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Case Report
Secondary Subcutaneous Rhizopus Infection in a Posttransplant
Recipient with Calcific Uremic Arteriolopathy
Urmila Anandh ,
1
Rakesh Kumar,
1
and Vishnu Rao
2
1
Dept of Nephrology, Yashoda Hospitals, Alexander Road, Secunderabad 500003, India
2
Dept of Infectious Diseases, Apollo Hospitals, Jubilee Hills, Hyderabad 500033, India
Correspondence should be addressed to Urmila Anandh; uanandh@gmail.com
Received 9 October 2019; Revised 15 June 2020; Accepted 17 June 2020; Published 30 June 2020
Academic Editor: Gloria Taliani
Copyright ©2020 Urmila Anandh et al. is is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Calcific uremic arteriolopathy is a rare condition affecting chronic kidney disease (CKD) patients on long-term dialysis. e
clinical manifestations include subcutaneous skin necrosis and ulcers secondary to calcification of the subcutaneous blood vessels.
e necrotic tissue often becomes a nidus of infection. e 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. e patient underwent surgical
debridement and antifungal therapy. e infection resolved completely. Our case represents agrave underlying condition
predisposing a rare and serious posttransplant infection. e outcome was favourable because of early identification and
treatment of the infection.
1. Introduction
Multiple factors (immunosuppressive medications, renal
dysfunction, uncontrolled hyperglycemia, presence of uri-
nary catheters, subcutaneous drains, etc.) are responsible for
an increased risk of infection in kidney transplant recipients.
Long-term hemodialysis and presence of malnutrition be-
fore transplant also have an impact on posttransplant in-
fections [1]. Calcific uremic arteriolopathy (CUA), a
complication of long-term hemodialysis, can increase the
risk of secondary infections in areas of subcutaneous is-
chemia and ulcers. Usually, bacterial infections predominate
in the early posttransplant period and fungal infections are
rare [2]. We present a case of subcutaneous fungal infection
in a renal allograft recipient who had calcific uremic arte-
riolopathy. Despite the gravity of the clinical situation, the
outcome was favourable with treatment with antifungals.
2. Case Report
A 57-year-old male with type 2 diabetes mellitus, coronary
artery disease (status postcoronary artery bypass grafting),
and chronic kidney disease on dialysis for three years un-
derwent a deceased donor transplantation. His immediate
posttransplant period was uneventful, and at discharge, he
had normal renal functions. He returned to hospital after 2
weeks with high-grade fever, chills, and allograft dysfunc-
tion. He was diagnosed to have allograft pyelonephritis. He
was treated with 14 days of intravenous colistin with res-
olution of his clinical symptoms and allograft dysfunction.
His second admission 10 days later was with back pain, and
on evaluation, there was evidence of lumbar discitis in the
MRI of the lumbar spine. A biopsy of the infected disc was
noncontributory, and he was empirically started on ATT and
carbapenems based on an infectious disease consult. During
his follow-up, he complained of the presence of a new-onset
subcutaneous maculonodular necrotic lesion on his ab-
dominal wall (Figure 1). At this time, he had symptoms of
abdominal discomfort after eating food. He had evidence of
mild allograft dysfunction (creatinine: 2.2 mg/dl), low serum
albumin (3.2 g/dl), normal calcium levels (8.10 mg/dl),
slightly high phosphorus (5.6 mg/dl), high PTH (572 pg/ml),
and normal vitamin D levels (33 ng/ml). His PTH level
before transplant was 1029 pg/ml. An allograft biopsy was
Hindawi
Case Reports in Infectious Diseases
Volume 2020, Article ID 8695204, 3 pages
https://doi.org/10.1155/2020/8695204
essentially normal with evidence of resolving pyelonephritis.
e abdominal CT scan was noncontributory except for
extensive calcification of the intra-abdominal vessels. e
anterior abdominal wall vessels were also calcified (Figure 2).
A diagnosis of calcific uremic arteriolopathy-associated
abdominal wall (subcutaneous) necrosis was made. As the
lesion was warm and tender, a diagnosis of secondary in-
fection was considered and a biopsy was taken from the edge
of the nodule. e biopsy showed extensive tissue necrosis
and presence of nonseptate fungi (Figure 3). e culture
isolate was identified as Rhizopus spp. (Figure 4). He un-
derwent surgical debridement of the lesion and was treated
with 6 weeks of liposomal amphotericin. On completion of
therapy, his skin lesion had healed and allograft function was
stable (serum creatinine: 1.5 mg/dl).
3. Discussion
Fungal infection in the posttransplant period is a rare entity.
e cumulative incidence in the first year is 3% [3], with a
lower risk for kidney transplants (1.3%) than in other solid
organ transplants [4]. e common fungal infections are
Candida,Aspergillus, and cryptococcosis. ey occur much
later after transplant than bacterial infections [3]. e fungal
infections in the tropics have a different epidemiology. Fungi
of the Mucorales spp. are important pathogenic organisms
besides Aspergillus,Candida, and Cryptococcus [5].
Mucormycosis infection after transplant is often invasive
and has a high mortality rate. e most frequent site of
involvement is rhinocerebral, followed by pulmonary and
cutaneous infections [6].
e risk factors for the development of fungal infections
are often a complex interplay of host and environmental
factors. e net state of immunosuppression (old age, in-
duction therapy, antirejection therapy, diabetes mellitus,
prior antibiotic use, etc.) plays an important factor in the
development of these infections [7]. Our patient had almost
all predisposing factors which put him at a high risk of
developing fungal infections. Presence of necrotic tissue is
another predisposing factor for the development of
mucormycosis [8]. Our patient had subcutaneous tissue
necrosis which was responsible for the secondary Rhizopus
infection. e subcutaneous necrosis was attributed to his
extensive calcific uremic arteriolopathy.
As the infection was localised to an area of necrosis on
the anterior abdominal wall and was identified and treated
swiftly, the patient had a better outcome than what is ob-
served in renal allograft recipients with mucormycosis
[9, 10]. Also, after transplant, the patient’s renal function
Figure 1: Necrotic nodular lesion on the anterior abdominal wall.
Figure 2: Volume-rendering technique image of the abdominal CT
scan showing extensive vascular calcification.
Figure 3: Silver stain of the skin biopsy showing subcutaneous
mucormycosis.
Figure 4: Fungal culture showing broad aseptate hyphae with
sporangiophores arising from nodes above the rhizoids suggestive
of Rhizopus spp.
2Case Reports in Infectious Diseases
improved which had an ameliorating effect on the under-
lying calcific uremic arteriolopathy.
4. Conclusion
Because of aggressive immunosuppression and use of broad
spectrum antibiotics, fungal infections are becoming com-
mon in kidney transplant recipients. Early identification of
the infection leads to early institution of appropriate ther-
apy. Besides antifungals, surgical debridement is required
for the complete resolution of infection as was noted in our
case.
Data Availability
Data are not available in public archives.
Conflicts of Interest
e authors declare that they have no conflicts of interest.
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