Westerdykella Reniformis Masking as Histoplasmosis

Abstract

<h3>Introduction</h3> Fungal infections contribute to significant morbidity and mortality in lung transplant patients. The incidence of a fungal infection is about 8.6% post transplant. Here, we present a lung transplant patient with fungal infection by Westerdykella reniformis, mimicking as histoplasmosis. <h3>Case Report</h3> A 65-year-old male 2 years post bilateral lung transplant presented with recurrent low-grade fevers, for over a month. His immunosuppression included tacrolimus, belatacept, azathioprine and prednisone. On presentation, patient did give a history of working on chicken coops. Physical exam was benign. Work up was significant for pancytopenia, ground-glass density in the left lower lobe anteromedial segment and a 5 mm subpleural nodule in the right middle lobe lateral segment. Serum galactomannan and1,3 Beta D glucan were elevated. Urine histoplasma Ag was high. BAL cytology showed fungal organisms, however, could not be definitively identified. BAL Galactomannan was negative. Based on above testing, patient received Abelcet followed by Itraconazole for histoplasmosis. With the treatment, fever resolved, blood cell counts improved, urine histoplasma antigen trended down. However, on further testing of the BAL fungal species at Fungus Testing Laboratory, DNA probe was negative for histoplasmosis and cultures revealed Westerdykella reniformis. <h3>Summary</h3> Westerdykella is an ascomycete fungus, ubiquitously present in soil and plant material. About 10 species of Westerdykella have been identified to date and several of them exist as asexual Phoma anamorph state. There have been sporadic reports of infection related to Phoma species in immunocompromised patients. A case of angionvasive infection from Westerdykella dispersa was reported in a bone marrow transplant patient, who presented with fever, neutropenia, skin lesions and pulmonary nodules, which resolved with anti-fungal therapy. To our knowledge, this is the first case report of pulmonary infection from westerdykella reniformis, mimicking as histoplasmosis.