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 MUCORMYCOSIS OF TRANSPLANTED KIDNEY

BG Ponnappa*, D Venugopal**, Simran Singh***,M Paul Korath****, K Jagadeesan*****
*Registrar in Surgery; **Registrar in Medicine; ***Resident in Radiology; ****Chief Physician; *****Director, KJ Hospital, Chennai - 600 084.

A 30 year old lady suffering from chronic renal failure underwent renal transplantation. Post operatively she developed graft dysfunction for which she was initially treated as rejection. Subsequently it was found that she had mucormycosis of the graft kidney. This case is discussed with relevant literature.

CASE REPORT

A 30 year old female, known case of end stage renal disease was admitted to our hospital for renal replacement therapy. She was well until a year ago when she developed nausea, vomiting and increasing fatiguability for which she was evaluated elsewhere and found to be suffering from chronic renal failure. There was no significant past history. Family history was non contributory. She was a house wife and has a 12 yrs old male child. She was treated elsewhere initially with a couple of peritoneal dialysis and later with regular haemodialysis. After initiation of haemodialysis she developed refractory ascites which was treated elsewhere with repeated therapeutic abdominal paracentesis. She was not a diabetic.

On physical examination she was thin built. Her vital signs were normal except for high blood pressure (BP 160/100 mm of Hg). There was mild pallor and pedal oedema. An infected AV fistula wound was noted on the left fore arm. Abdominal examination revealed tense ascites. Other principal systems examinations were normal.

Laboratory work up revealed low haematocrit value, elevated blood urea and serum creatinine, reversed albumin and globulin ratio with mildly elevated serum aminotransferase levels and markedly reduced 24 hr. urinary creatinine clearance. Other laboratory parameters were well within normal limits. CT scan of the abdomen showed granular contracted kidneys, ascites and a right renal cyst. She was put on regular haemodialysis. Her blood pressure was controlled with antihypertensive therapy. She was given multiple packed cell transfusions and injection erythropoietin to build up haemoglobin level in addition to iron and vitamin supplements. Large volume therapeutic paracentesis was done with albumin infusion. During her long stay in the hospital she also had recurrent fever with persistent elevated polymorphonuclear leucocytosis for which she was treated with various antibiotic regimens. However no definite source of infection could be made out. Investigations for koch’s infection including a PCR were negative. After adequate preparation she underwent live related heterotopic renal transplant under epidural anaesthesia. In the immediate post operative period her graft kidney started functioning well with adequate urine output and her general condition was steadily improving. Triple drug immunosuppressive therapy consisting of cyclosporin, azathioprine and steroids were continued with dosage adjustment on day to day basis depending on her clinical condition, white cell count and serum drug levels. However on the 4th post operative day her urine out put suddenly reduced and she complained of mild dyspnoea. Blood counts done revealed neutrophilic leucocytosis and lymphcytosis. Blood urea and serum creatinine levels were elevated. She was treated with anti-rejection steroid pulse therapy for the next 3 days. However her graft function further deteriorated. She became anuric and developed pulmonary oedema. Emergency haemodialysis was done. On the 8th post operative day she developed multiple erythematous tender intracutaneous nodules in the territory of right femoral artery. Ultrasound scan of the graft kidney revealed minimal periallograft collection. A diagnostic biopsy of the graft kidney was performed and the specimen processed by microwave technique and reported on the same day which showed cortical necrosis with infection by mucor mycosis. Biopsy of the intracutaneous nodules also showed mucor mycosis. She was started on liposomal amphotericin infusion. The next day her right lower limb was cold and cyanosed, no pulsations below right femoral artery could be palpable. Emergency graft nephrectomy and revascularisation procedure was carried out under local anaesthesia. Post operatively her right lower limb became warm and doppler study could pick up vascular flow signal. However the persistent hypotension did not respond to inotropic support and the next day she succumbed to her illness.

DISCUSSION

Mucor mycosis is a dreaded fungal infectioncaused by fungi of the order mucorales and German Rhizipine, Absidia and Mucor. [1] These fungi are usually found in vegetative and organic matter and have minimal intrinsic pathogenicity. However it can cause serious and fatal infection in immunocompromised conditions especially in patients who have diabetic ketoacidosis, viral hepatitis, chronic renal failure and post transplant patients on immunosuppressive therapy. [2-4] The usual portal of entry includes infection through inhalation, ingestion, contamination of skin wounds or via vascular channels such as intravenous drips. The clinical presentation of mucor mycosis depending on the portal of entry, includes rhinocerebral, pulmonary, gastrointestinal, disseminated and miscellaneous forms involving isolated organs like bone, heart and kidneys.

In one study 22% renal involvement was reported in patients with disseminated mucor mycosis. [5] Berenguer et al reported one case of mucor mycosis in renal allograft patient. [6] Isolated renal involvement is a rarity even in immunocompromised host. Veera et al reported a case of renal mucor mycosis in a patient infected with human immunodeficiency virus. [7,8]

In our case there was evidence of mucor mycosis in the renal graft causing thrombosis of anastomotic vessels and the right femoral artery. The possibility of catheter related peritoneal seeding of mucor mycosis infection due to peritoneal dialysis was strongly considered which could have flared up due to immunosuppressive therapy resulting in loss of graft function.

The treatment of choice for renal mucor mycosis is intravenous amphotericin B and early nephrectomy. Recently liposomal preparation of amphotericin B has been found to be less toxic and more effective than the conventional amphotericin B. [8] However the delay in diagnosis and late administration of therapy results in a high mortality. The case in discussion was administered liposomal amphotericin B immediately on diagnosis of mucor mycosis and the graft nephrectomy was done the next day when right lower limb vascular thrombosis supervened.

CONCLUSION

This case illustrates the need for a high index of clinical suspicion, early diagnosis and treatment of mucor mycosis in renal allograft patient who develop sudden deterioration of graft function. In such situations suspecting acute graft rejection is not unusual, but it would be prudent for the treating renal physician to exclude the possibility of mucor mycosis or other fungal infection of graft kidney before administering high dose steroid pulse therapy. Failure of early diagnosis of mucor mycosis infection of graft kidney is a disaster in patients receiving high dose of immunosuppressive drugs.

REFERENCES

  1. Ulise GJ, Silver DA. Fungal infection of the genitourinary system. J Urol 1993; 149 : 1377-88.
  2. Lehrer RI, Horward DH, Syphered PS, Edwards JE, Segal GP, Ulinston DJ. Mucormycosis review. Ann Intern Med 1980; 93-108.
  3. Gupta KL, Radotra BD, Sakhuja V, Banerjee AK, Chugh KS. Mucormycosis in patients with renal failure. Rn fail 1990; 11 : 195-99.
  4. Levy E, Bia MJ. Isolated renal mucormycosis, case and report and review. J Am Soc Nephrol 1995; 5 : 2014-19.
  5. Ingram CW, Sennesh J, Cooper JN, Prefet JR. Disseminated Zygomycosis. Report of four cases and review. Rew Infet Dis 1989; 11 : 741-54.
  6. Berenguer J, Seleva J, Moreno S, Munoz P, Parras P. Mucor mycosis. The disease spectrum in 13 patients. Med Clin Base May 26, 1990; 94 (20) : 766-72.
  7. Veera J, Biellsa O, Arango O, Hado C, Gelabert A. Massive renal infarction in an aids patient. Infection Jul-Aug. 1992; 20 (4) : 234-6.
  8. Ng TT, Dennigo DW. Liposomal Amphotericin B (Ambisome) therapy in massive fungal infection. Evaluation of United Kingdom com passionate use data. Arch Intern Med 1995; 155 : 1093-98.

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