A Double Therapeutic Challenge: Handling Acremonium sp. Hyalohyphomycosis and Atypical Mycobacteriosis in Tandem in a Kidney Transplant Recipient

Introduction: Acremonium sp. hyalohyphomycosis and Mycobacterium cheloane mycobacteriosis are opportunistic infections, often resistant to medical therapy and requiring prolonged antibiotic treatment. Despite rare, they have become more frequent as imunnosupression efficacy enhances. Herein, we present the first case of succesfully treated concurrent Acremonium sp. hyalohyphomycosis and atypical M. chelonae cutaneous mycobacteriosis in a kidney transplant recipient. Case Description: A 66-year-old 0% PRA kidney transplant recipient from 2013 with a history of wayward compliance to standard immunossupression and multiple opportunistic infections presented with a one-year history of dorsal right hand erythematous-violaceous, nodular lesions, impaired 2nd to 5th finger flexion and purpuric plaques on abdomen and right thigh (figure 1). Magnetic Resonance Imaging (MRI) of his right hand is also shown (figure 2). Direct examination and culture of his hand and thigh lesions yielded positive for Acremonium sp., while abdominal lesions were biopsied and cultured, revealing Mycobacterium chelonae positivity and chronic inflamation. Oral voriconazole was prescribed to address the fungal infection for twelve months, whereas a combination of Levofloxacin, Linezolid and Azithromycin was initiated for the atypical mycobacteriosis. One year later, marked inflamation control and clinical response was achieved (figure 3), corroborated by follow-up MRI findings (figure 4). Discussion: To our knowledge, this is the first case of concomitant hyalohyphomycosis and atypical mycobacteriosis in a kidney transplant recipient. While transplantation stands as a top renal replacement choice, suspicion for these rare but highly morbid infections must be raised given their demanding follow-up. When combined, they challenge even experienced nephrologists and infectious disease specialists, but therapy can be effective and optimal response achieved when adequate surveillance and care are provided.