Refractory Invasive Pulmonary Aspergillosis Following Treatment of Acute Rejection in a Kidney Transplant Recipient: A Case Report

Invasive pulmonary aspergillosis (IPA) is an uncommon but highly morbid complication after solid organ transplantation, particularly following treatment for acute rejection. We report a case of refractory IPA caused by Aspergillus terreus in a 70‐year‐old kidney transplant recipient, diagnosed 2 weeks after receiving thymoglobulin and pulse corticosteroids for acute T cell–mediated rejection. The patient presented with acute hypoxic respiratory failure requiring intubation, and a chest computed tomography scan demonstrated a large, necrotic, mass‐like cavitary opacity in the left upper lobe and lingula. Serum and bronchoalveolar lavage (BAL) galactomannan (GM) were markedly elevated, the Aspergillus PCR was positive, and BAL culture grew A. terreus . Initial treatment included voriconazole and micafungin, and immunosuppression was substantially reduced. Although the patient initially improved radiographically, his outpatient course was complicated by persistently high GM antigenemia despite antifungal therapy, requiring the addition of terbinafine as a third antifungal agent. Serum GM eventually became negative after 33 weeks of treatment, and adjunctive micafungin and terbinafine were discontinued at Week 42, with the continuation of a long‐term azole. This case highlights the risk of rapidly progressive IPA following rejection therapy in kidney transplant recipients and underscores the importance of prompt species identification, serial GM and radiographic monitoring, and timely adjustment of both antifungal therapy and immunosuppression.