Aspergillosis Osteomyelitis and Joint Infection in a Renal Transplant Recipient A. Ersoy, I. Akdag, H. Akalin, B. Sarisozen, and B. Ener ABSTRACT Invasive Aspergillosis occurs in almost every human organ, most commonly in the lungs. Bone involvement classically has been considered exceedingly rare for both immunocom- promised and immunocompetent hosts, however, there are limited data in transplant recipients. We report an unusual case of osteomyelitis and joint infection of the ankle caused by Aspergillus fumigatus in a renal transplant recipient. F UNGAL infections that cause significant morbidity and mortality in renal transplant recipients are relatively rare, occurring usually in the first 6 months posttransplan- tation. They are mainly due to Candida and Aspergillus. Aspergillus usually affects the lungs, central nervous system, sinuses, skin, and, rarely, urinary tract. 1,2 Aspergillus osteo- arthritis is extremely rare in this setting. 3,4 Herein, we have reported a recipient with Aspergillus osteomyelitis and joint infection. CASE REPORT A 34-year-old man received a renal transplant from a living related donor in October 2003. Until that day he was on hemodialysis for end-stage renal disease due to chronic pyelonephritis with vesi- coureteral reflux (VUR) since 1994. In June 2002, a liver biopsy was performed because of anti– hepatitis C virus (HCV) presence and HCV RNA positivity; it revealed evidence of minimal chronic hepatitis. After interferon treatment, HCV RNA became negative. In May 2003, he underwent left ureteronephrectomy for VUR. In the pretransplantation period, he underwent treatment for maxil- lary sinusitis. His chest radiograph showed calcified granulomas in the upper zone of the right lung. Acid-resistant bacilli in tracheal aspirates and skin test for tuberculin were negative. Posttransplan- tation isoniazid (INH) prophylaxis was started. His immunosup- pressive regimen consisted of prednisolone, mycophenolate mofetil (MMF), and tacrolimus. He had an acute rejection episode at 1 week after transplantation that responded to steroids. The creati- nine level after the episode was 1.6 mg/dL. He developed a high fever and a cough on the third week. Thoracic computed tomog- raphy (CT) scan revealed pneumonic infiltration and nodules consistent with calcified granulomas in the lung apices. He was treated with intravenous imipenem plus vancomycin. The cultures were negative for bacteria and fungi. On follow-up, he had a lymphocele that required drainage, as well as de novo diabetes mellitus, which required diet and oral antidiabetic treatment for 6 months. In January 2004, Mycobacterium tuberculosis was demonstrated in his sputum culture, which was obtained during a lung infection. Quadruple antituberculous treatment was started, but regimen change was required due to hepatotoxicity. MMF was withdrawn. At this time the patient admitted complaints of a swollen, painful left ankle without a history of trauma to the ankle. The radiograph was found to be normal. Magnetic resonance imaging (MRI) revealed mild effusion in the talocalcaneal joint space and edema in the talar bone. In April 2004, a control MRI showed inflamatory changes consistent with peripheral extensive heterogenous signal increase containing small abscesses localized in the tibiotalar, talocalcaneal, and talonavicular joint spaces, the lateral ankle, and the paraosseos soft tissue planes. After the consultation with the orthopedic department, the left ankle joint was immobilized by splinting and antibiotic treatment was presented. A radionuclide bone scan showed increased uptake in the bones of the left foot and ankle, suggesting Sudeck’s atrophy. In August 2004, a fluctuant mass in the right malleolus was aspirated at another center. The culture was negative and he received cefuroxime therapy. After 1 week, he had a rejection episode partially steroid responsive but he refused the allograft biopsy. He had prolonged neutropenia. No serological evidence of active cytomegalovirus (CMV) infection was detected. His creatinine level decreased to 3 mg/dL. A mild amount of purulent drainage was present from the swollen left ankle joint. Joint aspiration showed abundant neutrophils with no crystals. The culture was sterile. He was treated with ampicillin sulbactam 3 g/d and discharged on prednisolone, sirolimus, and azathioprine treatment. In October 2004, he was admitted with similar complaints. Generalized tenderness with increased warmth over the entire ankle and decreased range of motion were noted. Laboratory tests revealed the following: hemoglobin 8.6 g/dL, leukocyte 6700 /mm 3 , sedimentation rate 35 mm/h, and creatinine 3.6 mg/dL. Urinary protein excretion was trace. Creatinine clearance was 25.8 mL/min. From the Department of Nephrology, Uludag University Med- ical Faculty, Gorukle, Bursa, Turkey. Address reprint requests to Alpaslan Ersoy, MD, Department of Nephrology, Uludag University Medical Faculty, Gorukle, Bursa 16059, Turkey. E-mail: alpersoy@uludag.edu.tr 0041-1345/07/$–see front matter © 2007 by Elsevier Inc. All rights reserved. doi:10.1016/j.transproceed.2006.11.020 360 Park Avenue South, New York, NY 10010-1710 1662 Transplantation Proceedings, 39, 1662–1663 (2007)