Invasive pulmonary aspergillosis secondary to immunosuppressive therapy in nephrotic syndrome: a case report

doi:10.16138/j.1673-6087.2024.05.06

Abstract

Abstract:

A 61-year-old male with a one-year history of membranous nephropathy was placed on combined therapy of glucocorticoids and rituximab. On the 12th day of treatment, the patient developed high fever, accompanied by mild cough and night sweats. Chest CT revealed multiple nodules and patchy opacities in both lungs. Bronchoalveolar lavage fluid (BALF) analysis using next-generation sequencing (NGS) identifed Aspergillus infection, and two consecutive β-D-glucan tests were positive. The clinical diagnosis of invasive pulmonary aspergillosis (IPA) was established. The patient received intravenous voriconazole for six months. Follow-up chest CT showed significant absorption of pulmonary lesions. The treatment regimen led to recovery of the patient and achieved partial remission of nephrotic.

Key words: Membranous nephropathy, Invasive pulmonary aspergillosis, Immunosuppressive therapy, Rituximab, Next-generation sequencing

CLC Number:

R692

RUAN Yilin, XU Tian, FENG Xiaobei, XU Jing, SHI Hao, REN Hong. Invasive pulmonary aspergillosis secondary to immunosuppressive therapy in nephrotic syndrome: a case report[J]. Journal of Internal Medicine Concepts & Practice, 2024, 19(05): 318-321.

Figures/Tables 2

References 19

[1]	Hull RP, Goldsmith DJA. Nephrotic syndrome in adults[J]. BMJ, 2008, 336(7654):1185-1189.
[2]	Li J, Zhang Q, Su B. Clinical characteristics and risk factors of severe infections in hospitalized adult patients with primary nephrotic syndrome[J]. J Int Med Res, 2017, 45(6):2139-2145. doi: 10.1177/0300060517715339 pmid: 28661269
[3]	van den Brand JAJG, Ruggenenti P, Chianca A, et al. Safety of rituximab compared with steroids and cyclophosphamide for idiopathic membranous nephropathy[J]. J Am Soc Nephrol, 2017, 28(9):2729-2737. doi: 10.1681/ASN.2016091022 pmid: 28487395
[4]	Kidney Disease: Improving Global Outcomes (KDIGO) Glomerular Diseases Work Group. KDIGO 2021 clinical practice guideline for the management of glomerular diseases[J]. Kidney Int, 2021, 100(4S):S1-S276. doi: 10.1016/j.kint.2021.05.021 pmid: 34556256
[5]	Debiec H, Ronco P. Immunopathogenesis of membranous nephropathy[J]. Semin Immunopathol, 2014, 36(4):381-397. doi: 10.1007/s00281-014-0423-y pmid: 24715030
[6]	Teisseyre M, Cremoni M, Boyer-suavet S, et al. Advances in the management of primary membranous nephropathy and rituximab-refractory membranous nephropathy[J]. Front Immunol, 2022, 13:859419.
[7]	Fervenza FC, Appel GB, Barbour SJ, et al. Rituximab or cyclosporine in the treatment of membranous nephropathy[J]. N Engl J Med, 2019, 381(1):36-46.
[8]	Smith MR. Rituximab (monoclonal anti-CD20 antibody): mechanisms of action and resistance[J]. Oncogene, 2003, 22(47):7359-7368. doi: 10.1038/sj.onc.1206939 pmid: 14576843
[9]	Ruggenenti P, Cravedi P, Chianca A, et al. Rituximab in idiopathic membranous nephropathy[J]. J Am Soc Nephrol, 2012, 23(8):1416-1425. doi: 10.1681/ASN.2012020181 pmid: 22822077
[10]	Del Vecchio L, Allinovi M, Rocco P, et al. Rituximab therapy for adults with nephrotic syndromes: standard schedules or B cell-targeted therapy?[J]. J Clin Med, 2021, 10(24):5847.
[11]	Zilberberg MD, Harrington R, Spalding JR, et al. Burden of hospitalizations over time with invasive aspergillosis in the United States, 2004-2013[J]. BMC Public Health, 2019, 19(1):591. doi: 10.1186/s12889-019-6932-9 pmid: 31101036
[12]	Thompson GR, Young J-AH. Aspergillus infections[J]. N Engl J Med, 2021, 385(16):1496-1509.
[13]	Liu Z, Li Y, Tian X, et al. Airway-invasion-associated pulmonary computed tomography presentations characteristic of invasive pulmonary aspergillosis in non-immunocompromised adults: a national multicenter retrospective survey in China[J]. Respir Res, 2020, 21(1):173.
[14]	冯珍, 董春霞, 郭岚, 等. 肾病综合征应用免疫抑制剂治疗并发肺及皮肤隐球菌感染一例报道并文献复习[J]. 中国全科医学, 2019, 22(17):2130-2135. doi: 10.12114/j.issn.1007-9572.2018.00.354
[15]	Donnelly JP, Chen SC, Kauffman CA, et al. Revision and update of the consensus definitions of invasive fungal disease from the European organization for research and treatment of cancer and the mycoses study group education and research consortium[J]. Clin Infect Dis, 2020, 71(6):1367-1376. doi: 10.1093/cid/ciz1008 pmid: 31802125
[16]	Desoubeaux G, Bailly É, Chandenier J. Diagnosis of invasive pulmonary aspergillosis: updates and recommendations[J]. Med Mal Infect, 2014, 44(3):89-101.
[17]	Lamoth F. Galactomannan and 1,3-β-d-glucan Testing for the diagnosis of invasive aspergillosis[J]. J Fungi (Basel), 2016, 2(3):22.
[18]	唐晓丹, 李光辉. 2016年美国感染病学会曲霉病诊断处理实践指南[J]. 中国感染与化疗杂志, 2017, 17(4):456-462.
[19]	中国医师协会血液科医师分会, 中国侵袭性真菌感染工作组. 血液病/恶性肿瘤患者侵袭性真菌病的诊断标准与治疗原则(第六次修订版)[J]. 中华内科杂志, 2020, 59(10):754-763.

时间	（1-3）-β-D葡聚糖（pg/mL）	降钙素原（ng/mL）	蛋白尿定量（mg/24h）	肌酐（μmol/L）
2022年9月	9.99	0.12	13 810	131
2022年10月
入院第1天	560.20	0.23	5 829	117
入院第7天	208.77	0.22	4 520	113
入院第17天	56.04	—	4 531	115
2023年6月	9.99	0.04	4 096	135
2023年8月	9.99	0.04	3 309	141