Produção Nacional
Revisado por pares
Renal Aspergillosis in a 6-Year-Old Male with Burkitt’s Lymphoma
2015; Lippincott Williams & Wilkins; Volume: 34; Issue: 6 Linguagem: Inglês
10.1097/inf.0000000000000696
ISSN1532-0987
AutoresFabianne Carlesse, Ana Carolina Cavalcanti Marcos, Adriana Seber, Antônio Sérgio Petrilli, Flávio Augusto Vercillo Luisi, Gianina Ricci, Marco Túlio de Mello, Maria Teresa de Seixas Alves, Sarah Santos Gonçalves, Simone de Campos Vieira Abib, Arnaldo Lopes Colombo,
Tópico(s)Infectious Diseases and Mycology
ResumoTo the Editors: Invasive aspergillosis (IA) in hematologic patients is commonly associated with pulmonary and/or paranasal sinus infections.1–3 Primary renal aspergilloma has been rarely described in patients with cancer.4 We report a 6-year-old child who developed primary renal aspergillosis after relapsing a Burkitt lymphoma and required nephrectomy to control the infection. A 6-year-old male was diagnosed with primary abdominal Burkitt lymphoma in January 2011 and treated with standard chemotherapy for 4 months. Two months later, he presented with an isolated mediastinal mass and received a second-line chemotherapy that included prednisone and rituximab (anti-CD20 monoclonal antibody). An asymptomatic nodular lesion was found in the right kidney in a routine follow-up computerized tomography (CT) scan, and a core needle biopsy was performed to rule out a second relapse. Histopathology revealed inflammation and hyaline fungal hyphae. Chest CT scan and magnetic resonance imaging (MRI) of the sinuses were normal, and serum galactomannan was negative. Seminested polymerase chain reaction (PCR) method of DNA purified from formalin fixed paraffin embedded tissue samples and sequencing of PCR products targeting the mitochondrial DNA of Aspergillus species5 were performed and were positive for Aspergillus fumigatus. This result became available 4 weeks after the kidney biopsy, and the patient was initially treated with amphotericin B deoxycholate 1 mg/kg/d, which was the standard of care at that time in our country. With the final PCR result, he was changed to oral voriconazole 7 mg/kg/dose twice a day. Serum values were not available. After 7 weeks of antifungal therapy, the patient remained clinically well and afebrile, but the renal lesion was unchanged. Therefore, the nodule was surgically removed and revealed inflammation and the presence of hyphae. Culture grew A. fumigatus. The patient continued to receive oral voriconazole at the same dose and route for 6 more weeks. Two weeks after therapy, he underwent an autologous peripheral-blood hematopoietic stem cell transplantation conditioned with melphalan and targeted busulfan. Four days after transplant he became neutropenic and was given oral voriconazole as secondary prophylaxis (7 mg/kg/dose twice daily). Using CT scan, he was found to have another lesion in the same kidney. At that time, voriconazole levels became available, and despite having an adequate voriconazole value (2.6 μg/mL), the patient remained febrile and severely neutropenic, with an unchanged renal nodule. Nephrectomy was performed to control the infection. Pathology demonstrated a hyalohyphomycosis with necrosis of the upper kidney lobe, and the culture grew again A. fumigati. The sequencing of the internal transcribed spacer region and the fragment of β-tubulin gene confirmed A. fumigatus. The child received voriconazole for 3 additional weeks after nephrectomy and recovered from neutropenia; the fungal infection was finally controlled, and the underlying disease remained in remission. What makes this case unique is the fact that the Aspergillus renal lesion was identified during a routine abdominal CT scan performed for the lymphoma follow-up when the patient was neither neutropenic nor febrile. Sinus MRI and chest CT were normal. Serum galactomannan assay performed 3 times a week during neutropenia and after the diagnosis of renal aspergilloma remained negative (less than 0.5). Galactomannan has high sensitivity and specificity in neutropenic patients with pulmonary aspergillosis, but the sensitivity of this test is not well defined in extra pulmonary lesions, such as renal aspergilloma.6–8 Encapsulated and localized aspergillosis, as in our case with renal aspergilloma, might hamper the release of the galactomannan to the blood stream and have a negative serum assay result.8 IA restricted to the urinary tract is rare and has been described in immunocompromised patients with AIDS or in transplant recipients.9–14 Galactomannan assay was not performed in a urinary sample, and blood and urinary cultures never grew any organism. Renal aspergillosis can be secondary to hematogenous infection, bezoar formation in renal pelvis and ascending panurothelial aspergillosis. Ascending panurothelial fungal infection is a clinical presentation of primary urinary aspergillosis that has been described in kidney transplant recipients12,13,15 but not after hematopoietic stem cell transplantation. Voriconazole is the best drug to treat IA, but it reaches limited urinary tract tissue concentrations. Most patients with renal aspergillosis reported in the literature were treated with combination antifungal therapy (voriconazole and liposomal amphotericin B or amphotericin B deoxycholate) and surgery.14,16–18 Our patient did not respond to amphotericin B followed by voriconazole probably because of the intense immunosuppression and the low tissue penetration of the drugs in the encapsulated renal lesion. From a surgical standpoint, resection of the entire kidney or spleen and lobectomies is usually recommended over nodulectomy in immunosuppressed patients. Fabianne Carlesse, MD, PhD Instituto de Oncologia Pediatrica (IOP/GRAACC) Ana Carolina Cavalcanti Marcos, MD Pediatric Department Escola Paulista de Medicina Universidade Federal de São Paulo Adriana Seber, MD Pediatric Division, Hospital Samaritano Antonio Sergio Petrilli, MD, PhD Flávio Augusto Luisi, MD, PhD Instituto de Oncologia Pediatrica (IOP/GRAACC), Escola Paulista de Medicina, Universidade Federal de São Paulo Gianina Ricci, PhD Division of Infectious Diseases, Escola Paulista de Medicina Universidade Federal de São Paulo Universidade Nove de Julho Henrique Manuel Lederman, MD, PhD Instituto de Oncologia Pediatrica (IOP/GRAACC), Escola Paulista de Medicina Universidade Federal de São Paulo Maria Teresa de Seixas Alves, MD, PhD Pathology Department Escola Paulista de Medicina Universidade Federal de São Paulo Sarah Santos Gonçalves, PhD Medicine Department Universidade Federal de São Paulo Simone Campos Vieira Abib, MD, PhD Instituto de Oncologia Pediatrica (IOP/GRAACC), Escola Paulista de Medicina, Universidade Federal de São Paulo Arnaldo Lopes Colombo, MD, PhD Division of Infectious Diseases, Escola Paulista de Medicina Universidade Federal de São Paulo São Paulo, Brazil
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