Abstract: SA-PO1123
Allograft Mucormycosis Presenting as AKI
Session Information
- Transplant Trainee Case Reports
November 09, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 1902 Transplantation: Clinical
Authors
- Liaqat, Aimen, Saint Barnabas Medical Center, Livingston, New Jersey, United States
- Kandula, Praveen, Saint Barnabas Medical Center, Livingston, New Jersey, United States
- Adeboye, Adedamola M., Newark Beth Israel Medical Center, Newark, New Jersey, United States
- Khan, Hameeda, Saint Barnabas Medical Center, Livingston, New Jersey, United States
Introduction
Mucormycosis is a life-threatening complication of kidney transplantation associated with a 50% mortality rate. About 25 cases of renal involvement have been reported in the literature.
Case Description
A 62-year-old asymptomatic diabetic male was seen in the clinic 6 weeks after an uncomplicated 0 antigen mismatch living donor kidney transplant from his sister. He received basiliximab induction and standard immunosuppression. Labs showed an acute rise in creatinine (0.8 mg/dl to 1.5 mg/dl). Transplant ultrasound revealed hydronephrosis and creatinine worsened despite stent placement. Allograft biopsy was negative for rejection. His graft function worsened and dialysis was started on day 5. A nuclear scan showed decreased uptake in upper and middle poles. Intra-operative allograft exploration, biopsy and angiogram on day 7 revealed good perfusion but fungal hyphae were seen. A pulmonary nodule was seen on Chest X-ray ordered for worsening respiratory status on day 7. Whole body imaging revealed 3 scattered, cavitary pulmonary nodules suggesting disseminated fungal disease. Emergent transplant nephrectomy was performed and a repeat wedge biopsy revealed hyphae in the glomerular, tubular and vascular segments suggestive of allograft mucormycosis. Immunosuppression was stopped and Amphotericin was initiated.
Discussion
Risk factors in the post-transplant period include heightened immunosuppression (induction and anti-rejection therapy), diabetes, donor transmission, surgical contamination or presence of immunomodulating viruses (CMV and Hepatitis C). Being angioinvasive, mucor leads to thrombosis, ischemia or irreversible tissue necrosis. Histopathology is diagnostic and demonstrates ribbon-like, aseptate hyphae with wide angled branching. Blood and tissue cultures have a poor diagnostic yield. Management includes extensive surgical debridement, graft removal and antifungal agents. Amphotericin is the first line drug and posaconazole has been used as a step down or salvage therapy. Experimental therapies with iron chelation, hyperbaric chamber and cytokines (like G-CSF) have been tried with minimal benefits.
Diagnostic challenges such as lack of serological tests, isolation difficulties and poor staining techniques delay recognition. A high index of clinical suspicion and prompt action with aggressive surgical resection and anti-fungal therapy is necessary for a favorable outcome.