Abstract: SA-PO1158
Polymicrobial Fungal Allograft Infection with Disseminated HSV-1 and Incidental Tubulocystic Carcinoma Leading to Transplant Nephrectomy
Session Information
- Transplantation: Clinical - Infectious Diseases
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Soliman, Abdelsalam Karim, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Randhawa, Parmjeet S., University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Hih, Nouraldin, Mansoura University Faculty of Medicine, Mansoura, Dakahlia Governorate, Egypt
- Puttarajappa, Chethan M., UPMC, Pittsburgh, Pennsylvania, United States
- Cruz Peralta, Massiel Penelope, UPMC, Pittsburgh, Pennsylvania, United States
- Wright, Susan Guthrie, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Tevar, Amit D., University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Shah, Nirav A., University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Soliman, Karim, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
Introduction
Invasive fungal infections of the renal allograft are rare and carry high morbidity. Simultaneous detection of multiple fungal species with concurrent viral dissemination and incidental allograft malignancy has not been previously described.
Case Description
Case Presentation: A 39-year-old male with ESKD secondary to posterior urethral valves underwent a second living donor kidney transplantation in July 2024 (paternal donor),following failure of his first allograft received in 2002 and lost in 2024. Post-transplant course was complicated by TCMR, AMR, Ureaplasma parvum UTI, recurrent bacterial UTIs, invasive Lichtheimia corymbifera allograft infection, and disseminated HSV-1 (oral ulcers, peri-incisional vesicles, positive plasma PCR) treated with IV acyclovir then valacyclovir.Progressive allograft deterioration necessitated transplant nephrectomy on 8/21/2025.Pathological Findings: Explant pathology (Fig.1) demonstrated fungal pyelonephritis with hydropelvis; Next-generation sequencing (NGS) identified five organisms: Lichtheimia corymbifera, Alternaria species, Cyberlindnera jadinii, Wickerhamiella versatilis, and a Tremellomycetes basidiomycete. HSV immunohistochemistry was positive, concordant with the clinical presentation. Gram-positive cocci in clusters reflected recurrent bacterial superinfection. Banff scoring showed significant active and chronic injury (i:2, ti:2, t:3, ptc:3; ci:1, ct:2, cv:2, ah:2) with negative C4d despite prior AMR history. Incidentally, a 1.2 cm medullary multicystic lesion within the fungal abscess bed was diagnosed as low-grade tubulocystic carcinoma (T1a, NX, MX) with no invasive features. Management: Post-nephrectomy liposomal amphotericin B (7.5 mg/kg) was administered for four months, discontinued after negative PET-CT, MRI, and CT abdomen/pelvis. The patient is maintained on posaconazole and valacyclovir prophylaxis and is currently being evaluated for re-listing.
Discussion
This case demonstrates the catastrophic convergence of five-species polymicrobial fungal pyelonephritis, disseminated HSV-1 with allograft histologic involvement, concurrent rejection, and incidentally discovered tubulocystic carcinoma in a failed allograft. It illustrates the diagnostic value of NGS in complex transplant infections and the importance of systematic explant pathology, including for occult malignancy.
Acknowledgment
The authors would like to thank the transplant pathology and transplant infectious diseases teams for their contributions to the diagnostic evaluation and multidisciplinary care of this patient.