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Kidney Week

Abstract: TH-PO133

Renal Amyloidosis and Intracranial Mucormycosis in an Intravenous Drug User

Session Information

Category: Trainee Case Report

  • 102 AKI: Clinical, Outcomes, and Trials

Authors

  • Yu, Mon-Wei, Massachusetts General Hospital, Newton, Massachusetts, United States
  • Verma, Ashish, Massachusetts General Hospital, Newton, Massachusetts, United States
  • Klepeis, Veronica E., Massachusetts General Hospital, Newton, Massachusetts, United States
  • Rhee, Eugene P., Massachusetts General Hospital, Newton, Massachusetts, United States
  • Fenves, Andrew Z., Massachusetts General Hospital, Newton, Massachusetts, United States
Introduction

Mucormycosis is a rare but fatal fungal infection commonly seen in immunocompromised states such as end-stage kidney disease and post-renal transplantation. Here we report a unique case of invasive mucormycosis associated with severe acidemia in a patient with impaired renal function and AA amyloidosis.

Case Description

A 37-year-old Caucasian man with a history of active intravenous drug use including heroin was admitted for one week of slurred speech, right-sided weakness and right facial droop. CTH showed a 2x3 cm lesion in the left deep frontal white matter with surrounding vasogenic edema. His labs showed a serum creatinine (SCr) of 15.04 mg/dL (estimated GFR: 4 mL/min/1.73m2), BUN of 120 mg/dL, and bicarbonate of 10 mmol/L. The pH and pCO2 of the first venous gas were 7.14 and 28 mmHg respectively. His urinalysis was positive for 3+ glucose with a pH of 8.0. A spot urine protein/creatinine ratio was 6.87. A brain biopsy confirmed the diagnosis of mucormycosis and a renal biopsy was subsequently performed. Outcomes: The patient received maintenance isotonic bicarbonate fluid with daily urine output about 3-4L. His SCr improved but plateaued at 7 mg/dL. A course of IV amphotericin B, IV micafungin, and oral posaconazole were implemented. Renal biopsy (Fig.1) demonstrated AA amyloidosis, with greater than 90% of glomeruli showing mostly global involvement by amyloid. There was also vascular and tubulointerstitial involvement, and approximately 70-80% interstitial fibrosis and tubular atrophy were noted. He was eventually started on peritoneal dialysis and remains on posaconazole.

Discussion

Invasive intracranial mucormycosis can occur in patients with profound acidemia. Therefore, aggressive bicarbonate repletion is essential to control the infection in addition to appropriate antibiotic treatment. Glucosuria and bicarbonate wasting in our patient may suggest proximal tubular injury from AA amyloidosis. A comprehensive history taking is pivotal to diagnose heroin-related AA amyloidosis, which results from chronic subcutaneous injections.