S2505 Aspergillus Fumigatus Vertebral Osteomyelitis With Intracardiac and Renal Aspergillomas in a Liver Transplant Recipient: A Clinical Vignette

Abstract

INTRODUCTION: Immunosuppressed patients are at risk of fungal infections associated with high morbidity and mortality. Invasive aspergillosis (IA) leading to vertebral osteomyelitis, intracardiac and renal aspergillomas in the post-transplant setting is a rare infectious complication. CASE DESCRIPTION/METHODS: A 64-year-old former prison nurse, with a history of alcohol dependence and COPD, presented to our university medical center with fulminant hepatitis A requiring urgent orthotopic liver transplantation (OLT). Intra-operatively, she was noted to have focal ischemic colitis of the cecum and proximal ascending colon with mucosal necrosis, necessitating a right hemicolectomy and primary ileocolostomy. She received induction immunosuppression with basiliximab, followed by maintenance tacrolimus and mycophenolate mofetil. Post-operatively, she received antimicrobial and antifungal prophylaxis and was discharged to a rehab unit on post-op day 11. Her post-OLT course was further complicated by failure to thrive and de novo cytomegalovirus (CMV) viremia at 2 months (CMV D+/R−). > 90 days post OLT she developed fevers and lower back pain. MRI of the spine demonstrated lumbar discitis/osteomyelitis and abdominal CT scan showed a right renal nodule. Biopsies of the L-spine and right kidney revealed septated fungi and tissue cultures were positive for Aspergillus fumigatus. Immunosuppression was stopped and she was treated with amphotericin B, but later switched to isavuconazole and anidulafungin. Despite aggressive medical therapy, she continued to deteriorate clinically, and a TEE and CT chest revealed multi-chamber intracardiac and left ventricular free wall involvement by IA that had progressed. The prognosis was felt to be extremely poor, and she later died in hospice, 5 months post-OLT. DISCUSSION: IA has been recognized as one of the most highly lethal opportunistic fungal infections in organ transplant recipients. In this unique case, late-onset IA (>90 days post-OLT) manifested with vertebral, intracardiac, and renal involvement. Her risk factors included immunosuppression, hemodialysis, and CMV infection. Early initial treatment of IA involves immunosuppression minimization and systemic antifungal therapy using a combination of an azole with or without echinocandin. Surgical resection of an aspergilloma may be indicated prior to starting medical therapy. However, despite aggressive therapy, there is generally <35% survival from IA in this high-risk population.Figure 1.: CT chest showing intracardiac masses in the left atrium (white arrow; left image). CT abdomen showing a right renal nodule that was biopsied (white arrow; right image).