Mucormycosis after kidney transplantations: Report of seven cases

Outcomes after lung resection in renal transplant patients with pulmonary mucormycosis

Pulmonary mucormycosis has been associated with high mortality (reported up to 100%) in renal transplant recipients. This was a retrospective analysis of renal transplant patients with pulmonary mucormycosis between April 2014 - March 2020, who underwent surgical resection of the affected lung along with liposomal amphotericin therapy. Patients with lower respiratory illness features underwent chest X-ray, high-resolution computed tomography of the chest, and those with suspicious findings underwent analysis of bronchioloalveolar fluid and transbronchial lung biopsy. Patients with histological or microbiological evidence of mucormycosis were started on liposomal Amphotericin B. Tacrolimus and mycophenolate mofetil were stopped at the time of diagnosis. Patients were taken up for surgical resection of the affected part of the lung. Ten patients underwent combined management, while five patients were managed medically. At last follow up, seven out of ten patients (70%) who underwent combined management and two of the five patients (40%) who were managed medically, had a mean survival of 28.86 months (sd = 15.71, median = 25) and 14.17 months (sd = 12.21, median = 18), respectively, post-diagnosis of pulmonary mucormycosis. Surgical resection combined with antifungals in the perioperative period and decreased immunosuppression may improve the outcomes in renal transplant patients with pulmonary mucormycosis. This article is protected by copyright. All rights reserved.

Has the mortality from pulmonary mucormycosis changed over time? A systematic review and meta-analysis

OBJECTIVES

Pulmonary mucormycosis (PM) is increasingly being reported in immunocompromised patients and has a high mortality. Our aim was to assess the mortality of PM and its trend over time. We also evaluated the role of combined medical-surgical therapy in PM.

METHODS

We performed a systematic review of Pubmed, Embase, and Cochrane central databases. Studies were eligible if they described at least five confirmed cases of PM and reported mortality. We also assessed the effect of combined medical-surgical therapy versus medical treatment alone on PM mortality. We used a random-effects model to estimate the pooled mortality of PM and compared it across three time periods. The factors influencing mortality were assessed using meta-regression. We evaluated the risk difference (RD) of death in the following: subjects undergoing combined medical-surgical therapy versus medical therapy alone, subjects with isolated PM versus disseminated disease, and PM in diabetes mellitus (DM) versus non-DM as a risk factor.

RESULTS

We included 79 studies (1544 subjects). The pooled mortality of PM was 57.1% (95% confidence interval [CI] 51.7-62.6%). Mortality improved significantly over time (72.1% versus 58.3% versus 49.8% for studies before 2000, 2000-2009, and 2010-2020, respectively, p 0.00001). This improved survival was confirmed in meta-regression after adjusting for the study design, the country's income level, and the sample size. Combined medical-surgical therapy was associated with a significantly lower RD (95%CI) of death: -0.32 (-0.49 to -0.16). The disseminated disease had a higher risk of death than isolated PM, but DM was not associated with a higher risk of death than other risk factors.

CONCLUSIONS

While PM is still associated with high mortality, we noted improved survival over time. Combined medical-surgical therapy improved survival compared to medical treatment alone.

Donor-derived renal allograft mucormycosis in a combined liver and kidney transplantation: Case report and review of the literature

Mucormycosis infrequently may present with isolated renal involvement. Among solid organ transplant recipients, renal allograft mucormycosis has been most often associated with medical tourism or transplantation outside of the western world. We report a case of an HIV/HCV co-infected woman who underwent simultaneous liver and kidney transplantation with a Public Health Service increased risk donor organ. 16 days after transplant, she developed massive hematuria and was found to have renal allograft Rhizopus spp. involvement, we surmise to have been from donor-derived infection. Therapy included nephrectomy, debridement, liposomal amphotericin B, and posaconazole with survival. We reviewed PubMed indexed, English-language cases of isolated renal mucormycosis in general, in HIV/AIDS, and from donor-derived renal allograft infections.

