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Kidney Week

Abstract: SA-PO032

Focal Fungal Granulomatous Interstitial Nephritis on a Background of Class II Lupus Glomerulonephritis

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical‚ Outcomes‚ and Trials

Authors

  • Martinez Pitre, Pedro J., Ochsner Medical Center, New Orleans, Louisiana, United States
  • Stark, Ana Isabel, Ochsner Medical Center, New Orleans, Louisiana, United States
  • Fernandez-Correa, Tomas, Ochsner Medical Center, New Orleans, Louisiana, United States
  • Velagapudi, Ramya Krishna, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Lusco, Mark, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Velez, Juan Carlos Q., Ochsner Medical Center, New Orleans, Louisiana, United States
  • Bodana, Shirisha, Ochsner Medical Center, New Orleans, Louisiana, United States

Group or Team Name

  • Ochsner Nephrology
Introduction

Fungal infections are an exceedingly rare form of granulomatous interstitial nephritis (GIN). Most cases of GIN are associated with sarcoidosis or drug exposure. The most common etiology of infectious GIN is mycobacteria. Herein, we report a case of fungal GIN diagnosed in a patient with systemic lupus erythematous (SLE) receiving low-dose corticosteroids.

Case Description

A 54-year-old woman was hospitalized with acute respiratory failure, acute kidney injury (AKI), anemia and thrombocytopenia following 2 weeks of generalized weakness and altered mental status. The patient had a medical history of SLE and remote history of class III and V SLE glomerulonephritis (GN) for which she had received immunosuppression 27 years prior to presentation. Current medications included low-dose prednisone, hydroxychloroquine, nifedipine, furosemide and insulin glargine. Upon arrival, she was noted to be hypotensive and oliguric. Laboratory data showed a serum creatinine of 3.4 mg/dL (baseline 1.0 mg/dL). Urinalysis revealed hematuria, proteinuria and leukocyturia. Urine microscopy revealed budding yeast and pseudohyphae. Urine culture was negative and blood culture was positive for Proteus mirabilis. CT of the abdomen revealed bilateral perinephric stranding consistent with pyelonephritis. She was started on broad spectrum antibiotics, pulse steroids for possible SLE flare, and dialysis for volume and metabolic derangements. Kidney biopsy was performed for suspected relapse of SLE-GN. Specimen revealed acute tubular necrosis, class II SLE-GN (activity index 0) and focal fungal granuloma with budding yeast and hyphae (by electron microscopy). Repeat cultures grew Candida albicans and Candida glabrata in blood and Candida albicans in the urine. The patient was started on liposomal amphotericin B and her kidney function recovered to a serum creatinine of 1.0 mg/dL.

Discussion

Candiduria is a common finding on routine evaluation of hospitalized patients with AKI and often represents colonization or a urinary tract infection. However, in the context of immunosuppression, those findings should raise suspicion for fungal GIN, as shown in this case, so that appropriate intervention can be promptly implemented.