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NEPHROLOGY IMAGE
Year : 2022  |  Volume : 16  |  Issue : 2  |  Page : 237-238

An unanticipated fatal infection after kidney transplantation


Department of Nephrology and Kidney Transplantation, Virinchi Hospitals, Hyderabad, Telangana, India

Date of Submission08-Dec-2021
Date of Acceptance05-Apr-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Dr. Praveen Kumar Etta
Department of Nephrology and Kidney Transplantation, Virinchi Hospitals, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_130_21

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How to cite this article:
Etta PK, Madhavi T, Panjwani RS. An unanticipated fatal infection after kidney transplantation. Indian J Transplant 2022;16:237-8

How to cite this URL:
Etta PK, Madhavi T, Panjwani RS. An unanticipated fatal infection after kidney transplantation. Indian J Transplant [serial online] 2022 [cited 2022 Aug 15];16:237-8. Available from: https://www.ijtonline.in/text.asp?2022/16/2/237/349369



In India, we have witnessed an epidemic of mucormycosis (MM) during COVID-19 pandemic recently. We present a case of fatal rhino-orbital MM caused by Mucor at 2 years after kidney transplantation, following recovery from COVID-19 of moderate severity. He was on standard triple-drug maintenance immunosuppression, i.e., steroids, tacrolimus, and mycophenolate mofetil. His posttransplant course was uneventful until he was affected with COVID-19, about 1 month ago. He was treated elsewhere and received parenteral steroids and anticoagulants for COVID-19. Tissue biopsy from nasal sinuses showed broad, nonseptate filamentous fungal hyphae [Figure 1]. Later, culture confirmed Mucor as the causative pathogen.
Figure 1: (a) KOH mount showed broad, nonseptate, irregular nondichotomous right-angled branching filamentous fungal hyphae characteristic of mucormycosis. (b) Lactophenol cotton blue staining of growth on Sabouraud dextrose agar revealed that broad, nonseptate hyphae, and sporangiophores are long, branched with terminal round, spore-filled sporangia with no rhizoids, confirming it as Mucor (pin mold)

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Filamentous fungi (molds) grow by apical extension of their filaments, known as hyphae. They also produce asexual (conidiophores or sporangiophores) and sexual reproductive structures. The characteristics of these structures help in differentiation of two clinically important subtypes of molds, i.e., MM and Aspergillus. Most cases of MM (zygomycosis or phycomycosis) are caused by those of the order Mucorales, which include genera Rhizopus (most common pathogen), Mucor, Rhizomucor, Lichtheimia (Absidia), Apophysomyces, and Cunninghamella. They are vasotropic and angio-invasive, usually affecting immunocompromised patients including transplant recipients as an opportunistic infection. Rhino-orbital-cerebral MM is the most common form. Invasive aspergillosis primarily affects respiratory system, but dissemination can occur in immunocompromised hosts. Aspergillus fumigatus is the most common etiologic agent, being responsible for ~90% of human infections. Aspergillus flavus, Aspergillus terreus, Aspergillus niger, and Aspergillus nidulans can also cause human infections.

Mucorales are characterized by broad (5–20 μm), irregular, varying caliber, ribbon-like hyphae with little or no septations, and random, irregular, nondichotomous right-angled branching with the presence of sporangiophores, whereas Aspergillus species show thinner (3–6 μm), uniform caliber and septate hyphae with regular dichotomous acute angled (45°) branching with the presence of conidiophores. Mucorales are difficult to culture, and often, cultures are negative due to unviable organisms in necrotic tissues. Sometimes, colonies of Mucorales show cotton candy appearance. Rhizopus (black mold) is characterized by the presence of rhizoids at branch points of sporangiophores, whereas Mucor (pin mold) does not have rhizoids, stolons, and apophyses but has branched sporangiophores.

Our patient was found to have Mucor as the causative pathogen [Figure 1]. He was treated with extensive debridement along with liposomal amphotericin B (5 mg/kg/day). Later, parenteral posaconazole was also added as there was no improvement. The patient continued to deteriorate and eventually succumbed from septic shock, with near-normal graft function. The delay in diagnosis, surgical debridement, and antifungal therapy are associated with high mortality in MM.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.




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