POS-093 ODYNOPHAGIA AND SEVERE WEIGHT LOSS IN A CHILD TEN YEARS POST KIDNEY TRANSPLANT

Abstract

Kidney transplantation is an immunosuppressive state with high risk of opprtunistic infections. Case report A 15 year old girl with history of live related kidney transplant at the age of 5 yrs due to end stage renal disease secondary to congenital bilateral dysplastic kidney, presented with low grade fever, odynophagia and significant weight loss of 11 kg over last 3 months (47kg dropped to 36Kg). She was on maintenance tacrolimus, mycopheolate mofetil (MMF) and prednisolone with stable creatinine at 0.7 mg/dl. She had past history of pulmonary aspergillosis 3 years ago for which she was treated with voriconazole for one and half years and recent chest CT was normal. On examination; apart from pallor, there were no other significant findings. Her haemoglobin was 8.8 gm/dl and C - reactive protein was elevated at 1.83 mg/dl (normal <0.6mg/dl). Despite normal looking oropharynx, upper gastrointestinal endoscopy was undertaken. This revealed 2 deep ulcers with raised margin and surrounding erythema in distal esophagus (Fig 1). Histopathology showed dense infiltrate with histiocytes, lymphocytes, polymorphs and fine dot like structures which were confirmed to be PAS positive fungal element (Fig 2a and 2b). Final diagnosis was established as fungal esophagitis due to histoplasmosis. Subsequently urine antigen for histoplasmosis also came as positive. She was treated for disseminated histoplasmosis with amphotericin for 14 days which was thereafter switched to long term itraconazole. Simultaneously her MMF was stopped and she was maintained on Tacrolimus (Target 12 hour’s trough 5ng/ml) and 5 mg of daily steroid. At 6 month follow up her creatininie has remained stable (0.7 mg/dl). She is afebrile and her appetite has normalized and weight is back to pre symptomatic level.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Histoplasmosis is a common cause of odynophagia especially in immunocompromised patients but esophageal involvement is uncommon. Only less than 1% patients with disseminated histoplasmosis have esophageal involvement. A high index of suspicion and low threshold for undertaking upper gastrointestinal endoscopy helped us in establishing the diagnosis and instituting specific treatment.