Unclear fever 7 weeks after renal transplantation in a 56-year-old patient.

A 56-year-old male patient with end-stage renal disease, due to focal sclerotic segmental glomerulonephritis, underwent renal cadaveric transplantation after 2 years of haemodialysis (full-house HLA-match, donor age 48 years, donor and recipient cytomegalovirus (CMV) negative, cold ischaemia time 16h). Due to initial graft non-function, alternate-day haemodialysis was continued for the following 3 weeks until the kidney function gradually improved. The immunosuppressive treatment consisted of prednisone, ciclosporin and mycophenolate mofetil. Five weeks after transplantation, pp65-antigenaemia was detected. Although clinical symptoms were absent, daily treatment with 150mg gancyclovir p.o. over 3 weeks was initiated. The pp65-antigenaemia disappeared. In the seventh week post-transplant, the patient presented with fever (38.78C), an elevated white blood cell count (12.0G/l) (normal range 4.3–10.0) and an increased C-reactive protein (CRP) level (162mg/l) (normal range <5). Microbiological testing revealed Stenotrophomonas maltophilia in cultures obtained from the surgical site. Under treatment with 250mg levofloxacin p.o. per day, laboratory signs of inflammation persisted. Since a thorough diagnostic work-up for the underlying infection did not lead to a sufficient diagnosis, an inflammation scintigraphy with Tc-labelled antineutrophilic antibodies was performed 12 weeks after transplantation. The scan revealed accumulation of granulocytes in the left lobe of the thyroid gland. At physical examination the thyroid gland was slightly enlarged and indolent. Ultrasonography showed multiple liquid abscess formations (Figure 1). Fine needle aspirates yielded Aspergillus fumigatus hyphae. Neither clinical examination nor chest radiography or magnetic resonance imaging exhibited signs of disseminated Aspergillus infection. Aspergillus antigenaemia could not be detected by serological ELISA-screening for galactomannan antigen. The triple immunosuppressive treatment with ciclosporin, mycophenolate mofetil and prednisone was discontinued and replaced by prednisone monotherapy for the following 3 months. Antifungal treatment with caspofungin was initiated. After an initial reduction of the inflammatory parameters however, the CRP level stabilized at above 60mg/l at week 19, and repeated fine needle aspirates of the thyroid gland were still positive for Aspergillus. After voriconazole was added to caspofungin, the sonographic findings improved and inflammatory parameters normalized. On the day of discharge, 6 months after transplantation and 3 months after the development of the mycotic thyroiditis, fine needle aspirates of the left thyroid lobe still revealed minor growth of Aspergillus. However, CRP had dropped to a level <5mg/l. After discharge, the treatment with voriconazole was continued for the following 4 months until subsequent aspirations became negative at month 10. After discharge, mycophenolate mofetil was included in a daily dosage of 1000mg and prednisone was reduced.