A SIRIWARDANA1, J HOLT1, J GREENSTEIN1
1Department of Renal Medicine, The Wollongong Hospital, Wollongong, NSW
Background: Scedosporium apiospermum is a fungal species that has been rarely reported to cause serious infections in solid organ transplant recipients. 14 cases have been reported among renal allograft recipients between 2000-2015, with a mortality rate of 4/14 (28.6%). Case report: A 45 year old man with end-stage renal failure secondary to crescenteric glomerulonephritis underwent a cadaveric renal transplant in 2015 and was maintained on standard immunosuppression with tacrolimus, mycophenolate sodium and prednisone. Other past medical history included idiopathic thrombocytopaenic purpura and hypertension. 3 months post-transplant, he presented with acute on chronic graft dysfunction with creatinine 235μmol/L and left 4th toe swelling. Left foot X-ray demonstrated soft tissue oedema and MRI identified subcutaneous fluid locules at the level of the middle and proximal phalanges. No clinical improvement was seen despite intravenous antibiotics and repeat MRI 3 weeks later demonstrated rapid progression to osteomyelitis involving the metatarsal head and proximal and distal phalangeal bases. He underwent a left 4th toe amputation. Bone histopathology showed abundant septate fungal hyphae amidst actively inflamed marrow, and culture grew Scedosporium apiospermum and methicillin-resistant Staphylococcus aureus. Therapy with 4 weeks intravenous vancomycin and 6 months oral voriconazole was undertaken, necessitating tacrolimus dose reduction due to voriconazole-tacrolimus drug interactions. He had good clinical recovery, however his course has also been complicated by BK nephropathy which has responded to reduced immunosuppression. Conclusion: Scedosporium apiospermum is an opportunistic pathogen that can cause rare but serious soft tissue infection in immunocompromised patients; treatment in renal allograft recipients may be complicated by drug interactions and have subsequent impacts on graft outcomes.