Pulmonary histoplasmosis in a renal allograft recipient
A 55-year-old lady, on dialysis since February 2011, underwent a renal transplantation on 23rd February 2012 with an allograft kidney from her daughter. She had been diagnosed with tuberculous lymphadenopathy in September 2011 and received isoniazid, rifampicin, pyrazinamide and ethambutol from September to December 2011. Pyrazinamide was stopped in December 2011 and rifampicin replaced with ciprofloxacin in February 2012. There was 1 B and 1 DR mismatch and the lymphocyte cross match by complement dependent cytotoxicity was negative at 4%.\nImmunosuppression consisted of intraoperative methylprednisolone, followed by tapering doses of oral prednisolone until 10 mg daily, tacrolimus 0.15 mg/kg/day adjusted according to trough levels and azathioprine 2 mg/kg/day.\nShe was admitted on 18th July 2012 with daily evening fever up to 100°F for 10 days, dry cough for 7 days and left sided pleuritic chest pain for 5 days. She had received oral amoxicillin clavulunate and paracetamol with temporary relief, but symptoms had worsened on the day of admission. Examination revealed a temperature of 100.4°F, pulse of 96/min and respiratory rate of 20/min. Blood pressure was 130/85 mm of Hg. Auscultation of the chest revealed decreased breath sounds at the left infraaxillary and infrascapular regions, without any bronchial breathing, rub or rales. A chest roentgenogram showed a homogeneous opacity without an air bronchogram in the left lower zone with obscured left costophrenic angle [].\nOther investigations are shown in .\nShe received empirical cefotaxime 2 g q 12 h, azithromycin 0.5 g daily and nebulization to induce sputum production. She continued to have chest pain and fever despite negative blood cultures and a complete absence of sputum. A left lateral roentgenogram confirmed the opacity and showed no evidence of pleural fluid. A high resolution computed tomography scan of the thorax on the 25th of July 2012, revealed a heterogeneously enhancing necrotic mass lesion in the left lower lateral basal segment reaching up to the pleural surface, multiple discrete lower lobe nodules bilaterally, a discrete 1 cm nodular density in the inferior and paracardiac region of the right upper lobe and enlarged pre-tracheal, paratracheal, precarinal and subcarinal lymph nodes [].\nA fine-needle aspiration and biopsy of the lesion was performed on 26th July 2012, under computed tomographic guidance. The aspirate showed a necrotic background with few polymorphs, lymphocytes, eosinophils and budding yeast like fungal elements and was negative for acid fast bacilli, nocardia and Pneumocystis jiroveci. The biopsy showed widespread areas of necrosis, infiltration with polymorhonuclear leukocytes and lymphocytes and histiocytic proliferation and fibrosis. The histiocytes contained multiple tiny, budding yeast like structures, which on Periodic acid Schiff (PAS), showed a distinct positively stained capsule []. The lesion was suggestive of histoplasmosis, which was confirmed on culture after 23 days of incubation. Patient was treated with liposomal amphotericin B 200 mg daily, (4 mg/kg/day) and discontinuation of azathioprine. After 20 days, her chest roentgenogram showed significant improvement and she was discharged on oral itraconazole 200 mg bid and her chest roentgenogram after 5 months of treatment [], showed complete resolution of the lesion. In October 2012, she was found to have developed new onset diabetes after transplantation, which was controlled with oral hypoglycemic agents.