Secondary Subcutaneous Rhizopus Infection in a Posttransplant Recipient with Calcific Uremic Arteriolopathy

Calcific uremic arteriolopathy is a rare condition affecting chronic kidney disease (CKD) patients on long-term dialysis. The clinical manifestations include subcutaneous skin necrosis and ulcers secondary to calcification of the subcutaneous blood vessels. The necrotic tissue often becomes a nidus of infection. The prognosis is often poor. We present a case of a renal allograft recipient who developed a subcutaneous necrotic lesion which was subsequently infected by Rhizopus spp. The patient underwent surgical debridement and antifungal therapy. The infection resolved completely. Our case represents agrave underlying condition predisposing a rare and serious posttransplant infection. The outcome was favourable because of early identification and treatment of the infection.

Case of early-disseminated Rhizopus microsporus var. microsporus mucormycosis in a renal transplant patient

Mucormycosis is a rare infection caused by the ubiquitous filamentous fungi of the order Mucorales and class Zygomycetes. These species are vasotropic, causing rapid onset of tissue infarctions and necrosis and subsequent thrombosis by invading vascular bed. The disease spectrum ranges from involvement of skin, sinuses, lung, and brain to disseminated and mostly fatal infections, especially in immunocompromised hosts. Here, we present a case of a fatal disseminated mucormycosis in a 56-year-old female who had deceased donor renal allograft transplantation ~2 weeks prior to presentation. She presented with shortness of breath and dry cough. Despite being on broad-spectrum antibiotics/antifungals and proper management by transplant, infectious disease, and primary team, she died within 3 weeks of admission. Autopsy showed disseminated mucormycosis of lungs and thyroid. Disseminated infection within 2 weeks of solid organ transplantation in this patient was one of the rare features of mucormycosis.

Mucormycosis in Iran: a systematic review

Fungi in the order Mucorales cause acute, invasive and frequently fatal infections in susceptible patients. This study aimed to perform a systematic review of all reported mucormycosis cases during the last 25 years in Iran. After a comprehensive literature search, we identified 98 cases in Iran from 1990-2015. The mean patient age was 39.8 ± 19.2 years. Diabetes was the most common underlying condition (47.9%), and 22.4% of the patients underwent solid organ or bone marrow transplantation. The most common clinical forms of mucormycosis were rhinocerebral (48.9%), pulmonary (9.2%) and cutaneous (9.2%). Eight cases of disseminated disease were identified. Overall mortality in the identified cases was 40.8%, with the highest mortality rate in patients diagnosed with disseminated infection (75%). The mortality rate in rhinocerebral infection patients was significantly lower (45.8%). Rhinocerebral infection was the most common clinical manifestation in diabetes patients (72.9%). Patients were diagnosed using various methods including histopathology (85.7%), microscopy (12.3%) and culture (2.0%). Rhizopus species were the most prevalent (51.7%), followed by Mucor species (17.2%). Sixty-nine patients were treated with a combination of surgery and antifungal therapy (resulting survival rate, 66.7%). Owing to the high mortality rate of advanced mucormycosis, early diagnosis and treatment may significantly improve survival rates. Therefore, increased monitoring and awareness of this life-threatening disease is critical.

Two cases of transplant renal artery thrombosis and spontaneous rupture caused by mucormycosis

Mucormycosis is an uncommon infectious complication after renal transplantation and is associated with fatal outcomes. We report 2 cases of transplant renal artery thrombosis and spontaneous rupture caused by mucormycosis. As stenosis, thrombosis, and spontaneous rupture of the transplant renal artery began to occur in both cases after renal transplantation, nephrectomy of the transplanted kidney was performed. Postoperative pathological findings in the transplanted kidney revealed an invasive mucormycosis infection in the renal artery. One patient survived, but the other patient died. This report also presents the diagnosis and treatment processes used for this transplant complication.

