To the editor: Four years after receiving a kidney  transplant from an unrelated living donor for polycystic kidney

disease,1 a  49-year-old  female  patient started  to experience episodes of hyperthermia. The immunosuppression

regimen consisted of methylprednisone 4  mg/day,  micophenolate  mofetil  2 g/day,  and  tacrolimus  2  mg/day.  She was  admitted  to  hospital  for  suspicion of  complicated  renal  cysts  and  was found  subcutaneous  nodules  that were biopsied and seen to be consistent with erythema  nodosum.  Nephrectomy  of the right native kidney was performed, but  fever persisted. Cultures were persistently  negative.  Patient  developed massive  ascites.  Magnetic  resonance imaging  showed  ascites  and  a  complicated liver cyst, that was marsupialized, and  two  liters of  ascites were drained. Peritoneum  was  normal  upon  inspection. After 22 days of  incubation, subcutaneous  nodules  developed  colonies of Histoplasma capsulatum. Fever persisted  despite  itraconazole  administration, and amphotericin B was therefore added. Subsequent blood, urine, and ascites  fluid  cultures  were  positive  for Histoplasma capsulatum. Fever and ascites resolved 29 days after hospital admission,  and  patient  was  discharged home. Two weeks later, fever and subcutaneous nodules in the arms recurred. Severe  pericardial  effusion with  ultrasonographic  signs  of  tamponade  was diagnosed. The patient died during  the procedure.



While early fungal infections are less commonly  reported  in  kidney  transplant  patients  than  in  other  transplant

patients,  their  mortality  is  high.2 These patients have a high risk of suffering  late  opportunistic  infections,

particularly  by  Listeria, Nocardia, Mycobacteria,  or  fungi,  associated  to use  of  venous  catheters,  antibiotics,

corticosteroids,  surgical procedures, and diabetes mellitus.



Approximately after 6 months since transplant, incidence of opportunistic fungal infections decreases, but an increase occurs in the incidence of systemic endemic fungal disease, of which histoplasmosis and coccidioidomycosis are the most significant. Histoplasmosis is  the most  common  endemic mycosis in  immunosuppressed  patients  in  Argentina,3,5 with  an  incidence  rate up  to 40%  in humid,  temperate areas.  In our country, the most common clinical presentations  in healthy  individuals  include the pulmonary variant and the chronic  disseminated  variant  associated  to mucocutaneous  lesions,  adenomegalies, hepatomegaly, and splenomegaly.6 In normal subjects, primary infection is  usually  asymptomatic  in more  than 90%  of  cases.  In  a  lower  proportion, clinical  signs  include  pericarditis, mediastinitis,  erythema  nodosum,  or  retinitis.7



Ascites is a complication of systemic histoplasmosis  not  previously  reported in the 48 cases of histoplasmosis in kidney  transplant.  It  should  be  noted  that surgeons  did  not  take  peritoneal  biopsies during abdominal  laparoscopy because  of  the  normal  characteristics  of the serosa. This could be due to the abnormal inflammation patterns in immunosuppressed  patients.  We  think  random  peritoneal  biopsies  should  be

performed  despite  absence  of  gross structural  changes  when  the  cause  of ascites has not been diagnosed.8



Patients  transplanted  solid  organs have an  increased  risk of suffering opportunistic  infections.  Systemic  histoplasmosis  is  a  rare  and  serious  condition  that  should  be  considered  as  a long-term  complication  in  transplant patients.