Successful non-surgical management of isolated hepatic mucormycosis
Author(s):
Swarnalaxmi Umapathy; Lori Kautzman; Machaiah Madhrira; Imran Memon; Balamurugan Sankarapandian; Sridhar Allam; Ashraf Reyad
Background:
Isolated hepatic mucormycosis without other organ involvement is very rare among solid organ transplant recipients and is associated with poor prognosis. Often a combination of surgical and antifungal treatment is required. We present a successful case of non-surgical management of isolated hepatic mucormycosis after a kidney transplant.
Hypothesis:
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Methods:
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Results:
A 46-year-old male with end stage renal disease secondary to diabetes mellitus and hypertension received a kidney transplant with uneventful immediate post-operative course. He recieved depleting antibody induction followed by maintenance immunosuppression regimen of tacrolimus, mycophenolate and prednisone. Two months post transplant, patient presented with fever, abdominal pain and elevated liver function tests. CT abdomen showed 5 cm x 5 cm abscess in the inferior right hepatic lobe and 7 cm x 7 cm abscess in the dome of right hepatic lobe. Broad spectrum antibiotics were started and percutaneous drains were placed into these abscesses. Drain cultures grew Mucor species. Patient was started on intravenous liposomal amphotericin B and mycophenolate was discontinued. However, despite a week of intravenous amphotericin B therapy, patient remained febrile. So trans-catheter administration of amphotericin B through the percutaneous drains with 30 minutes of dwelling time for a total of 14 days was initiated with significant clinical response with fever resolution and normalization of liver function tests. Intravenous amphotericin was continued for a total of 30 days followed by oral posaconazole for a total of 3 months. Follow-up CT showed interval resolution of hepatic abscesses. Patient is now three years post transplant with normal renal function and no recurrence of mucormycosis.
Conclusions:
Mucormycosis especially isolated hepatic involvement in solid organ transplant recipients is very rare but can lead to significant morbidity and mortality. In cases where surgical debridement is difficult or contraindicated, percutaneous drainage and trans-catheter administration of amphotericin B can be an option along with lowering immunosuppression for transplant and prolonged course of systemic antifungal therapy.