|Year : 2004 | Volume
| Issue : 2 | Page : 168-169
Cutaneous mucormycosis in a cadaveric renal allograft recipient - a case report
VD Trivedi1, HD Trivedi1, P Dangle1, SA Salve1, U Tendolkar2
1 Department of Urology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, India
2 Department of Microbiology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, India
V D Trivedi
Department of Urology, Lokmanya Tilak Municipal Medical College and Hospital, Sion, Mumbai - 400 022
Source of Support: None, Conflict of Interest: None
Keywords: Fungal infection, immunosuppressed patient.
|How to cite this article:|
Trivedi V D, Trivedi H D, Dangle P, Salve S A, Tendolkar U. Cutaneous mucormycosis in a cadaveric renal allograft recipient - a case report. Indian J Urol 2004;20:168-9
|How to cite this URL:|
Trivedi V D, Trivedi H D, Dangle P, Salve S A, Tendolkar U. Cutaneous mucormycosis in a cadaveric renal allograft recipient - a case report. Indian J Urol [serial online] 2004 [cited 2019 Nov 13];20:168-9. Available from: http://www.indianjurol.com/text.asp?2004/20/2/168/21538
| Case Report|| |
A 59-year-old male, with type II diabetes mellitus and hypertension on treatment was diagnosed to have end stage renal disease (ESRD). He was dialysis dependent. He underwent cadaver renal transplant in April 2002. His serological status was as follows: CMV IgG and IgM-ve, HbsAg -ve, HCV -ve and HIV -ve.
Postoperatively, the graft started functioning within 6 hours and the serum creatinine reached a value of 1.2 mg% on the 7 th postoperative day. Immunosuppression was given in the form of prednisolone, mycophenolate and basilaximab on day one and five. On the 7 th postoperative day, it was observed that the wound margins had blackened, dusky echymotic patches were seen and there was a discharge from the wound. On examination, the discharge showed no bacteria. However, on KOH mount, tissue debrided locally showed aseptate branching hyphae suggestive of mucormycosis [Figure - 1]. All the dead necrotic tissue was radically debrided. Twelve hours later there was further blackening of the skin edges [Figure - 2] and hence daily inspection and several debridements were done for a period of 10 days, until the KOH mount from the edges and floor of the wound showed no evidence of branching hyphae.
Systemic antifungal agent in the form of liposomal amphotericin-B 0.25 mg/kg increased to 0.5 mg/kg over the next 24 hours was started and continued till a total dose of 2 gm in 40 days was reached. In the meanwhile all immunosuppression except prednisolone was stopped. The patient also received twenty sittings of hyperbaric oxygen therapy at 20 litre/sq meter, each sitting of 2 hour duration. Antibiotic cover in the form of levofloxacin (400 mg) od, ceftazidime 1 g iv od, piperacillin 4 g iv od and ampitum 1.5 g iv bd were given for 7 days. The patient had full graft function and his serum creatinine was maintained at 1.2 mg%.
As a result of the radical debridement the patient had a large defect deep to the external oblique aponeurosis occupying one-half of the anterior abdominal wall. This was left to heal by secondary intention as infection of the donor site was a major threat if skin grafting was contemplated.
| Comments|| |
Fungal infections constitute about 5% of the infectious complications of transplant.  Mucormycosis constitutes about 11 % of these infections. It is an invasive disease with both cutaneous and systemic manifestation. It is associated with diabetes, ketoacidosis, steroids, antibiotic therapy, immunosuppression, renal failure, cirrhosis and burns.
Several types of cutaneous forms of this disease have been described, i.e. primary or secondary forms in diabetics, in patients with burns, associated with elastoplast bandages, nodular lesions.of hematogenous seeding and burn wound mucormycosis gangrene. 
All forms of cutaneous involvement are characterized by vessel invasion and black necrotic debris. Typically, these zygomycotic fungi are seen as broad, aseptate and with irregularly branching hyphae on KOH preparation.
As we performed in our patient, daily inspection and debridement is mandatory as this invasive infection spreads very fast.
Hyperbaric oxygen therapy has been shown to inhibit the growth of certain fungi in vitro  and to prevent secondary bacterial infection. On reviewing literature, we found that hyperbaric oxygen has been used to treat rhinocerebral mucormycosis by Rhizopus  but we found no reference for its use in cutaneous mucormycosis.
This is a report of our successful management of cutaneous mucormycosis in a cadaveric renal allograft recipient. The patient has now a follow-up period of about 1½ years with normal graft function.
| References|| |
|1.||Chugh KS, Sakhiya V, Jain S. Fungal infections in renal allograft recipients. Transplant Proc 1992; 24: 1940. |
|2.||Leherer RI and Moderator. Mucormycosis. Ann Int Med 1980; 93(Part I): 93-108. |
|3.||No authors listed. Hyperbaric oxygen halts Rhizopus infection. JAMA 1979; 242: 276. |
[Figure - 1], [Figure - 2]