A Case Series of Ruptured Fungal Mycotic Pseudoaneurysms in Renal Transplant Patients

Abstract

Mycotic pseudoaneurysms (MPs) occur in <1% of renal transplant patients, with rupture being even rarer. We present clinical symptoms, surgical techniques, and postoperative courses of four transplant patients with MPs who presented with acute bleeding. All patients presented within 3 weeks of transplant. All patients underwent immunosuppression induction with rabbit anti-thymocyte globulin and high-dose steroids, and following transplant, were managed with a triple therapy immunosuppression regimen of mycophenolate sodium, a prednisone taper, and tacrolimus, as well as an infection prophylaxis regimen of valganciclovir, clotrimazole, and sulfamethoxazole-trimethoprim. All patients presented with bleeding originating from the iliac or transplant renal artery. Despite the antifungal prophylaxis, all four patients were found to have candida infections at the transplant site. Hemorrhage control was obtained using different techniques in each case, including open and endovascular techniques. Endovascular balloon occlusion was used for immediate stabilization, followed by open arterial resection, extra-anatomic bypass, or patch repair. One allograft was salvaged while three required nephrectomy. MPs in immunocompromised transplant patients may not present with infectious symptoms before rupture, but infection should be considered in acutely bleeding transplant patients. Open and endovascular approaches can be employed to control hemorrhage; however, infection risk must be considered with prosthetics.