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Fatal fungal nephropathy in an immunocompetent host: an interesting case Kiran Preet Malhotra,1 Saumya Shukla,1 Ashish Singhal2 1
Department of Pathology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India 2 Department of Surgical Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India Correspondence to Dr Kiran Preet Malhotra, drkiranpreetmalhotra@yahoo. co.in Accepted 19 October 2015
DESCRIPTION Isolated renal mucormycosis is rarely encountered in immunocompetent individuals. Mucor affects the kidney producing extensive necrosis and vascular thrombosis. Aggressive antifungal therapy is generally attempted in such cases, but the kidney is seldom salvageable and fatality is high. We report a unique case of fatal renal rupture and infarction presenting in an immunocompetent host who presented with fever of unknown cause. A 50-year-old patient without diabetes presented to the emergency department in a state of shock. This was preceded by low-grade fever and malaise for 10 days, with reports of moderate lymphocytosis and an erythrocyte sedimentation rate of 42 mm. Chest X-ray was normal and urinalysis showed haematuria, but no bacterial growth was seen on urine and blood cultures. A CT of the abdomen revealed a ruptured right kidney. The nephrectomy specimen showed an irregular rupture across the lower pole and cortical infarcts (figure 1). Extensive renal parenchymal necrosis and vascular thrombi were present along with numerous broad-based aseptate fungal hyphae consistent with Mucor (figure 2). Prompt amphotericin therapy was instituted; however, the patient succumbed to the illness. A fungal blood culture report available posthumously was negative. Isolated renal mucormycosis is of rare occurrence and may be consequent to haematological spread from a silent pulmonary lesion or an ascending infection from the urinary tract.1 There was no evidence of known predisposing factors such as HIV infection, diabetes, intravenous drug use,
Figure 2 Photomicrograph showing necrosed (arrow head) renal parenchyma with several broad fungal hyphae; some showing branching at right angles (arrow) ( periodic acid-Schiff staining, ×400). alcoholism, malnutrition or renal transplantation in our case. Rare cases of renal mucormycosis in immunocompetent individuals have been reported; however, this is the first such case with consequent renal rupture and fatality.1–3
Learning points ▸ Renal mucormycosis is generally encountered in immunosuppressed individuals though rare cases may present as fever of unknown origin in immunocompetent patients. ▸ The combination of benign clinical findings with negative blood cultures and paradoxical severe inflammation on CT scan should raise suspicion for infection with angio-invasive organisms such as Mucor. ▸ Renal infarcts, rupture and high fatality are the norm. Contributors KPM was involved in making the pathological diagnosis of the case, and conceptualising and writing the draft of the article. SS was involved in making the pathological diagnosis of the case and writing the draft of the article. AS was the treating physician of the case and contributed clinical data, and assisted in writing the case. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES To cite: Malhotra KP, Shukla S, Singhal A. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015212244
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Figure 1 Nephrectomy specimen showing a rupture across the hilum and lower pole and an infarct at the upper pole (arrow).
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Chakrabarti A, Singh R. Mucormycosis in India: unique features. Mycoses 2014;57(Suppl 3):85–90. Singh SK, Wadhwa P, Sakhuja V. Isolated bilateral renal mucormycosis. Urology 2004;63:979–80. Gupta V, Singh SK, Kakkar N, et al. Splenic and renal mucormycosis in a healthy host: successful management by aggressive treatment. Trop Gastroenterol 2010;31:57–8.
Malhotra KP, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-212244
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Copyright 2015 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
2
Malhotra KP, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-212244
Fatal fungal nephropathy in an immunocompetent host: an interesting case Kiran Preet Malhotra,1 Saumya Shukla,1 Ashish Singhal2 1
Department of Pathology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India 2 Department of Surgical Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India Correspondence to Dr Kiran Preet Malhotra, drkiranpreetmalhotra@yahoo. co.in Accepted 19 October 2015
DESCRIPTION Isolated renal mucormycosis is rarely encountered in immunocompetent individuals. Mucor affects the kidney producing extensive necrosis and vascular thrombosis. Aggressive antifungal therapy is generally attempted in such cases, but the kidney is seldom salvageable and fatality is high. We report a unique case of fatal renal rupture and infarction presenting in an immunocompetent host who presented with fever of unknown cause. A 50-year-old patient without diabetes presented to the emergency department in a state of shock. This was preceded by low-grade fever and malaise for 10 days, with reports of moderate lymphocytosis and an erythrocyte sedimentation rate of 42 mm. Chest X-ray was normal and urinalysis showed haematuria, but no bacterial growth was seen on urine and blood cultures. A CT of the abdomen revealed a ruptured right kidney. The nephrectomy specimen showed an irregular rupture across the lower pole and cortical infarcts (figure 1). Extensive renal parenchymal necrosis and vascular thrombi were present along with numerous broad-based aseptate fungal hyphae consistent with Mucor (figure 2). Prompt amphotericin therapy was instituted; however, the patient succumbed to the illness. A fungal blood culture report available posthumously was negative. Isolated renal mucormycosis is of rare occurrence and may be consequent to haematological spread from a silent pulmonary lesion or an ascending infection from the urinary tract.1 There was no evidence of known predisposing factors such as HIV infection, diabetes, intravenous drug use,
Figure 2 Photomicrograph showing necrosed (arrow head) renal parenchyma with several broad fungal hyphae; some showing branching at right angles (arrow) ( periodic acid-Schiff staining, ×400). alcoholism, malnutrition or renal transplantation in our case. Rare cases of renal mucormycosis in immunocompetent individuals have been reported; however, this is the first such case with consequent renal rupture and fatality.1–3
Learning points ▸ Renal mucormycosis is generally encountered in immunosuppressed individuals though rare cases may present as fever of unknown origin in immunocompetent patients. ▸ The combination of benign clinical findings with negative blood cultures and paradoxical severe inflammation on CT scan should raise suspicion for infection with angio-invasive organisms such as Mucor. ▸ Renal infarcts, rupture and high fatality are the norm. Contributors KPM was involved in making the pathological diagnosis of the case, and conceptualising and writing the draft of the article. SS was involved in making the pathological diagnosis of the case and writing the draft of the article. AS was the treating physician of the case and contributed clinical data, and assisted in writing the case. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES To cite: Malhotra KP, Shukla S, Singhal A. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015212244
1 2
Figure 1 Nephrectomy specimen showing a rupture across the hilum and lower pole and an infarct at the upper pole (arrow).
3
Chakrabarti A, Singh R. Mucormycosis in India: unique features. Mycoses 2014;57(Suppl 3):85–90. Singh SK, Wadhwa P, Sakhuja V. Isolated bilateral renal mucormycosis. Urology 2004;63:979–80. Gupta V, Singh SK, Kakkar N, et al. Splenic and renal mucormycosis in a healthy host: successful management by aggressive treatment. Trop Gastroenterol 2010;31:57–8.
Malhotra KP, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-212244
1
Images in…
Copyright 2015 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
2
Malhotra KP, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-212244
