A Rare Case of Tracheobronchitis Alternariosis in a Renal Transplant Recipient

Invasive filamentous fungal infections are an important source of morbidity and mortality among the immunocompromised population. Due to long-term immunosuppressive therapy, in organ transplant recipients have a highly increased risk of acquiring unusual opportunistic infections1. Alternaria alternata is an uncommon cause of invasive fungal infection and the majority of cases of phaeohyphomycosis due to Alternaria species have been encountered in immunocompromised individuals2. In the immunocompromised patient, Alternaria is recognised as a source of sinus, nail, palatal, and ocular infections, especially Alternaria alternata34. We report a rare case of tracheobronchitis Alternaria species in an immunocompromised patient.

A 53-year-old female from Tabriz, Iran was referred to a central Hospital in Tabriz on June 24, 2014 (day 0). The patient presented with recurrent cough from 3 years ago, without sputum and blood that did cause dysphonia in this patient. She had a clinical history of 6 years (in April 2008) kidney transplantation and she was treated by immunosuppressive therapy consisting of tacrolimus (1 mg twice a day orally), and mycophenolate mofetil (500 mg triple a day orally). Her post-transplantation course was uneventful, but 3 years after the transplantation in 2011 year she had some times recurrent 1 cough until 2014. On day 3, chest X-ray was performed, with negative results and did not show any opacity in right and left side chest. Bronchoscopy revealed of the left bronchus thick purulent secretions that on day 5, sent to the Bacteriology Laboratory of the hospital, no bacteria were identified by Gram stain, but in modified Ziehl-Neelsen stain showed macroconidia of Alternaria (Figure 1). In bronchial washings sample, did not bacterial growth on blood agar and MacConkey agar, where it remained negative after 48 hours of incubation on day 7. The final diagnosis was tracheobronchitisalternariosis. The patient started antifungal therapy on day 12 with voriconazole (400 mg daily) and patient was relieved of symptoms within 6 weeks (on day +54).

Figure 1

This figure shows a macroconidium on microscopy of bronchial washings stained with a modified Ziehl-Neelsen technique (×400).

Alternaria has worldwide distribution and is a large and complex genus that encompasses hundreds of species and several species being common saprophytes in soil5. Alternaria can be isolated from nature normal human skin or as a laboratory contaminant therefore, its involvement in human infection must be equires cautious evaluation6. Alternaria has been associated with several types of infections such as parasinusitis, ocular infections, oncychomycosis, and cutaneous and subcutaneous infections also granulomatous pulmonary disease and majority of the reported cases occurred in patients who either had severe underlying disease or were im-munocompromised7.

The main clinical manifestation due to Alternaria is a respiratory disease such as, rhinitis, pneumonia, asthma and in more than 80% of patients the Alternaria infection occurs in immunosuppressed patients8. Secnikova et al.9in a study reported a case of Alternaria cutaneous and pulmonary infection in immunosuppressed man after heart transplantation that treatment with posaconazole. We report a case of tracheobronchitis infection due to Alternaria spp. in a renal transplant recipient woman that is immunocompromised patient and treated with voriconazole. We report a rare case of tracheobronchitis with Alternaria spp. after renal transplantation. Hence, it seems identifying Alternaria spp. as the pathogen in an immunocompromised patient is necessary.