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Diffuse Alveolar Hemorrhage Secondary to Disseminated Histoplasmosis After Kidney Transplantation
Pulmonary Manifestations of Systemic Disease SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
Diffuse Alveolar Hemorrhage Secondary to Disseminated Histoplasmosis After Kidney Transplantation
INTRODUCTION: Histoplasma capsulatum is endemic to the Ohio and Mississippi River Valley regions of the US. The demographics of histoplasmosis have changed following the advent of antiretroviral therapy and the use of immunosuppressive agents for organ transplantation and chronic inflammatory conditions1. Patients with kidney transplants make up more than half of this new demographic1, 2. While severe pulmonary histoplasmosis can cause acute respiratory distress syndrome, diffuse alveolar hemorrhage (DAH) in adults has rarely been described3. Early recognition and initiation of therapy is imperative in an immunocompromised host - including withdrawal of immunosuppression. CASE PRESENTATION: A 23 year old white female with type 1 diabetes, and end stage renal disease with failed transplant on tacrolimus and dialysis, presented with two weeks of fever and dry cough. On physical exam there was labored breathing and diffuse crackles on auscultation of the chest. Initial chest radiograph showed no acute changes. Within hours, she developed worsening respiratory failure and a subsequent CT scan of the chest revealed diffuse ground-glass opacities in the lungs. She was intubated, and sequential bronchoalveolar lavage (BAL) showed findings consistent with DAH. Serum and urinary Histoplasma antigen returned strongly positive. BAL fungal cultures were positive for Histoplasma. Autoimmune serology was negative. The DAH was treated with intravenous steroids, with significant clinical repsonse. She was also treated for disseminated histoplasmosis with amphotericin B followed by a 12-month course of itraconazole. Tacrolimus was discontinued. DISCUSSION: Unrecognized alveolar microvascular injury can have life threatening consequences. Hemoptysis can be absent in up to 33% of DAH cases, and radiographic findings are similar to other acute alveolar filling processes. Systemic vasculitides including ANCA vasculitis, SLE, and connective tissue disorders are the most common clinical causes for DAH. Histoplasmosis has only recently been implicated amongst infectious causes3. Immunosuppressive therapy post-transplant increases the risk for fungal infections. CONCLUSIONS: Histoplasmosis in the post-transplant setting poses a unique problem in immunomodulation. Surveillance data indicate that the rates of infection with endemic mycoses remain low in transplant patients and do not warrant routine screening of candidates or recipients. However, clinical suspicion and early diagnosis are crucial to mitigate poor outcomes from infection. Reference #1: Myint, T., et al., Temporal trends, clinical characteristics, and outcomes of histoplasmosis in a tertiary care center in Kentucky, 2000 to 2009. J Int Assoc Provid AIDS Care, 2014. 13(2):100-5 Reference #2: Assi, M., et al., Histoplasmosis after solid organ transplant. Clin Infect Dis, 2013. 57(11):1542-9 Reference #3: Valdivia-Arenas, M.A., N. Sood, A 77-year-old farmer with respiratory failure and thrombocytopenia. Chest, 2006. 129(5):1378-81 DISCLOSURE: The following authors have nothing to disclose: Alok Bhatt, Robert Burkes, Hala Karnib, Mohamed Saad No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1212
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
1105A
PULMONARY MANIFESTATIONS OF SYSTEMIC DISEASE
Alok Bhatt MBBS* Robert Burkes MD Hala Karnib MD; and Mohamed Saad MD University of Louisville, Louisville, KY
Diffuse Alveolar Hemorrhage Secondary to Disseminated Histoplasmosis After Kidney Transplantation
INTRODUCTION: Histoplasma capsulatum is endemic to the Ohio and Mississippi River Valley regions of the US. The demographics of histoplasmosis have changed following the advent of antiretroviral therapy and the use of immunosuppressive agents for organ transplantation and chronic inflammatory conditions1. Patients with kidney transplants make up more than half of this new demographic1, 2. While severe pulmonary histoplasmosis can cause acute respiratory distress syndrome, diffuse alveolar hemorrhage (DAH) in adults has rarely been described3. Early recognition and initiation of therapy is imperative in an immunocompromised host - including withdrawal of immunosuppression. CASE PRESENTATION: A 23 year old white female with type 1 diabetes, and end stage renal disease with failed transplant on tacrolimus and dialysis, presented with two weeks of fever and dry cough. On physical exam there was labored breathing and diffuse crackles on auscultation of the chest. Initial chest radiograph showed no acute changes. Within hours, she developed worsening respiratory failure and a subsequent CT scan of the chest revealed diffuse ground-glass opacities in the lungs. She was intubated, and sequential bronchoalveolar lavage (BAL) showed findings consistent with DAH. Serum and urinary Histoplasma antigen returned strongly positive. BAL fungal cultures were positive for Histoplasma. Autoimmune serology was negative. The DAH was treated with intravenous steroids, with significant clinical repsonse. She was also treated for disseminated histoplasmosis with amphotericin B followed by a 12-month course of itraconazole. Tacrolimus was discontinued. DISCUSSION: Unrecognized alveolar microvascular injury can have life threatening consequences. Hemoptysis can be absent in up to 33% of DAH cases, and radiographic findings are similar to other acute alveolar filling processes. Systemic vasculitides including ANCA vasculitis, SLE, and connective tissue disorders are the most common clinical causes for DAH. Histoplasmosis has only recently been implicated amongst infectious causes3. Immunosuppressive therapy post-transplant increases the risk for fungal infections. CONCLUSIONS: Histoplasmosis in the post-transplant setting poses a unique problem in immunomodulation. Surveillance data indicate that the rates of infection with endemic mycoses remain low in transplant patients and do not warrant routine screening of candidates or recipients. However, clinical suspicion and early diagnosis are crucial to mitigate poor outcomes from infection. Reference #1: Myint, T., et al., Temporal trends, clinical characteristics, and outcomes of histoplasmosis in a tertiary care center in Kentucky, 2000 to 2009. J Int Assoc Provid AIDS Care, 2014. 13(2):100-5 Reference #2: Assi, M., et al., Histoplasmosis after solid organ transplant. Clin Infect Dis, 2013. 57(11):1542-9 Reference #3: Valdivia-Arenas, M.A., N. Sood, A 77-year-old farmer with respiratory failure and thrombocytopenia. Chest, 2006. 129(5):1378-81 DISCLOSURE: The following authors have nothing to disclose: Alok Bhatt, Robert Burkes, Hala Karnib, Mohamed Saad No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1212
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
1105A
PULMONARY MANIFESTATIONS OF SYSTEMIC DISEASE
Alok Bhatt MBBS* Robert Burkes MD Hala Karnib MD; and Mohamed Saad MD University of Louisville, Louisville, KY