To Bite the Bullet of Early Graft Nephrectomy: A Case Report A. Pradhan, S. Gadela, R.S.V. Kumar, A. Kalghatghi, and S. Pradhan ABSTRACT Isolated renal allograft mucormycosis is rare. Only 8 cases have been reported to date, with patient survival in only 3. We recently encountered a case. The presentation was fever and graft dysfunction, which were unresponsive to extended antibiotic treatment and support- ive care. It was only after three graft biopsies that mucormycosis was diagnosed and amphotericin B started. Urgent graft nephrectomy was performed, but the patient died of septicemia. In retrospect, we believe that early institution of amphotericin B and graft nephrectomy are needed for patient salvage in this difficult clinical situation. F UNGAL infections are rare, occuring in about 10% of renal allograft recipients, 1 but they are associated with a high mortality. Mucormycosis (phycomycosis, zygomycosis) can be ubiquitous, present in the air, water, and soil. They belong to the order Mucorales of the class Zygomycetes. The various species include Rhizopus arrhizus, Rhizopus oryzae, Absidia corymbifera, Abisidia ramosa, Mucor pusillus, and other species of Mucor, Basidiobolus, Mortierella, and Cunningha- mella. 2 Infections occur in immunocompromised states like organ transplantation, diabetes mellitus, malignancies, and burns. On fungal stains, hyphae typically appear to be broad based and septate. They have a propensity to invade blood vessels, causing thrombosis, infarction, and necrosis with ab- scess formation. Rhinocerebral, pulmonary, cutaneous, and gastrointestinal lesions are the commonest forms. 3 The only effective treatment for the condition is vigorous surgical extir- pation of the focus together with systemic amphotericin B. We report a case of isolated renal allograft mucormycosis. CASE REPORT A 22-year-old male patient reached end-stage renal disease due to chronic glomerulonephritis and was on maintainence hemodialysis. Bilateral open nephrectomy was performed as hypertension was uncontrollable with six drugs. He had also been treated for pulmonary tuberculosis a year earlier. He underwent live related renal transplantation. The immediate 2 months posttransplant were uneventful. The patient was put on routine immunosuppres- sion with cyclosporine, mycophenolate mofetil, and prednisolone. There was no rejection or infection. Blood pressure was well controlled on two drugs. His urine output was about 2 L and the serum creatinine was 1 mg/dL. The patient then developed fever, which persisted over 45 days. Initially a urine culture grew E. coli, and antibiotics were adminis- tered as per sensitivity to sterilize the urine. When fever persisted despite the antibiotic cover, treatment was extended to include antituberculous drugs, voriconazole and gancyclovir. A vigorous survey for an infective focus included blood cultures, bone marrow aspiration, X-rays, and CT scans of chest and abdomen as well as CSF studies. Subsequently, the patient developed oliguria, which progressed to anuria and an increased serum creatinine. Doppler ultrasound of the graft showed a mild increase in the resistive index and few debris floaters in the calyces. Graft biopsy performed twice only showed mild acute tubular necrosis (ATN) and no rejection. This combination of fever and anuria was not responsive to intensive antibiotics, daily dialysis, or other supportive measures over the ensuring 2 weeks. Causes thought to be missed included From Command Hospital, Departments of Urology (A.P.), Nephrology (S.G., R.S.V.K.), Microbiology (A.K.), and Pharma- cology (S.P.), Era’s Lucknow Medical College, Lucknow, India. Address reprint requests to Aditya Pradhan, MBBS, MS, DNB, Department of Urology, Era’s Lucknow Medical College; Hardoi Road, Lucknow, Uttar Pradesh 226002, India. Fig 1. Septate hyphae in parenchyma of kidney. 0041-1345/07/$–see front matter © 2007 by Elsevier Inc. All rights reserved. doi:10.1016/j.transproceed.2007.01.092 360 Park Avenue South, New York, NY 10010-1710 1664 Transplantation Proceedings, 39, 1664 –1665 (2007)