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Disseminated Neosartorya pseudofischeri Infection Associated With Tracheal Bronchus Post Lung Transplantation FREE TO VIEW

Diana Kelm, MD; Mark Wylam, MD; Steve Peters, MD; Mark Wilhelm, MD; John Scott, MD; Cassie Kennedy, MD
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Mayo Clinic, Rochester, MN

Chest. 2014;145(3_MeetingAbstracts):625A. doi:10.1378/chest.1836172
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SESSION TITLE: Transplantation Case Report Poster

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Neosartorya pseudofisheri is widely found in the soil and acquired by aeroinhalation. It is a distinct species, but morphologically similar to Aspergillus fumigatus. Although an uncommon human pathogen, it is primarily encountered in immunocompromised hosts.

CASE PRESENTATION: A 36- year-old female, 22 months following bilateral lung transplantation for cystic fibrosis, presented with anorexia, weight loss and three days of fever, dyspnea and cough. Past history was significant for prolonged bronchopleural fistula at transplant due to pretransplant right upper lobectomy and tracheal bronchus, causing mediastinal abscess secondary to multi-drug resistant Pseudomonas aeruginosa, three episodes of rejection (A3), and aspergillosis infection treated with amphotericin, high-dose caspofungin, and posaconazole. Her immunosuppressive regimen included prednisone and tacrolimus. Chest CT noted progression of bilateral irregular pulmonary nodules and an enlarging soft tissue nodule posterior to the right mainstem bronchus. Bronchoalveolar lavage was positive for N. pseudofischeri. Laboratory review of previous Aspergillus fumigatus isolates were re-identified as N. pseudofischerii. Transbronchial biopsy was negative for acute rejection; however numerous fungal organisms were seen, consistent with Aspergillus spp. Biopsy of new subcutaneous nodular lesions demonstrated numerous filamentous fungal forms, consistent with N. pseudofischeri. Transthoracic echocardiogram showed large mitral vegetations with severe mitral valve regurgitation causing flail of the posterior leaflet. She was not a surgical candidate; patient and family elected comfort measures and she died shortly thereafter.

DISCUSSION: There have been case reports of N. pseudofisheri associated osteomyelitis, peritonitis, keratitis, and endocarditis but fungal destruction of cardiac valves is rare (1). N. pseudofisheri can show resistance to antifungal medications. Tracheal bronchus (bronchus suis) is an abnormal bronchus that originates from the trachea and supplies the right upper lobe with an incidence between 0.1 and 5% (2). Recurrent or persistent pneumonia can occur due to abnormal pulmonary clearing, rarely requiring upper lobectomy. Successful transplants have been reported involving either a recipient or donor with a tracheal bronchus.

CONCLUSIONS: In this case, the tracheal bronchus was sacrificed during the pre-transplant right upper lobectomy and ultimately left a nidus for infection.

Reference #1: Jarv H, Lehtmaa J, et al. Isolation of Neosartorya pseudofischeri from Blood: First Hint of Pulmonary Aspergillosis. J Clin Microbiol. 2004; 42(2): 925-928.

Reference #2: Setty S, Michaels A. Tracheal Bronchus: Case Presentation, Literature Review, and Discussion. J Trauma. 2000;49:943-945.

DISCLOSURE: The following authors have nothing to disclose: Diana Kelm, Mark Wylam, Steve Peters, Mark Wilhelm, John Scott, Cassie Kennedy

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