The Double-Edged Sword of Immunosuppressive Therapy in Kidney Transplantation: A Rare Case Report of Pulmonary Mucormycosis Post-Transplant and Literature Review

Abstract

Immunosuppressive therapy is improving the graft survival of kidney transplant recipients and increasing the potential risk of infection. Pulmonary mucormycosis is a rare post-operative infection complication characterized with rapid deterioration and high mortality. In this case, a 33-year-old patient underwent a kidney transplantation with regular immunosuppressive therapy. Soon, 38 days post-transplant, pulmonary patchy shadows can be seen in the radiological examination and rounded into a large cavity formation with splenic rupture 25 days later. The diagnosis of mucormycosis was confirmed by lung biopsy and spleen histopathology. This case is a reminder that early diagnosis is imperative, meanwhile, rational antifungal therapy, timely elimination of immunosuppressants, and alternatively, abandoning the graft should be prudently assessed in the treatment of mucormycosis.

Keywords: case report; immunosuppressant; infection; kidney transplantation; mucor; mucormycosis; pulmonary.

Figure 1

The clinical course of the patient. The pivotal clinical events after surgery of this kidney transplant recipient are showed in this figure.

Figure 2

Abdominal and chest computed tomography (CT) scans before and after mucor infection. (A) The pre-transplant chest CT is presented without obvious abnormality. (B) On 18 days post-transplant, abdominal CT examination revealed a mixed density mass shadow in the medial inferior right side of kidney graft, hematoma considered. (C) The chest CT revealed patchy shadows in the left lung on 38 days after transplantation. (D) After 7 days of initial treatment, the cavity formed in the left lung can be seen in radiological examination. (E) A chest CT showed consolidation of the left upper lobe with a ground-glass density shadow, multiple nodules in both lungs on 52 days. (F) A chest CT showed the cavity in the upper left lung had become larger than that in the previous examination 2 weeks earlier.

Figure 3

Pathological presentation of pulmonary and splenic mucormycosis. (A) Percutaneous lung biopsy showed alveolar epithelial hyperplasia, interstitial hyperemia, inflammatory cell infiltration, and fungal hyphae and spores can be seen in necrotic tissues. (B) Pathological results of spleen tissue showed multifocal necrosis was formed under the spleen capsule with mycelia and spores (Arrow: mycelia).