A 49-year-old woman received a kidney transplant from a cadaveric donor.
Induction therapy: Human antithymocyte immunoglobulin, 5 doses 1.5 mg/kg/day.
The patient presented delayed graft function and urinary fistula.
A biopsy showed capillaritis with positive C4d in diffuse peritubular capillaries (50% positivity), treated with three pulses of 500 mg methylprednisolone and intravenous immunoglobulin 400 mg/kg/day for five days.
Immunosuppression: tacrolimus 8 mg/day, mycophenolate sodium 1440 mg/day and methylprednisone 4 mg/day.
Prophylaxis for cytomegalovirus and cystic carinii pneumonia: valganvir and trimethoprim a
Forty days after transplantation, the patient developed urinary tract infections due to Pseudomonas aeruginosa and Escherichia coli.
Fifteen days later she was admitted with dyspnea and fever.
A chest computed tomography revealed bilateral pulmonary infiltrates, consolidation and cavitary images in both lungs.
A bronchioloalveolar lavage was performed, as well as a magnetan antigen ELISA test (Platelia Aspergillus, BioRad, France) with a positive result in siblings, 1.20 units.
Hematological analysis: hematocrit 27.2%, hemoglobin 9.6 g/dl, platelets 149000/mm3, leukocytes 691000/mm3, glycemia 103 mg/dl, urea 56 mg/dl, creatinine 1.46 mg/dl real DNA chain reaction.
Fresh microscopic examination with potassium hydroxide showed neither intracellular yeasts compatible with histoplasma capsulatum.
Neither Koch bacilli nor methicillin-resistant Staphylococcus aureus were found.
With a presumptive diagnosis of invasive pulmonary aspergillosis, voriconazole (200 mg twice daily) was added and immunosuppression was suspended.
Two days later, enlargement of the thyroid gland and compression pain were detected.
An ultrasound revealed moderate goiter with predominance of the left lobe with hypoechogenicity of the parenchyma and heterogeneous echo-structure left lobe changes: heterogeneous nodular lesion solid-cystic lesion size 27 x 16 x 23 mm thick nodule;
Thyroid enlargement was sudden.
Thyroid profile: thyrotropin 0.45 μUI/ml, ultrasensitive antiperoxidase 7.6 IU/ml, anitiroglobulin 10 IU/ml.
The gland was punctured and purulent fluid was extracted with antifungal agents that developed Aspergillus flares.
After 48 hours, fever and pain disappeared.
Treatment with voriconazole lasted 20 weeks.
The patients condition was favorable and, 45 days after diagnosis, the gland ultrasound revealed normal shape, size and echo-structure.
Left lobe, 48 x 17.5 x 16 mm, cystic nodule with peripheral halo of 21 x 14 x 13 mm, denser, without microcalcifications.
The right lobe was 52 x 15 x 14 mm, colloid cysts, the largest 4 mm. Isthmus mm. 2.4 mm. units were repeated after 60 days.
Plasma creatinine was 1.02mg/dl.
