Aspergillosis

Pt B.D., a 52 year old male presents to the transplant clinic with a fever, cough, generalized weakness and, weight loss. The patient is admitted to the hospital under the diagnosis of fever with an unknown origin.

The relevant medical history of the patient consists of a small bowel transplant 4 months prior. Two months after the transplant the patient was treated for rejection. The rejection treatment consisted of bolus steroids. This treatment was unsuccessful and a second treatment regimen was initiated. Twelve doses of Thymoglobulin were given over twelve days followed by improvement in the grafted small bowel and a decrease in the level of organ rejection. That patient was sent home on additional immunosuppressant medications as follows, tacrolimus, prednisone and myfortic acid. Prophylaxis treatment against viral, fungal, and bacterial infections was continued throughout the rejection treatment. Prophylaxis treatment was also continued upon discharge and the patient was sent home on Valcyte, Nystatin, and Bactrim.

Possible causes of the patient’s symptoms could have been as follows, bacterial infection, viral infection, or fungal infection. A possible source of the infection could have been the patients PICC line which was removed upon patients admission to the hospital, abdominal drain or gastrointestinal tube. All of the patient’s invasive lines, blood, and sputum were cultured to find the source of infection.

The patient was prophylactically started on Zosyn, Diflucan, and ganciclovir. Fevers were relieved with Tylenol. A chest x-ray was obtained where multiple nodules were discovered. Infectious disease and pulmonologists were consulted. An additional chest CT was done to closer examine the nodules. Upon the results of the chest CT pulmonologists recommend biopsies of the nodules done. Both sputum culture and nodule biopsies confirmed the diagnosis of Aspergillosis a fungal invasive infection in both lungs.

Due to the patient’s medical history the patient was a prime candidate for a fungal infection of this nature. The patient was on long term immunosuppressants and steroids. He had also recently received high doses of immunosuppressants to fight the rejection of his transplanted organ. He also had a poor nutritional state that also inhibited his body’s defense system due to his transplant. As a result he was not able to fight off this fungal infection.

He was started on Voriconazole but his immunosuppressants were not changed due to the risk of rejection. He remained on Voriconazole or Vfend. The fevers subsided however the cough persisted. Periodic chest x-rays were performed and the nodules did not progress any further. Despite the poor prognosis of this disease he did respond positively to the Vfend treatment and the infection did not spread. The mortality of this disease is high however a balance may be found between treating this infection and preventing rejection with the use of immunosuppressants and steroids.

Unfortunately for this patient his concurrent patterns of acute rejection resulted in chronic rejection and loss of function of the transplanted graft. The patient was recently extransplanted. However, with the extransplantation and the stopping of immunosuppressant and steroids the Vfend may become more effective at fighting off the aspergillosis infection due to the increased body defenses and immune system.