Rhinocerebral mucormycosis: a retrospective study

Mucormycosis is an acute often fatal infection caused by fungi of family mucoracea (Kauffman and Malani Curr Infect Dis Rep 9(6):435-440). The principal pathogens in this family are rhizopus, mucor and absidia species. Mucoracea are found in soil, decaying vegetation and other organic matter. Mucormycosis is a polymorphic disease with diverse clinical manifestation. It is divided into rhinocerebral, pulmonary, cutaneous, cardiac, gastrointestinal and disseminated. Rhinocerebral mucormycosis the most commonest manifestation of mucormycosis is usually a fatal fulminant infection. Rhinocerebral mucormycosis can be further divided into rhino-maxillary and rhino-orbito-cerebral. The disease commonly occur in diabetics who have ketoacidosis but is also seen in severely debilitated or immunosuppressed patients. It has also been reported from otherwise normal individuals. Early diagnosis and treatment is mandatory for a successful management of this infection.

Disseminated mucormycosis in a patient with recent kidney transplantation: a case report and review of the literature

Mucormycosis is an invasive fungal infection commonly seen in diabetics and immunocompromised patients. We report a case of disseminated mucormycosis in a 47-year-old diabetic male who underwent deceased donor renal allograft transplantation about 5 weeks prior to presentation. Our patient presented with increasing fatigue, diarrhea and oligoanuria and was found to have significant acute kidney injury. Doppler ultrasound of the allograft revealed segmental decreased renal perfusion in the upper pole of the allograft with moderate hydronephrosis. Nephrostomy tube placement yielded minimal urine output. An allograft biopsy showed diffuse C4d-positive staining and fungal hyphae suggestive of Mucor infection. Computed tomography (CT) imaging revealed a right upper lobe mass, a small hypodensity in the liver and normal findings in the head. Despite prompt management including discontinuation of immunosuppression, amphotericin B and allograft nephrectomy, the patient had a rapid decompensation, developed respiratory failure requiring intubation, hypotension and supraventricular tachycardia with multiple new areas of hypoattenuation on head CT – all of which ultimately resulted in his death. A review of the literature revealed that mucormycosis is a relatively rare disease with a cumulative 12-month incidence rate of 0.07% in solid organ transplant recipients. Disseminated disease was found in about 23% of cases, with a mortality rate of 96%.

Rhinomaxillary mucormycosis in a renal transplant recipient: case report

OBJECTIVES

Rhinomaxillary mucormycosis is a clinical manifestation of zygomycosis in solid-organ transplant recipients. Without proper diagnosis and treatment, rhino-orbital-cerebral zygomycosis, particularly a central nervous system disease, will develop with substantial complications.

CASE REPORT

A 42-year-old man who had undergone renal transplant was admitted to our otolaryngology department with unilateral bloody nasal discharge. Mucormycosis was detected in the necrotic tissue of the maxillary sinus. Surgical ablation of the infected parts, along with antifungal treatment, restricted extension of the infection.

CONCLUSIONS

Early detection of opportunistic infections in transplant recipients plays an important role in preventing dissemination. Fungal infections, including zygomycosis, should be considered in all solid-organ recipients, especially in persons with local unusual manifestations. Early diagnosis and successful treatment reduce mortality.

Iron overload and unique susceptibility of liver transplant recipients to disseminated disease due to opportunistic pathogens

The propensity of liver transplant recipients to develop more fulminant disease presentation and a higher risk of disseminated disease due to a number of opportunistic infections, including invasive aspergillosis, cryptococcosis, zygomycosis, may be related to iron overload. Abnormalities in iron homeostasis may also be a contributor to severe manifestations due to other pathogens such as cytomegalovirus and Staphylococcus aureus in liver transplant recipients. Iron is essential not only for microbial pathogenesis, but directly impairs pivotal pathogen specific host defenses. Studies to assess iron homeostasis and the mechanisms by which iron overload contributes to the pathogenesis of opportunistic infections in liver transplant recipients are warranted.