rajesh ng department of pathology jipmer puducherry interesting case presentation

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Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

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Page 1: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

Rajesh NGDepartment of Pathology

JIPMERPuducherry

Interesting Case Presentation

Page 2: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

Clinical presentation

• 58 year old male manual labourer presented with loose stools – 4 days

• Several episodes of watery stools, non blood stained

• ↓ed urine output – 1 day• Minimal breathing difficulty• No h/o cough, expectoration• Frequent NSAID intake for arthritis• Not a known diabetic or hypertensive

Page 3: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

Clinical course

Page 4: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

Initial Investigations• Hemoglobin – 12.8 g/dl• Total WBC count – 8700• Platelet count – 179000• Blood urea – 105 mg/dl• Serum creatinine – 5.6 mg/dl (Post Dialysis)• Na+ - 139 mEq.L, K+ - 3.3 mEq/L• Total protein 6.4 g/L• Serum Albumin 3.2 g/dl • SGOT – 39 IU/L, SGPT – 17 IU/L, ALP -120 IU/L• Blood glucose – 86 mg/dl

Page 5: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

Investigation ChartInvestigation Day 1

(predialysisDay 1 (post dialysis)

Day 3 Day 5

Hemogram

P. Smear

12.8 g/dlWBC count – 8700Platelet count – 179000Normocytic, normochromicNo hemolysis

-do- 11.6 g/dlWBC- 13,600Platelet count – 1,80,000Normocytic, normochromicNo hemolysis

7.7 g/dlWBC - 15,200 Platelet – 75,000Normocytic, normochromicNo hemolysis

S. Urea 105 105 mg/dl 108 mg/dl 106 mg/dl

S. Creatinine 15.2 5.6 7.2 9.2

Urine output 300 ml 400 ml 500 ml 1400 ml

K+ 3.3 3.2 4.2 4.5

Page 6: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

Clinical course – Day 3• Developed worsening breathlessness– Persisted after second session of hemodialysis on

day 3• Worsening tachypnea & hypoxic on O2 mask– Patient intubated with mechanical ventilation

• Chest X ray – bilateral infiltrates L>R• Total WBC count elevated with fever spikes• USG abdomen – – Bilateral normal sized kidneys with maintained

cortico-medullary differentiation• Echocardiogram – normal, no vegetations

Page 7: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

Clinical course – Day 5• Hematologic profile over ICU stay – Hb dropped to 7.7 g/dl– Thrombocytopenia with lekocytosis– P. Smear – normocytic, normochromic with no

evidence of hemolysis/ Schistocytes• Started on piperacilin & Tazobactum (adjusted

for creatinine clearance) and Levofloxacin for nosocomial infection

• Alternate day hemodialysis– Urine output gradually improved

• Ventilatory requirements static (intermittent sedation)

Page 8: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

Clinical course – Day 7• Fever reappeared– Blood culture – Staph aureus sensitive to

vancomycin– Urine pyuria – persisted– C Xray – new infiltrates, presumed to be ventilator

associated pneumonia• Started on Meropenam & Linezolid• Inotropes for sepsis/SIRS/septic shock– Sensorium worsened

• Taken up for slow efficiency dialysis (SLED) as he was on inotropes

Page 9: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

Clinical course - Day 9 • Urine output – normal– But worsening azotemia

• Renal biopsy planned in view of non recovery– Deferred due to sepsis with positive urine culture

• Inotrope requirement increased – Could not be dialysed due to hemodynamic instability.

• Developed refractory hyperkalemia & sustained cardiac arrest.

• Post mortem kidney biopsy performed

Page 10: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation
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Page 14: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

Kidney biopsy• Revealed e/o fibrin thrombi occluding glomerular

capillaries & hilum• Tubules revealed neutrophilic casts• Tubules, interstitium and blood vessels revealed

infiltration of fungal hyphae• Branching, aseptate, broad fungal hyphae of

zygomycosis• Dense infiltration of neutrophils, lymphocytes

and eosinophils in interstitium

Page 15: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

Final Diagnosis

• Thrombotic microangiopathy with invasive mucormycosis and acute pyelonephritis

Page 16: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

Review of Literature• Acute renal failure secondary to systemic mucormycosis is

extremely rare– Most commonly associated with immunosuppression

(primary or secondary)– Mucormycosis is rarely reported secondary to aggressive

antibiotic use• Thrombotic microangiopathy – Is a medical emergency – Most patients recover completely– Approximately 3-5% die during acute phase of illness due

to CVS or neurological complications– Poor prognostic factors – marked leukocytosis and older

age of onset

Page 17: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

Conclusion• Biopsy is indicated early in diagnosis of

unknown cause of AKI• Systemic invasive fungal infection in non

immuno-suppressed patient extremely rare• High index of clinical suspicion needed to

suspect and diagnose fungal infections• Clinical diagnosis of thrombotic micro-

angiopathy can be difficult– With variable hematologic and systemic findings

Page 18: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

References• KL Gupta et al, Papillary necrosis with invasive fungal infections: a

case series of 29 patients. Clin Kid J. 2013;6:390-394• Marie Scully et al, Guidelines on the diagnosis and management of

thrombotic thrombocytopenic purpura and other thromboticMicroangiopathies. Br J Hematology 2012; 1-13

• KL Gupta et al. Renal zygomycosis: an underdiagnosed cause of acute renal failure. NDT 1999;14:2720-2725

• KL Gupta, Fungal infections and the Kidney. Indian J Nephrol 2001;11: 147-154

• KL Gupta et al, Disseminated mucormycosis presenting as acute renal failure. Postgrad Med J 1987;63:297-299

• Melnick JZ et al, Systemic mucormycosis complicating acute renal failure: case report and review of the literature. Ren Fail. 1995;17:619-27.

Page 19: Rajesh NG Department of Pathology JIPMER Puducherry Interesting Case Presentation

Thank You