A 55-year-old Australian indigenous male, with chronic kidney disease of uncertain etiology, received a deceased donor renal transplant in September 2008. Prior to renal transplantation, he was treated for latent tuberculosis. His immunosuppression included induction with basiliximab followed by maintenance with tacrolimus, mycophenolate mofetil and prednisolone. There was no history of foreign travel.
Eight months after transplantation, he presented with 2 days history of a well circumscribed discolored lesion on the anterior abdominal wall and the left thigh, following insect bites while camping in the "bush".
He was afebrile vital signs were normal. An indurated, well demarcated, hyperpigmented tender lesion, 4 cm x 4 cm was present on the right anterior abdominal wall and another lesion 10 cm x 3 cm on the anterior aspect of his left thigh. He also had a tender swelling on the posterior aspect of the right calf. The lesions over the anterior abdominal wall and the left thigh increased in size with the breakdown and necrosis of the overlying skin. Neurological examination revealed Grade 4 power in the left leg with reduced pin prick in L2/3/4 dermatomal distribution with absent left knee and ankle reflexes. Plantar response was equivocal on the left foot.
His investigations were - total leukocyte count 3.7 x 109/L, neutrophils 2.5 x 109/L, lymphocytes 0.4 x 109/L, hemoglobin 12.9 g/dl, platelet count 1.53 lakhs/mm3, creatinine kinase 722 U/L, serum 2.5 mg/dl, C-reactive protein 209 mg/L, bilirubin 0.52 mg/dl, alkaline phosphatase 314 U/L, alanine aminotransferase 22 U/L, Gammaglutamul transpeptidase 34 U/L, serum albumin 41 g/L, total protein of 7.8 g/dl Chest X-ray showed a small right lower lobe consolidation. Hepatitis A, B and C antibodies were not detected. Q fever, rickettsial serology and Cryptococcus neoformans antigen negative in the serum. Urine and blood cultures were sterile.
In the hospital, he developed intermittent fever up to 39.5 C. He was empirically commenced on intravenous cephazolin for presumed cellulitis after blood and urine cultures were drawn.
Ultrasound examination showed edema of the subcutaneous tissues, but no focal collections. Skin biopsies of the abdominal and right calf lesions were obtained. Initial gram stain of the biopsy specimen did not show any organism. Subsequent urine and blood cultures were sterile. Computed tomography (CT) scan of the thorax [Figure 1], abdomen and lumbar spine showed an inflammatory mass lesion within the right lower lobe lung with edema of the left iliopsoas muscle.
Four days after presentation, he became confused and restless. He developed hypotension. In the intensive care unit, he was initiated on inotropes, was intubated and ventilated. Meropenem, doxycycline, vancomycin and intravenous voriconazole were administered.
A whole body CT scan was carried out, which showed a large left occipital infarct with hemorrhagic transformation, [Figure 2], and wide spread infarctions in the spleen, liver, native kidneys, and transplanted kidney. These were presumed to be secondary to the spread of the fungal infection. Echocardiographic examination was normal.
The patient's general condition continued to deteriorate, and he died 6 days after presentation. An autopsy was not performed.
Fungal cultures obtained from skin biopsies, subsequently showed growth of a zygomycete, identified as A. elegans.