Sir,
A 42-year-old man underwent a live-related renal transplant in India. Unfortunately, details of surgical prophylaxis and initial immunosurpressive therapy were unknown. Three weeks post-transplant, he returned to the UK and presented with pyrexia, generalized muscle weakness and pain in the lower back.
Examination, including digital rectal examination (DRE), was unremarkable. Investigations demonstrated a normal white cell count (WCC) and a slightly raised C-reactive protein (CRP) with a creatinine of 88 µmol/l and a prostate-specific antigen (PSA) of 1.8 ng/ml. Urine and blood cultures were negative. He was started on broad antibiotic cover of amoxycillin (500 mg i.v. tds) and ciprofloxacin (500 mg bd) with TB prophylaxis (isoniazid 300 mg od).
The patient's symptoms persisted. Cytomegalovirus (CMV) infection was isolated and treated with ganciclovir (5 mg/kg i.v. bd). A further DRE demonstrated a tender, soft prostate, which on transrectal ultrasound (TRUS) looked grossly hyperaemic. Penile discharge and prostatic biopsies grew Aspergillus flavus. Acute fungal prostatitis was diagnosed, and treatment with itraconazole (200 mg i.v. od) was initiated. Subsequently he developed a perinephric collection, which on drainage grew Escherichia coli and Aspergillus. The antimicrobial regime was changed to vancomycin (1 g i.v. bd) and imipenem (1 g i.v. qds). The itraconazole was empirically changed to voraconazole (400 mg i.v. od) and caspofungin (50 mg i.v. od). The patient's pyrexia and symptoms took a further 8 weeks to resolve. He received voraconazole for a total of 75 days (28 days i.v. and 47 days orally) and caspofungin for 23 days.
Six months following discharge, the patient presented again with similar symptoms, reduced urinary flow and raised inflammatory markers. A further TRUS of his prostate demonstrated a cystic area involving the left seminal vesicle. He restarted anti-aspergillus treatment of voraconazole and capsofungin. The patient's obstructive urinary symptoms worsened and he underwent transurethral de-roofing of a prostatic abscess. The patient continued to improve and was discharged 3 weeks after the transurethral resection. He continues on long-term voraconazole and is currently well with a creatinine of 138 µmol/l, at 24 months post-renal transplant.
Discussion
Prostatitis is a rare presentation of invasive aspergillosis in the transplant setting, although previous cases of aspergillus prostatitis in immunocompromised patients have been reported [14]. This patient's only predisposing factor was the post-transplantation immunocompromising therapy, and no steroid boluses for rejection were required as the graft function remained stable throughout, at a creatinine of 150 µmol/l. The infection disseminated to the transplanted kidney in spite of supposedly effective treatment using older antifungal agents. Voriconazole and caspofungin were effective treatment agents, and this is the first report of caspofungin being used for the treatment of fungal prostatitis. This report highlights the requirement for an aggressive, prolonged multi-agent approach to the treatment of fungal prostatitis in immunocompromised patients.
Conflict of interest statement. None declared.
1 Department of Urology and Transplantation2 Department of Radiology Hammersmith Hospital London UK
References