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Kidney Week

Abstract: TH-PO546

Renal Mucormycosis Presenting as Rapidly Progressive Renal Failure

Session Information

  • Trainee Case Reports - I
    October 25, 2018 | Location: Exhibit Hall, San Diego Convention Center
    Abstract Time: 10:00 AM - 12:00 PM

Category: Trainee Case Reports

  • 102 AKI: Clinical, Outcomes, and Trials

Authors

  • Wang, Aileen, Indiana University School of Medicine, Indianapolis, Indiana, United States
  • Phillips, Carrie L., Indiana University School of Medicine, Indianapolis, Indiana, United States
  • Sharfuddin, Asif A., Indiana University School of Medicine, Indianapolis, Indiana, United States
  • Bacallao, Robert L., Indiana University School of Medicine, Indianapolis, Indiana, United States
Introduction

Mucormycosis is an invasive fungal infection with high mortality (~95% if disseminated). Caused by filamentous fungi in the Zygomycetes class, this infection has become increasingly frequent among immunosuppressed patients. The most common form of invasive mucormycosis is rhino-cerebral, with renal involvement being the rarest. Identification of mucormycosis as the cause of renal failure can be missed due to difficulty of successfully culturing mucorales. We describe a patient with chronic lymphocytic leukemia (CLL) and rapidly progressive renal failure (RPRF) with suspected Richter transformation who was diagnosed with angioinvasive mucormycosis based on renal biopsy specimen.

Case Description

70-year-old Caucasian man with relapsed CLL presented with fevers up to 102°F daily and night sweats. Creatinine (Cr) increased from baseline 1.1 mg/dL to 3.65 on admission. He had been maintained on rituximab/revlimid for the past half-year. He was recently hospitalized for dyspnea and cough, for which he received voriconazole for suspicion of pulmonary aspergillus. PET scan revealed a new metabolically active retroperitoneal mass, while kidneys were unremarkable. Urine sediment showed RBCs, WBCs, and no casts. ANCA was negative. Despite IV fluids and suspension of nephrotoxic drugs, he progressed within one week to anuric renal failure necessitating hemodialysis. CT-guided renal biopsy was performed. Light microscopy showed necrotizing granulomas with multinucleated giant cells and pleomorphic, PAS-positive fungal forms that were interstitial and intra-arterial. Fungi were broad, non-septate, and thick-walled with irregularly spaced branching hyphae typical of mucor. He was immediately treated with liposomal amphotericin-B and IVIG, then isavuconazole for maintenance therapy. He defervesced after initiation of amphotericin-B but remains dialysis-dependent.

Discussion

This is a unique presentation of mucormycosis in a patient with underlying hematological malignancy and RPRF. This biopsy specimen drastically changed management. Manifestation of renal mucormycosis includes hematuria, pyuria and acute renal failure that can mimic RPRF. As mucorales are notoriously difficult to culture and radiologic imaging is nonspecific, histological diagnosis is required. This case speaks to the importance of early biopsy in renal failure of unclear etiology in immunocompromised patients.