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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2011  |  Volume : 22  |  Issue : 1  |  Page : 134-135
Insulin site wound in a renal allograft recipient


Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India

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Date of Web Publication30-Dec-2010
 

How to cite this article:
Gupta A, Lal C, Dogra PM, Mahajan S, Agarwal SK. Insulin site wound in a renal allograft recipient. Saudi J Kidney Dis Transpl 2011;22:134-5

How to cite this URL:
Gupta A, Lal C, Dogra PM, Mahajan S, Agarwal SK. Insulin site wound in a renal allograft recipient. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Nov 11];22:134-5. Available from: http://www.sjkdt.org/text.asp?2011/22/1/134/74388
To the Editor,

A 56-year-old gentleman received live unre­lated renal transplant for his native kidney di­sease being diabetic nephropathy. He was on hemodialysis for two years prior to renal trans­plant. He got induction with antithymocyte glo­bulin and was maintained on prednisolone (10 mg/day), tacrolimus (4 mg/day) and mycophe­nolate mofetil (1000 mg/day). He was on insu­lin injections subcutaneously and the preferred site was abdominal wall. His clinical course was uneventful for the first four months after trans­plantation, when he stopped tacrolimus without medical advice. He developed biopsy proven acute cellular rejection grade 1b, and his serum creatinine increased to 3.0 mg/dL. He was given intravenous methyl prednisolone 750 mg for three days along with increasing the dose of mycophenolate to 1500 mg/day and reintro­duction of tacrolimus. He did not respond and also developed minor furuncle at the anterior abdominal wall at the site of subcutaneous in­sulin injection. This gradually increased in size over the next two weeks and became an oval, well-defined 15 cm Χ 10 cm ulcer with necrosis around the tissue [Figure 1]. His HbA1c was 8%. He received oral antibiotics from his pri­mary care physician but without any improve­ment. He later developed septic encephalopathy along with further graft dysfunction (serum creatinine 3.5 mg/dL) and was referred to our hospital. His mycophenolate and tacrolimus were stopped in view of life threatening sepsis. Blood glucose was controlled and broad spectrum antibiotics covering gram positive, gram negative and anaerobes were initiated. He re­ceived multiple sittings of debridement under surgery care. Blood and wound swab cultures were sterile. Microscopic examination of wound swab grew mucor from local site [Figure 2]. Patient was started on conventional amphotericin B at 1 mg/kg/day. He received a total of 2 g of amphotericin B over six weeks. Gradually, the wound became healthy with granulation tissue started appearing at the edges and the graft function started improving. There was no recur­rence of any growth, which was confirmed by potassium hydroxide wet mount preparation and culture of the wound. Patient was discharged with alternate day dressings.
Figure 1: The abdominal wall ulcer with necrotic margin and floor showing white, cottony filamentous growth.

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Figure 2: Potassium hydroxide wet mount preparation showing non-septate hyphae of mucormycosis (× 400).

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Primary cutaneous mucormycosis is a rela­tively rare entity in renal transplant patients. For example, only 19 of 310 (6.1%) recipients of live related renal transplants had documented systemic fungal infections, with only two having mucormycosis (non-cutaneous). [1] Infection of skin and soft tissues with zygomycetes results from inoculation of the spores into the dermis.

Fungal entry into the dermis has been associa­ted with intravenous catheters, [2] surgical wounds and trauma. [3] Our patient had insulin site as the probable inoculation source. Such a life-threa­tening fungal infection from a complication of local insulin site injection was only once re­ported. [4] This case highlights the importance of early management of even seemingly minor infections in post renal transplant patients, espe­cially with underlying diabetes mellitus. Good control of sugar and care of insulin injection site with a high index of suspicion may mitigate these unwanted complications.

 
   References Top

1.Chugh KS, Sakhuja V, Jain S, et al. High mor­tality in systemic fungal infections following renal transplantation in third-world countries. Nephrol Dial Transplant 1993;8:168-72.  Back to cited text no. 1
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2.Fisher J, Tuazon CU, Geelhoed GW. Mucor­mycosis in transplant patients. Am Surg 1980; 46:315-22.  Back to cited text no. 2
[PUBMED]    
3.Naguib MT, Huycke MM, Pederson JA, Pennington LR, Burton ME, Greenfield RA. Apophysomyces elegans infection in a renal transplant recipient. Am J Kidney Dis 1995; 26:381-4.  Back to cited text no. 3
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4.Quinio D, Karam A, Leroy JP, et al. Zygomy­cosis caused by Cunninghamella bertholletiae in a kidney transplant recipient. Med Mycol 2004; 42:177-80.  Back to cited text no. 4
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Correspondence Address:
Ankur Gupta
Department of Nephrology, All India Institute of Medical Sciences, New Delhi
India
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PMID: 21196630

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    Figures

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