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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2014  |  Volume : 25  |  Issue : 6  |  Page : 1282-1284
Reno-invasive fungal infection presenting as acute renal failure: Importance of renal biopsy for early diagnosis


1 Department of Urology and Kidney Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
2 Department of Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

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Date of Web Publication10-Nov-2014
 

   Abstract 

Renal zygomycosis, caused by invasive fungi, is a rare and potentially fatal infec­tion. The patient usually presents with non-specific symptoms and renal failure. A 34-year-old male non-diabetic and without any predisposing factors for systemic fungal infection presented to the emergency department with diffuse abdominal pain, high-grade fever and acute renal failure with a serum creatinine of 6.5. A computed tomography showed bilateral diffuse globular nephromegaly. A urine smear for fungal examination showed right angle branching hyphae and kidney biopsy showed fungal hyphae within the glomeruli, tubules and interstitium. Although radiological investigations can give us a clue, the definitive diagnosis can only be made by kidney biopsy. A high index of suspicion and timely diagnosis is important for a proper management.

How to cite this article:
Ranjan P, Chipde SS, Vashistha S, Kumari N, Kapoor R. Reno-invasive fungal infection presenting as acute renal failure: Importance of renal biopsy for early diagnosis. Saudi J Kidney Dis Transpl 2014;25:1282-4

How to cite this URL:
Ranjan P, Chipde SS, Vashistha S, Kumari N, Kapoor R. Reno-invasive fungal infection presenting as acute renal failure: Importance of renal biopsy for early diagnosis. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2020 May 29];25:1282-4. Available from: http://www.sjkdt.org/text.asp?2014/25/6/1282/144268

   Introduction Top


Renal zygomycosis is a rare and potentially fatal infection caused by invasive fungi. The patient usually presents with non-specific symp­toms and renal failure. Although radiological investigations can give us a clue, the definitive diagnosis is made by kidney biopsy. A high index of suspicion and timely diagnosis is important for a proper management.


   Case Report Top


A 34-year-old male presented to the emer­gency department with complaints of diffuse abdominal pain, high-grade fever, sepsis and acute renal failure. Biochemistry showed se­rum creatinine of 6.5. Urine examination was otherwise normal, except for some fungal ele­ments. He was non-diabetic and did not have any predisposing factors for systemic fungal infection. A computed tomography showed bilateral diffuse globular nephromegaly. A urine smear was sent for fungal examination, which showed right angle branching hyphae. We performed a kidney biopsy, which showed fungal hyphae within the glomeruli, tubules and interstitium [Figure 1]a and b. The fungal organisms were invading the vessel wall causing necrosis and thrombosis [Figure 1]c. They had broad ribbon-like hyphae having branching between 45 and 90°C [Figure 1]d. He was taken up for immediate bilateral nephrectomy and started on conventional amphotericin B. Post-operatively, the patient was dialyzed but he succumbed to septicemia and electrolyte imbalances on post-operative Day 2. Bilateral nephrectomy specimens showed grossly enlarged kidneys with areas of necrosis [Figure 2].
Figure 1: (a) Showing glomerular degeneration and disintegration due to zygomycosis, (b) extensive involvement of the interstitium with zygomycetes, (c) angioinvasion and vascular destruction along with intravascular thrombosis, (d) broad-based right-angled branching pauciseptate hyphae of zygomycosis.

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Figure 2: Nephrectomy specimen with grossly infarcted kidney and areas of thrombosis.

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In reno-invasive fungal infections, the kidneys can be involved in a focal or diffuse manner. They are enlarged and edematous. Hilar ves­sels may be thrombosed. [1],[2] Affected tissue is infiltrated by neutrophils, macrophages and multinucleated giant cells. [1],[2],[3] In tissues and in culture, zygomycete hyphae can be differen­tiated from other invasive molds by their greater width and obtuse angle branching. They are thin walled, which is responsible for weaker staining with Gomori's methanamine silver and periodic acid Schiff (PAS) stain. They are known to be angiotropic, causing vascular invasion and subsequent infarction of the tissues. Another less-common feature is neurotropism. [4],[5],[6],[7] Zygomycetes grow in standard laboratory media within 12-18 h after sample inoculation, and colony maturation occurs with­in four days, forming gray to brown cotton-like colonies.

In cases with a high index of suspicion, histology must be aggressively sought even in situations where other infectious agents have been isolated. Culture identification of zygomycetes has been difficult because >90% of the patients with disseminated zygomycosis have been diagnosed at autopsy. [8] Even though the frequency of zygomycosis is increasing with more number and improved survival of immunocompromised patients, an accurate diagnosis is often delayed. [9] There should be a low threshold to perform the renal biopsy, even on a mild suspicion of invasive fungal infection.

 
   References Top

1.
Flood HD, O'Brien AM, Kelly DG. Isolated renal mucormycosis. Postgrad Med J 1985;61:175-6.  Back to cited text no. 1
    
2.
Davilla RM, Moser SA, Grosso LE. Renal mucormycosis. A case report and review of literature. J Urol 1991;145:1242-4.  Back to cited text no. 2
    
3.
Prout GR, Goddard AR. Renal mucormycosis: Survival after nephrectomy and amphotericin B. N Engl J Med 1960;263:1246-8.  Back to cited text no. 3
    
4.
Chandler FW, Watts JC. Zygomycosis. In: Pathologic diagnosis of fungal diseases, Chicago, American Society of clinical pathologists. 1987; 85-95.  Back to cited text no. 4
    
5.
Marchevsky AM, Bottone EJ, Geller SA, Giger DK. The changing spectrum of disease, etiology and diagnosis of mucormycosis. Hum Pathol 1980;11:457-64.  Back to cited text no. 5
    
6.
Case records of Massachusetts General Hospital: Weekly clinic-pathological exercises; case 22- 1999: A 68 year old woman with multiple myeloma, diabetes mellitus and an inflamed eye. N Engl J Med 1999;341:265-73.  Back to cited text no. 6
    
7.
Frater JL, Hall GS, Procop GW. Histologic features of zygomycosis: Emphasis on perineural invasion and fungal morphology. Arch Pathol Lab Med 2001;125:375-8.  Back to cited text no. 7
    
8.
Freifeld AG, Iwen PC. Zygomycosis. Semin Respir Crit Care Med 2004;25:221-31.  Back to cited text no. 8
    
9.
Ribes JA, Vanover-Sams CL, Baker DJ. Zygomycetes in human disease. Clin Microbiol Rev 2000;13:236-301.  Back to cited text no. 9
    

Top
Correspondence Address:
Dr. Priyadarshi Ranjan
Department of Urology and Kidney Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
India
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DOI: 10.4103/1319-2442.144268

PMID: 25394451

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    Abstract
   Introduction
   Case Report
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    References
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