We report a case of a 39-year-old female, who presented to casualty with a 1-week history of right iliac fossa pain, associated vomiting and fever and no haematuria. She was HIV-positive, on highly active anti-retroviral therapy (HAART) for 3 years. Current treatment regimen was second-line therapy, including lopinarvir and ritonavir, and abacavir and lamivudine. Her T cell lymphocytes (CD4) cell count and HIV viral load were not known. She had completed treatment for pulmonary tuberculosis (PTB) 2 years prior. The only surgical history of note was an appendectomy 10 years prior. There was no history of intravenous drug or steroid use.
On clinical examination, the patient had a low-grade fever of approximately 37.5 C, generalised abdominal painwith right angle tenderness. She was admitted to the gynaecology ward and later transferred to the urology ward.
On admission, a urine dipstick test showed 1+ leukocytes without blood. Glucose, protein and ketones were not recorded. She was anaemic with haemoglobin of 10.2 grams per decilitre (g/dL) (n = 11.6 - 16.4), with a normal white cell count of 9.83 x 109/L and elevated C-reactive protein of 168 milligrams per litre (mg/L). Blood cultures were negative. Beta-(1,3)-d-glucan (B-D) assay, cryptococcal antigen test and glycated haemoglobin (haemoglobin A1c [HBA1c]) were not performed. These findings prompted for further investigation including radiological imaging. The computed tomography (CT) scan showed enhancing heterogeneously iso-dense right renal mass (Figure 1a), and magnetic resonance imaging (MRI) showed heterogeneously iso-intense right renal mass with solid and cystic areas (Figure 1b). On review of these findings, the revised differential diagnosis included a renal cell carcinoma, urothelial carcinoma or tuberculosis. A chest x-ray (CXR) showed bilateral nodular infiltrates. Ultrasound-guided renal biopsy tissue was submitted for histological assessment. Broad, irregular, right-angled branching aseptate fungal hyphae were identified within a necrotic background. Angioinvasion was not seen. Morphologically, these features favoured a diagnosis of renal mucormycosis. Fungal culture and susceptibility testing were not performed.
The patient was treated with deoxycholate amphotericin B 50 mg intravenously daily. On day 13 of treatment, the patient had deranged renal function with urea of 7.9 millimoles (mmol)/L; creatinine of 140 micromoles per litre (micromol/L). The treatment was stopped at day 14. Once the patient's condition had stabilised, a nephrectomy was planned for definitive management. Patient expressed reluctance to undergo the procedure and requested discharge from hospital to discuss it with family. She was discharged with analgesia and itraconazole 200 mg oral daily for 2 weeks. She was reviewed 2 weeks after discharge without any complain. She was then to be reviewed in 2 weeks time or once the decision had been made with regard to the nephrectomy. Six weeks later, she presented to the urology outpatient department with excruciating pain. Follow-up CT scan did not show any improvement. She agreed to undergo nephrectomy and the surgical procedure was uneventful. The kidney specimen was submitted for histopathological assessment. Gross assessment was that of an enlarged kidney with an intact capsule. The cut surface showed pale resident kidney with cystic degeneration, central necrosis with pus (Figure 2a). The haematoxylin and eosin (H&E) stained sections of this specimen were similar to the initial renal biopsy finding (Figure 2b) with angioinvasion now noted (Figure 2e, f). There was no co-infection or features of diabetes mellitus. Malignancy was not seen.