Rajesh NGDepartment of Pathology
JIPMERPuducherry
Interesting Case Presentation
Clinical presentation
• 58 year old male manual labourer presented with loose stools – 4 days
• Several episodes of watery stools, non blood stained
• ↓ed urine output – 1 day• Minimal breathing difficulty• No h/o cough, expectoration• Frequent NSAID intake for arthritis• Not a known diabetic or hypertensive
Clinical course
Initial Investigations• Hemoglobin – 12.8 g/dl• Total WBC count – 8700• Platelet count – 179000• Blood urea – 105 mg/dl• Serum creatinine – 5.6 mg/dl (Post Dialysis)• Na+ - 139 mEq.L, K+ - 3.3 mEq/L• Total protein 6.4 g/L• Serum Albumin 3.2 g/dl • SGOT – 39 IU/L, SGPT – 17 IU/L, ALP -120 IU/L• Blood glucose – 86 mg/dl
Investigation ChartInvestigation Day 1
(predialysisDay 1 (post dialysis)
Day 3 Day 5
Hemogram
P. Smear
12.8 g/dlWBC count – 8700Platelet count – 179000Normocytic, normochromicNo hemolysis
-do- 11.6 g/dlWBC- 13,600Platelet count – 1,80,000Normocytic, normochromicNo hemolysis
7.7 g/dlWBC - 15,200 Platelet – 75,000Normocytic, normochromicNo hemolysis
S. Urea 105 105 mg/dl 108 mg/dl 106 mg/dl
S. Creatinine 15.2 5.6 7.2 9.2
Urine output 300 ml 400 ml 500 ml 1400 ml
K+ 3.3 3.2 4.2 4.5
Clinical course – Day 3• Developed worsening breathlessness– Persisted after second session of hemodialysis on
day 3• Worsening tachypnea & hypoxic on O2 mask– Patient intubated with mechanical ventilation
• Chest X ray – bilateral infiltrates L>R• Total WBC count elevated with fever spikes• USG abdomen – – Bilateral normal sized kidneys with maintained
cortico-medullary differentiation• Echocardiogram – normal, no vegetations
Clinical course – Day 5• Hematologic profile over ICU stay – Hb dropped to 7.7 g/dl– Thrombocytopenia with lekocytosis– P. Smear – normocytic, normochromic with no
evidence of hemolysis/ Schistocytes• Started on piperacilin & Tazobactum (adjusted
for creatinine clearance) and Levofloxacin for nosocomial infection
• Alternate day hemodialysis– Urine output gradually improved
• Ventilatory requirements static (intermittent sedation)
Clinical course – Day 7• Fever reappeared– Blood culture – Staph aureus sensitive to
vancomycin– Urine pyuria – persisted– C Xray – new infiltrates, presumed to be ventilator
associated pneumonia• Started on Meropenam & Linezolid• Inotropes for sepsis/SIRS/septic shock– Sensorium worsened
• Taken up for slow efficiency dialysis (SLED) as he was on inotropes
Clinical course - Day 9 • Urine output – normal– But worsening azotemia
• Renal biopsy planned in view of non recovery– Deferred due to sepsis with positive urine culture
• Inotrope requirement increased – Could not be dialysed due to hemodynamic instability.
• Developed refractory hyperkalemia & sustained cardiac arrest.
• Post mortem kidney biopsy performed
Kidney biopsy• Revealed e/o fibrin thrombi occluding glomerular
capillaries & hilum• Tubules revealed neutrophilic casts• Tubules, interstitium and blood vessels revealed
infiltration of fungal hyphae• Branching, aseptate, broad fungal hyphae of
zygomycosis• Dense infiltration of neutrophils, lymphocytes
and eosinophils in interstitium
Final Diagnosis
• Thrombotic microangiopathy with invasive mucormycosis and acute pyelonephritis
Review of Literature• Acute renal failure secondary to systemic mucormycosis is
extremely rare– Most commonly associated with immunosuppression
(primary or secondary)– Mucormycosis is rarely reported secondary to aggressive
antibiotic use• Thrombotic microangiopathy – Is a medical emergency – Most patients recover completely– Approximately 3-5% die during acute phase of illness due
to CVS or neurological complications– Poor prognostic factors – marked leukocytosis and older
age of onset
Conclusion• Biopsy is indicated early in diagnosis of
unknown cause of AKI• Systemic invasive fungal infection in non
immuno-suppressed patient extremely rare• High index of clinical suspicion needed to
suspect and diagnose fungal infections• Clinical diagnosis of thrombotic micro-
angiopathy can be difficult– With variable hematologic and systemic findings
References• KL Gupta et al, Papillary necrosis with invasive fungal infections: a
case series of 29 patients. Clin Kid J. 2013;6:390-394• Marie Scully et al, Guidelines on the diagnosis and management of
thrombotic thrombocytopenic purpura and other thromboticMicroangiopathies. Br J Hematology 2012; 1-13
• KL Gupta et al. Renal zygomycosis: an underdiagnosed cause of acute renal failure. NDT 1999;14:2720-2725
• KL Gupta, Fungal infections and the Kidney. Indian J Nephrol 2001;11: 147-154
• KL Gupta et al, Disseminated mucormycosis presenting as acute renal failure. Postgrad Med J 1987;63:297-299
• Melnick JZ et al, Systemic mucormycosis complicating acute renal failure: case report and review of the literature. Ren Fail. 1995;17:619-27.
Thank You