Trichosporonosis Causing Mycotic Aortic Root Pseudoaneurysm after Cardiac Transplantation

Abstract

Introduction Trichosporonosis and complications at the aorto-allograft anastomosis are rare after cardiac transplantation (CTx). We report a case of Trichosporon endocarditis and mycotic pseudoaneurysm. Case Report A 51 year old female with dilated cardiomyopathy and adult polycystic kidney disease underwent bilateral nephrectomy and was listed for renal transplant (RTx). While waiting, her cardiac status progressed and she was assessed for combined CTx-RTx. Staged surgery was planned, with CTx followed by urgent RTx. She underwent orthotopic CTx in 2017. Early complications (including 2R rejection, drug-induced leucopenia, cytomegalovirus viraemia, and an infected fistula) delayed listing for RTx. Eventually, she underwent cadaveric RTx in 2019. Two weeks after RTx she was admitted with fevers, skin lesions and renal graft dysfunction. She had erythematous papules developing into bullae with ulceration and central necrosis, and loss of vision due to endophalmitis. Mycology from her skin and eye identified fungus of the Trichosporon species and she was treated with antifungal therapy comprising liposomal amphotericin B, Voriconzaole and Flucytosine. Transoesophageal echocardiography showed a large pseudoaneurysm at the aortic anastomosis with vegetations on the suture line and in the cavity. Serial computed tomography showed the pseudoaneurysm increasing in size despite medical therapy, and she underwent aortic valve and root replacement. Explanted tissue confirmed endocarditis with Trichlosporon species. She made a good surgical recovery. Five months after admission she was discharged with good cardiac and renal graft function, on lifelong voriconazole. Summary This is the first report of Trichosporon endocarditis and suture-line pseudoaneurysm after CTx. Haemodialysis was a key risk factor for infection, potentially avoided by earlier RTx. She remains free of recurrent fungaemia on long term suppression after 1 year, but there remains a risk of recurrent infection in the aortic root.