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CASE REPORT
Year : 2006  |  Volume : 22  |  Issue : 2  |  Page : 144-145
 

Isolated mucormycosis of renal allograft


1 Departments of Pathology, Kamineni Hospitals, Hyderabad, India
2 Departments of Urology, Kamineni Hospitals, Hyderabad, India
3 Departments of Nephrology, Kamineni Hospitals, Hyderabad, India

Correspondence Address:
S Radha
Dept of Pathology, Kamineni Hospitals, Hyderabad, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.26572

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   Abstract 

Infections continue to be a significant cause of morbidity and mortality in renal transplant recipients, as they are susceptible to opportunistic infections. During the first post- transplant year, two thirds of transplant recipients experience at least one infection. Infectious agents commonly implicated are BK polyoma virus, Cytomegalo virus and Ebstein Barr virus. Filamentous fungal infections are rare in the kidney. 5% of infections in transplant recipients are due to fungi.We report a rare case of isolated renal graft mucormycosis.


Keywords: Allograft, mucormycosis, renal


How to cite this article:
Radha S, Afroz T, Raju B, Fernandez D K. Isolated mucormycosis of renal allograft. Indian J Urol 2006;22:144-5

How to cite this URL:
Radha S, Afroz T, Raju B, Fernandez D K. Isolated mucormycosis of renal allograft. Indian J Urol [serial online] 2006 [cited 2019 Nov 11];22:144-5. Available from: http://www.indianjurol.com/text.asp?2006/22/2/144/26572


Mucormycosis is a rare opportunistic infection caused by fungi of the order, Mucorales. Renal involvement in disseminated mucormycosis ranges from 14-19%. Isolated renal mucormycosis is extremely rare; only few cases have been reported in English literature.[1] Immunosuppressive therapy and underlying medical conditions like diabetes and liver disease place the recipient at an increased risk for fungal infections. Infection due to mucorales is rare with potentially lethal complication. A high index of suspicion leading to early diagnosis and initiation of antifungal treatment, in addition to graft nephrectomy are keys to a favourable outcome.


   Case Report Top


A 52-year male presented with hypertension of one-year duration, nausea and vomitting of ten days duration. Evaluation revealed that the patient had advanced renal failure and bilateral contracted kidneys. The patient was initiated on hemodialysis and was advised to undergo hemodialysis thrice weekly, till renal transplantation. Two months later, he underwent a renal transplantation from a cadaver graft. Induction was with Basiliximab. Post operatively, he had oliguria lasting for two days with hyperkalemia and required a session of hemodialysis. His urine output and renal functions improved. Patient received methyl prednisolone starting with 500 mgs and cyclosporine-10 mgs/kg was started from the seventh post-transplant day. He was put on ganciclovir and fluconazole, as antiviral and antifungal prophylaxis. Ganciclovir was started at a dose of 125 mg twice daily and Fluconazole at 200 mg once daily. The doses were adjusted according to the creatinine clearance. He was discharged on the fourteenth postoperative day with a serum creatinine of 1.5 mg% and on immunosuppression of prednisolone- 20 mgs and cyclosporine, the dose of which was adjusted based on cyclosporine trough levels. On a routine regular follow up two months post transplant, there was asymptomatic rise of serum creatinine upto 4.9 mgs%. He was subjected to graft biopsy, which revealed acute rejection- Banff type 2. He was started on OKT-3 rescue, since the patient did not respond to three doses of 500 mgs of methyl prednisolone. There was no response to OKT-3. His renal functions worsened and the patient developed high-grade fever, severe graft tenderness and hematuria. His investigations revealed a total count of 24000/cumm, with a differential count of 95% neutrophils. His urine and blood cultures were sterile. Graft Doppler revealed a bulky graft with increased resistive index. He was subjected to emergency graft nephrectomy.


   Results Top


Pathology findings

The Nephrectomy specimen weighed 560 gms and measured 16 x 7 cms. The surface had multiple petechial hemorrhages. Cut surface revealed multiple necrotic areas. Microscopic examination revealed dense neutrophilic infiltration with focal giant cell reaction. There were broad nonseptate branching fungal mycelia. Silver Methenamine stains confirmed the morphology [Figure - 1]. Cultures were positive for mucor species.

Follow up

He was treated with amphotericin B and flucanozole and was discharged with an advice to continue hemodialysis.


   Discussion Top


Renal allograft mucormycosis is extremely rare. Few cases have been described till date.[1] Inspite of improvements in immunosuppressive therapy and surgical techniques, fungal infections remain a significant cause of morbidity and mortality in organ transplant recipients. Risk factors includes diabetes, chronic liver disease, reoperation, operative hemodialysis and use of monoclonal antibodies.[2] More than 90% of fungal infections belong to fungi imperfectii, such as aspergillosis, candidiasis, mucormycosis, coccidiodomycoses, histoplasmosis and paracoccidiodomycoses. Zygomycosis is a ubiquitous fungus and is found in decaying vegetative organic matter. They have minimal intrinsic pathogenicity, but can cause grave and often fatal infections in an immunocompromised host. Rhinocerebral mucormycosis is the most common presentation of mucormycosis in renal allograft recipients. Depending upon the portal of entry, well known clinical presentations of mucormycosis is described. Extrapulmonary sites like rhino cerebral, renal allograft and gastrointestinal infections have been reported.[3] Isolated renal involvement is rare.[4] Renal involvement of fungi has been found to be associated with increased morbidity and mortality, particularly in case of infections with angioinvasive fungi like aspergillus and mucormycosis.[4] The overall survival for different forms of mucormycosis varies from 33%-100%. Mortality in isolated renal mucormycosis is 52%.[5] Early tissue diagnosis and prolonged treatment with antifungal agents are required for eradication of these invasive infections. Our patient was treated with graft nephrectomy, followed by antifungal treatment. He had an uneventful recovery and is on hemodialysis.

 
   References Top

1.Mufazzal Ahmad. Graft mucormycosis in renal allograft recipient. J Nephrol 2005;18:783-86.  Back to cited text no. 1    
2.John GT. Infections after renal transplantation in India. Transplant Rev 1999;13:183-91.  Back to cited text no. 2    
3.Latif S, Saffarian N, Bellovich K, Provenzano R. Pulmonary mucormycosis in diabetic renal allograft recipients. Am J Kidney Dis 1997;29:461-4.  Back to cited text no. 3  [PUBMED]  
4.Gupta KL. Fungal infections of the kidney. Indian J Nephrol 2001;11:147-54.  Back to cited text no. 4    
5.Aarset H, Aasarod K, Bergan U, Angelsen A. Acute renal infarction in a woman with slight asthma. Nephrol Dial Transplant 2001;16:1711-2.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]


    Figures

  [Figure - 1]

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