles by Wilkie, M. E.