Thyroid infection caused by invasive aspergillosis in solid organ transplantation: a case report
Hector Solar1, Mariana Ortega1, Mariana Doeyo1, Elizabeth Madsen1, Claudia Nagel1, Gabriel Gondolesi1.
1Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
Introduction: Aspergillosis is a frequent fungal infection among immunocompromised patients, with an incidence between 0.1 to 11.6% in solid organ transplant recipients. Intestinal transplant patients are at the higher risk of infection; being lungs and central nervous system the main affected organs. Thyroid infection is an unusual extra pulmonary presentation secondary to a disseminated invasive aspergillosis.
Materials and Methods: We aim to report a case of a thyroid infection secondary to an invasive aspergillosis in an intestinal transplant recipient.
Results: A 29-year-old male, with history of chronic renal failure due to nephronophthisis in peritoneal dialysis since 2006, developed Cocoon syndrome. In 2014 a laparotomy was performed due to intestinal perforation and peritonitis. A total enterectomy, subtotal colectomy and cholecystectomy was carried out. Post-surgical anatomy was type 1 with 10 cm of jejunum left. Patient was discharged on home parenteral nutrition. Intestinal Failure associated Liver Disease was diagnosed by liver biopsy (Metavir 3). In 2018 an intestinal, liver and renal transplant was performed. A severe exfoliative cell rejection resistant to the medical treatment of the intestinal graft was developed, so enterectomy of the intestinal graft was performed. The patient evolved with fever, and a positive chest CT scan showing bilateral nodular opacities. Transbronchial biopsy was performed and the presence of Aspergillus nidulans was informed. Patient was started on Liposomal Amphotericin and Voriconazol, four months later Voriconazol was discontinued due to elevation of the liver function tests and completed six months on Amphotericin. The new CT scan at the end of treatment, showed absence of pulmonary infiltrates. But, 1 month later, he developed an indurated, erythematous, mobile, painful on palpation central cervical tumor of approximately 3x2cm, without cervical adenomegalies. A neck CT scan confirmed a thyroid nodule (Fig 1-2), requiring a right hemithyroidectomy. The definitive diagnosis was thyroid Aspergillosis, requiring post-surgical treatment with intravenous izovuconazol and caspofungin. Two months after the diagnosis the patient died due disseminated aspergillosis.
Conclusion: Thyroid aspergillus disease remains infrequently reported but if occurs, it has a mortality rate superior to 60%. A high clinical suspicion among those high-risk patients should lead to careful examination since most patients remain asymptomatic in the initial stage of invasive aspergillosis.
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