P284 A rare case of post covid bilateral renal mucormycosis
Authors: Shevkani Manoj 
Published: September 2022

Abstract

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

Objective
The most commonly reported sites of COVID-associated invasive mucormycosis till now have been rhino-cerebral-orbital followed by pulmonary. This is a rare instance where an apparently healthy male, who had recovered completely from COVID-19, presented with fulminant isolated bilateral renal mucormycosis.

Method
A 60-year-old male was presented with low-grade fever and increased CRP. He had a known history of diabetes, hypertension, and ischemic heart disease since 2007. On examination, he was tachypneic and afebrile; blood pressure and oxygen saturation were within normal limits.
He was also double vaccinated. Also had a history of moderate COVID (Omicron) in January, 2022. His CT score was 18/25. He got admitted for 10 days because of COVID and was treated with oxygen, antibiotics, remdesivir, and steroids.
Later on, patient developed fatigue, anorexia, abdominal discomfort, and pain in lower back. Also vomiting and nausea for 3 months. So patient was treated with tablets Zifi CV for 5 days bd followed by; IV meropenem 1 g tds for 5 days followed/by; tablets faropenem 200 md bd for 3 weeks followed by; tablets nitrilofurantoin 100 mg bd.
Ultrasonography remains the first line of investigation and can show the enlarged echogenic kidneys with hypoechoic areas of abscesses, perinephric fluid collections, hydronephrosis, and cystitis. Cortical thickness appeared normal with raised cortical echo. An unenhanced computed tomography (CT) of his abdomen and pelvis was performed and suggested of mild changes of acute bilateral pyelonephritis. CT features include diffuse patchy nephrogram, inhomogeneous enhancement with areas of low attenuation, perinephric fluid collections, and no contrast excretion.
Fungal culture sensitivity report was done and Candida albicans organism was isolated and it was found to be all drug-sensitive. Later on, a biopsy of the urethra was performed and a biopsy specimen revealed a fungal ball composed of thin septate and branching thick abroad aseptate hyphae. And also, which resembled morphologically mucor. spp and Aspergillus. A bacterial culture and sensitivity report were suggestive of E.coli.
The patient underwent surgical interventions, ie, cystoscopy with B/L RGP with B/L DJ stenting done under SA with a calculated risk of diabetes, hypertension, age, nature of illness, and high creatinine.
Patient started treatment with sulbacin 1.5gm injection with 100 ml sodium chloride 0.9% 6 hourly. As patient's creatinine is not stable so Liposomal Amphotericin B was not given. Later on, as creatinine stabilized patient he began receiving liposomal amphotericin B at a beginning dosage of 300 mg with 25% dextrose 250 ml over 5 h. Also, posaconazole started with a loading dose of 600 mg, and then, 300 mg OD was given to patient.

Result
Patient gradually recovered and a dose of liposomal amphotericin was completed for 4 weeks.

Conclusion
In conclusion, this paper describes that COVID-associated mucormycosis is a known entity, however, Renal Mucormycosis is a rare disease. Especially, bilateral involvement with limited drug penetration into a urogenital system of the agents which are active in mucormycosis. Its management involves, team approach of diabetologists, infectious disease physicians, urologists, radiologists, and microbiologists. Treatment of mucormycosis is challenging as anti-fungal penetration in renal tissue is difficult. High index of suspicion should be there to make the diagnosis. Early detection and aggressive management may have a favorable outcome.