13th Luso-Brazilian Transplantation Congress, 12th Portuguese Transplantation Congress and 1st Iberian Meeting of Transplantation
Case report
A Rare Paracoccidioidomycosis Diagnosis in a Kidney Transplant Receptor: Case Report

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Abstract

Introduction

Paracoccidioidomycosis (PCM) is a systemic mycosis of chronic presentation more frequent in adults, which may lead to disseminated severe and lethal forms involving the lungs, skin, lymph nodes, spleen, liver, and lymphoid organs of the digestive tract. Common in Latin America, it is rare in transplanted patients, with few cases described in the literature.

Purpose

To report a case of a patient who underwent kidney transplant 3 years ago with a pseudotumoral cervical PCM diagnosis.

Methods

A male patient, 45 years old, who underwent kidney transplantation 3 years ago presenting with diarrhea, severe weight loss, and anemia; no breathing complaints. Parasitological stool tests, fecal culture, urine culture, and abdomen USG were performed in order to assess the diarrhea, and were inconclusive. He was treated with antibiotics and antiparasitic drugs with no improvement and continued with weight loss of 15 kg within 3 months. Immunosuppression was changed, with the mycophenolic acid reduced until it was replaced by everolimus. The diarrhea returned to intensify, and there was an increase in the creatinine (from 1.5 to 3.4). He was empirically treated with sulfamethoxazole/trimethoprim, with total remission of the diarrhea. The patient underwent a kidney biopsy, anti-HIV examinations, PCR BK virus, and PCR for Mycobacterium tuberculosis—with no diagnostic conclusion. During his fifth hospitalization (6 months after the beginning of the diagnostic research), presenting a quite compromised general state, loss of 20 kg, anemia, kidney failure, and fever, he developed skin lesions on the legs and a voluminous and hard tumor in the right cervical region. Chest computed tomography was performed, and the tumoral lesions were removed from those regions. He was started on tuberculostatics and underwent a biopsy of the cervical tumoral lesion.

Result

Biopsy of the cervical tumor showed a fungal infection by paracoccidioidomycosis. The BAAR test of the biopsy was negative. The patient died a few weeks after the diagnosis.

Conclusion

The association between the organ transplant and PCM is rare and, in unusual clinical presentations, the diagnosis difficulty may compromise a successful treatment.

Section snippets

Purpose

The purpose of this description is to report a rare case of a patient with a diagnosis of cervical pseudotumoral PCM who underwent a kidney transplantation 3 years ago.

Case Report

The patient (45-year-old man) received a transplanted kidney 3 years ago from a living related donor (sister), haplo-identical HLA, with no diagnosis for the cause of the end-stage renal failure, using as an immunosuppressant tacrolimus, mycophenolic acid, and corticosteroid. He was from Paraiba (the northeast region of Brazil), where he spent all of his childhood and the major part of his adult life, while living some years in Rio de Janeiro (southeast region of Brazil). Before renal failure,

Results

The patient had received sulfamethoxazole/trimethoprim for 39 days with no clinical improvement, and his compromised clinical state progressed with anemia and renal failure (creatinine 3.5). He was hospitalized in the intensive care unit after presenting with septic shock, severe pancytopenia, and hyponatremia. He died a few days later.

Conclusion

After analyzing cases of deep mycosis and kidney transplantation at the Ribeirão Preto Medical School/São Paulo, the authors found 24.3% included pulmonary involvement. In these cases, PCM was responsible for 3.6% of the total, and of the 3 PCM cases described, 1 had involvement of the digestive tract, with the diagnosis performed only on autopsy [7]. Infection in kidney-transplanted patients by Paracoccidioides brasiliensis is unusual, and in the few cases described in the literature, clinical

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