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Kidney Week

Abstract: PO2480

Lend Me Your Ear: An Unusual Presentation of a Transplant Complication

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • McAdams, Meredith, University of Texas Southwestern Medical School, Dallas, Texas, United States
  • Yagnik, Kruti, University of Texas Southwestern Medical School, Dallas, Texas, United States
  • Levea, Swee-Ling, University of Texas Southwestern Medical School, Dallas, Texas, United States
  • Tessier, Jeffrey, University of Texas Southwestern Medical School, Dallas, Texas, United States
  • Arasaratnam, Reuben Jonathan, University of Texas Southwestern Medical School, Dallas, Texas, United States
Introduction

Infections are a major complication in solid organ transplant (SOT) patients due to need for life-long immunosuppression. Incidence of fungal infections following solid organ transplant ranges from 5-20%. Cryptococcosis is an invasive fungal infection that can cause several types of infections including meningitis, pulmonary, cutaneous, and disseminated disease.

Case Description

A 66 yo F with past medical history of ESRD s/p deceased donor kidney transplant 15 months ago, DM, HTN presented to renal transplant clinic with right ear pain for the past 4 weeks after being evaluated in the emergency room. Her exam was notable for painful ear and cheek lesions (Figures A and C). Fungal serologies were obtained and patient was sent to dermatology clinic for evaluation. Punch biopsies were taken from several lesions and cultures obtained. Serum cryptococcal antigen was positive with titer of 1:4096, fungal culture from lesion grew Cryptococcus neoformans. Skin biopsy showed cyryptococcus (Figure B). Patient was admitted to the hospital and further testing revealed positive CSF cryptococcal antigen, CT chest with nodular opacities, leading to a diagnosis of disseminated cryptococcus. She was treated with amphotericin B and flucytosine and eventually transitioned to oral fluconazole.

Discussion

Cryptococcal infection is the third most common invasive fungal infection in SOT patients and typically presents later in kidney transplant patients, 16-21 months, compared to other transplanted organs. Risk factors include type of immunosuppressive agent and comorbid conditions such as diabetes. The majority of transplant patients with cryptococcus present with CNS manifestations or disseminated disease, cutaneous involvement is less common. Our patient had risk factors including diabetes, older age, and use of induction immunosuppression. Initial presentation with skin lesions is atypical for cryptococcal infection. It is important to have a high suspicion for fungal infections in immunosuppressed patients even those with atypical presentations.