On the Cover

A 32-year-old woman with end-stage renal disease of unknown etiology underwent deceased donor renal transplantation. She was given induction with basiliximab and was on tacrolimus, mycophenolate mofetil and prednisolone. She was discharged with a creatinine of 1.7 mg/dl. She developed new-onset diabetes after transplantation controlled with insulin. Three months later she developed fever, abdominal pain, graft tenderness and worsening renal function. Lab investigations revealed Hb7.1gm/dl, white blood cell count 17900/ mcL, and creatinine 4.0mg/dl. Liver function tests, serum amylase and lipase were normal. Blood cultures were negative and she was placed on broad spectrum antibiotics. Doppler flow imaging of the graft kidney showed absent arterial flow and a nephrectomy was performed. Histology revealed extensive coagulative necrosis of the kidney which was infiltrated by aseptate broad fungal hyphae with irregular, non-parallel contours which branched irregularly at right angles. The fungus invaded blood vessel walls, consistent with mucormycosis. Following the nephrectomy, this patient received liposomal Amphotericin B but she expired 3 weeks later due to overwhelming sepsis. Mucormycosis is a systemic fungal infection caused by members of the class Zygomycetes. The infection occurs mostly in immunocompromised individuals. The organism gains entry through inhalation, ingestion, contamination of skin wounds or via vascular channels such as intravenous drips. They are angioinvasive and can cause vascular thrombosis, tissue infarction and necrosis. There are 5 forms of the disease: rhinocerebral, pulmonary, gastrointestinal tract, cutaneous and disseminated disease. Renal mucormycosis, which is usually a part of disseminated disease, is a rare complication of kidney transplantation with a high mortality rate. Diagnos is is usually made by demonstration of characteristic fungal hyphae in the infectedt issue on histopathological examination. The treatment is based on early recognition of the disease, surgical resection of necrotict issue and appropriate antifungaltherapy. (Cover image and text provided by Anila Kurien and Ramanathan Vijayakumar, Center for Renal and Urological Pathology, Chennai, Tamil Nadu, India.)