Kidney Week

Abstract: SA-PO1009

Fatal Pulmonary Mucormycosis in a Kidney Transplant Patient: Missed "Opportunism"

Session Information

• Transplantation: Clinical - 4
  October 26, 2024 | Location: Exhibit Hall, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Transplantation

• 2102 Transplantation: Clinical

Authors

• Correa, Tatiana, Baystate Medical Center, Springfield, Massachusetts, United States

Tatiana Correa, MD

• Greco, Barbara A., Baystate Medical Center, Springfield, Massachusetts, United States

Barbara A. Greco, MD

• Brand, Kenneth, Baystate Medical Center, Springfield, Massachusetts, United States

Kenneth Brand, MD

• Khan, Umair, Baystate Medical Center, Springfield, Massachusetts, United States

Umair Khan, MD

• Braden, Gregory Lee, Baystate Medical Center, Springfield, Massachusetts, United States

Gregory Lee Braden, MD

Introduction

Pulmonary mucormycosis (PM) has a high mortality rate if not diagnosed promptly. We present a fatal case in a patient presenting seven months post-transplantation whose diagnosis was delayed, and emphasize the need for early diagnosis of opportunistic infections.

Case Description

A 55-year-old man with ESRD and prior failed deceased donor kidney transplant (DDKT) underwent a second DDKT complicated by delayed graft function and antibody-mediated rejection treated with apheresis and IVIG. Seven months post-transplant, he presented with cough, fever, diarrhea, and weight loss. He was on tacrolimus, mycophenolic acid, and prednisone. Imaging revealed diverticulitis and a cavitating thick-walled right lower lung lesion. He was treated with ampicillin/sulbactam but had continued fevers and respiratory distress. Serologic infectious workup was unrevealing; galactomannan test was negative. Bronchoalveolar lavage on hospital day 4 identified Streptococcus species; piperacillin/tazobactam was given for seven days. The patient worsened and required noninvasive ventilation. Repeat imaging demonstrated a pleural effusion with invasion of the RLL mass into the right middle lobe, diaphragm, and liver. Thoracentesis was performed on hospital day 12 and a lung biopsy on day 19. Pleural fluid and tissue histology was consistent with mucor. Amphotericin was started and he was transferred for surgical debridement, but died within 24 hours.

Discussion

Kidney transplant patients are immunosuppressed and at risk for opportunistic infections. Mucormycosis accounts for 2-6% of fungal infections and emerges usually after 6 months post-transplantation as rhinocerebral, PM, skin, or disseminated disease. Concomitant bacterial pneumonia occurs in 30% of PM cases. A negative galactomannan test is expected as mucor lacks this cell wall antigen. Reverse halo sign on imaging is suggestive but histology is necessary for diagnosis. The presence of characteristic non-septate, right-angled branching hyphae confirms diagnosis. Treatment requires intravenous liposomal Amphotericin B and surgical debridement. PM is rapidly progressive, invasive, and carries a 60-70% mortality rate. This case highlights the pitfalls of empiric approaches to infections in immunocompromised hosts and the need for early suspicion for opportunistic infection and tissue diagnosis to optimize outcomes.