Mycophenolate mofetil/tacrolimus
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Talaromycosis: case report A 53-year-old woman developed talaromycosis during immunosuppressive treatment with mycophenolate mofetil and tacrolimus. The woman residing in England underwent living-donor renal transplant due to polycystic kidney disease. Her allograft was well functioning without prior history of opportunistic infection or rejection. For immunosuppression, she had been receiving tacrolimus and mycophenolate mofetil [dosages and routes not stated]. Eleven years after the transplant, she travelled to China. Prior to the travel, she did not seek counselling despite her immunocompromised status. She did not report any respiratory or other illness during her travel. Approximately 8 months after her return to England from the trip to China, she started feeling unwell. She developed productive cough with greenish sputum, night sweats and reduced exercise tolerance. She had no fever. The woman’s respiratory symptoms persisted despite receiving unspecified empiric antibacterial therapy. Hence, to find out the reason for her persistent respiratory symptoms chest x-ray was performed, which showed a left upper lobe mass. CT scan showed a large left upper lobe mass (10.4cm), while PET/CT scan showed highly metabolically active mass with high peripheral fluorodeoxyglucose (FDG) uptake (SuV of 21.4) with central necrosis and associated mediastinal lymphadenopathy. Endobronchial ultrasound-guided transbronchial fine-needle aspiration of the lung mass and lymph nodes was performed. Histopathology showed focal granulomas and necrosis, which was indicative of an infective process. Gomori methenamine silver stain demonstrated small, single, spherical to oval and clustered yeast forms. The cell walls were intensely stained with rounded ends to cells and single transverse septa. The findings were suggestive of Talaromyces marneffei. The organism grew on Sabouraud dextrose agar, which produced characteristic red pigment diffusing into the agar. Microscopy showed the "penicillate" heads and bi-verticillate branching producing multiple chains of dry and smooth spores from phialides. The organism was confirmed as Talaromyces marneffei, based on matrix-assisted laser desorption/ionisation mass spectrometry findings. Talaromyces marneffei infection (Talaromycosis) was thought to be acquired during a trip to China [durations of treatments to reaction onset not stated]. Thereafter, she was referred to infectious disease clinic, where she appeared ill, and was having chills. Physical examination showed clear lungs with good air entry bilaterally and no abnormal skin findings. Laboratory tests revealed WBC count of 14.5 × 109/L (neutrophils of 12.2 and lymphocytes of 0.78) and C-reactive protein of 159 mg/L. Her blood and urine culture showed no growth. Considering the extent of pulmonary infection and the concern of dissemination, brain MRI was performed, which showed no abnormalities. Allograft ultrasound was unremarkable. She was admitted to a hospital in England, following which she started receiving treatment with amphote
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