Isolated bilateral renal mucormycosis in apparently immunocompetent patients-a case series from India and review of the literature

• Published in: Clinical kidney journal Vol. 11; no. 6; pp. 769 - 776
• Main Authors: Bhadauria, Dharmendra, Etta, Praveen, Chelappan, Anand, Gurjar, Mohan, Kaul, Anupma, Sharma, Raj Kumar, Gupta, Amit, Prasad, Narayan, Marak, Rungmei S, Jain, Manoj, Srivastava, Aneesh, Lal, Hira
• Format: Journal Article
• Language: English
• Published: England Oxford University Press 01.12.2018
• Subjects: Amphotericin B; Antiparasitic agents; Epidemiology; Health aspects; Infection; Kidney diseases; Mucormycosis; Posaconazole; Risk factors; India; posaconazole; immunocompetent; isolated renal mucormycosis; nephrectomy; amphotericin B
• ISSN: 2048-8505; 2048-8513
• DOI: 10.1093/ckj/sfy034

ABSTRACT Background Isolated renal mucormycosis (IRM) is a potentially fatal disease affecting immunocompromised hosts. IRM affecting apparently immunocompetent patients is rare, with few previous reports, mostly from India. We describe 10 cases of bilateral IRM with no underlying risk factors. Methods We performed a retrospective analysis of cases of IRM from our hospital information system admitted between 2009 and 2016. We analyzed the data of this cohort of IRM, including epidemiological characteristics, clinical presentation, diagnostic procedures, treatment details and outcome. Results In all, 10 cases of bilateral IRM were identified. All of them were males with a mean age of 24.7 years (range 10-42). Most patients were initially managed as acute bacterial pyelonephritis with acute kidney injury. A total of eight patients were diagnosed antemortem. Diagnostic clues include sepsis not controlled with broad-spectrum antibiotics and enlarged kidneys with or without hypodensities on ultrasound/computed tomography imaging. Three patients also gave a specific history of passing white flakes in their urine. Eight patients received specific antifungal therapy with amphotericin B with or without posaconazole. Three patients in whom the disease was apparently confined to the pelvicalyceal system underwent local irrigation with Amp-B. One patient underwent bilateral nephrectomy. Four patients succumbed to the disease while five patients were successfully treated. One patient was discharged against medical advice. Conclusions IRM is a rare, life-threatening disease associated with high mortality even in immunocompetent individuals. Typical clinical and radiological findings and a high index of suspicion may help in early diagnosis, but definitive diagnosis requires histopathological and/or microbiological confirmation. Early and rapid diagnosis along with aggressive multidisciplinary management including initiation of specific antifungal therapy with or without surgical debridement is vital for a successful outcome.