Bilateral Renal Mucor Mycosis Presenting as Anuria in a Covid 19 Recovered Patient: A Case Report and Review of Literature.

CASE SUMMARY

A 62-year-old nondiabetic female presented to the emergency room with hematuria followed by anuria of 3 days duration. She had been discharged 1 week prior after a 10 day hospital admission for COVID 19 infection. On examination she was dyspneic with right renal angle tenderness. Her blood pressure was 80/50mmhg, respiratory rate 24 /minute and heart rate was 120 /minute and oxygen saturation of 85% on room air. Serum creatinine was 3.5mg/dl, total leucocyte count 35000 cells/cu mm, random blood glucose levels of 468mg/dl, serum potassium 6.1mmol/L. Urinalysis showed numerous white blood cells and proteinuria.

The patient was started on rivaroxaban, methylprednisolone,and azithromycin for presumed lung pathology and sepsis. CT chest showed fibrotic bands in both the lungs with organizing pneumonia changes in left lower lobe (Fig. 1 C). Non contrast CT (NCCT) abdomen showed bilateral bulky edematous kidneys with perinephric, periureteric fat stranding and bilateral mild hydroureteronephrosis (Fig. 1A,B). In view of NCCT abdomen findings demonstrating bilateral ureteric obstruction, the patient was taken to the operation theatre. Retrograde pyelography (RGP) showed bilateral multiple filling defects in renal pelvis and upper ureter of both the kidneys.(Fig. 1 D,E)

Figure 1

(A,B). NCCT abdomen showing bilateral perinephric fat stranding and bilateral mild hydroureteronephrosis.(red arrows) (C). CT Chest showing peripheral patchy interstitial thickening with fibrotic bands with organizing pneumonia changes in left lower lobe.(red arrows). (Color version available online.)

MOST PROBABLE CLINICAL DIAGNOSIS FOR THE ANURIA

Bilateral renal papillary necrosis

Bilateral Urothelial tumors of the upper urinary tract

Bilateral blood clots.

Bilateral fungal balls

ANSWER

D).Bilateral fungal balls .

Secondary fungal infections, especially those caused by Mucormycosis (MM), are on rise in the era of Covid 19. Over 11,000 cases of MM with more than 200 casualties were reported between March 2020 and May 2021, with the majority of cases occurring in India. , , , Rhino cerebral - pulmonary form is the most common presentation of MM in Covid 19 patients. , Recently isolated case reports of gastrointestinal, cutaneous, and musculoskeletal MM have been reported post Covid 19 infection. Isolated renal MM in Covid 19 is an extremely rare association. High index of suspicion, early initiation of antifungal therapy, and nephrectomy may decrease mortality due to isolated invasive renal MM, as mortality is 65% in unilateral and nearly 100% in bilateral MM without surgical intervention.

In the present case left double J stent and right percutaneous nephrostomy (PCN) were done due to compact filling defects on the right side (Fig. 2 ). Tissue aspirates from PCN were positive for renal MM (Fig. 3 ). Patient received Intravenous liposomal Amphotericin B, intravenous Posaconazole and was hemodialyzed for worsening of acute renal failure. Patient succumbed to her disease 3 days after admission, due to disseminated MM involving lungs and bilateral kidneys.

Figure 2

RGP showing bilateral multiple filling defects involving ureter, renal pelvis and calyces (A and C). (B) Fluoroscopic image of right PCN insertion. (D) Fluoroscopic image showing left double J stent placement. (Color version available online.)

Figure 3

Microbiological diagnosis of Mucormycosis.(A-C) (40x magnification) (A) KOH preparation showing aseptate broad hyaline hyphal filaments with wide angle branching(Day 1). (B). GMS(Gomori's methenamine silver stain (GMS) stain showing black aseptate hyphal forms. (C) Growth on blood agar showing rapidly growing mycelial colonies having hairy appearance - lid lifting sign. Histopathological diagnosis of Mucormycosis. (D and E) H&E stain (D) and GMS stain (E) at 40x magnification: Numerous collapsible aseptate non branching fungal hyphae (D&E) in necro inflammatory debris (D) (black arrow). (Color version available online.)