Altered mental status post transplant• 66 year-old woman h/o diabetes mellitus s/p

deceased donor renal transplantation

• One year post transplant admit to local hospital w urinary tract infection, cultures positive for Proteus and right arm cellulitis, treated with linezolid, keflex

Clinical presentation, cont.• Readmit one month later with neutropenic fever,

blood cultures positive for Pseudomonas, reportedly chest ab pelvis CT showed evidence of old granulomatous disease in lungs, liver, spleen

• The following month, admit again with headache, throat pain, diagnosed with thrush and fluconazole started

• Overnight developed altered mental status

MRI post admission

Multiple foci of recently completed infarction involving the bilateral cerebral and cerebellar hemispheres, in a distribution suggestive of an embolic etiology. A larger infarct in the right basal ganglia demonstrates associated expansile mass effect and minor petechial bleeding.

Chest CTpost admission

FNA performed showing fungal elements

Calcified right paraesophageal lymph nodes and similarly calcified subcentimeter nodule within right lower lobe (3-55), consistent with prior granulomatous disease. 39 x 35 mm lobulated mass-like consolidation within the right lower lobe superior segment, suspicious for bronchogenic carcinoma.

Post-lung FNA

• Aspergillus ag EIA 1.28• TTE negative for vegetations, valvular

disease• TEE was also negative. However, cardiac

bedside TEE did show possible vegetation

How to treat?

Is this fungal endocarditis?

Clinical course

• Started on IV voriconazole 6mg/kg q12• Amphotericin B lipid complex added to

regimen• CSF cultures all negative for bacterial and

fungal culture• No improvement in mental status, family

ultimately decided to withdraw care

Was this invasive pulmonary disease plus stroke, or fungal endocarditis +/- septic emboli?

Brain: histopath

Thrombosed vessel, R striatumMicrohemorrhage, R striatum

Heart and lung

Heart, posterior papillary Lung

Take home thoughts

• Unusual causes of endocarditis may be seen after transplantation although few published cases of endocarditis due to mold exist

• Aspergillus galactomannan or antigen EIA testing may be useful in making the diagnosis of aspergillosis

• Choices for empiric antifungal treatment for aspergillosis include voriconazole or Amphotericin B lipid formulations