Fatal Renal Mucormycosis Following Pediatric Deceased Donor Kidney Transplantation in a High-Risk Recipient: A Case...

Mucormycosis is a rare but devastating opportunistic fungal infection in immunocompromised hosts with particularly high morbidity and mortality in solid organ transplant recipients. Pediatric cases are exceedingly rare, and outcomes are often fatal.

We report a case of a 13-year-old girl on chronic peritoneal dialysis who received a deceased donor kidney transplant. She was at immunological risk due to a positive virtual crossmatch. Induction therapy included antithymocyte globulin and methylprednisolone, followed by a maintenance immunosuppressive regimen of prednisone, mycophenolate mofetil, and tacrolimus. Post-transplant, she developed early graft dysfunction, anuria, and hemodynamic instability. A graft biopsy showed acute tubular necrosis and C4d positivity prompting plasma exchange for suspected antibody-mediated rejection. Graft explant on day nine revealed angio-invasive mucormycosis due to Rhizopus arrhizus. The rapid onset suggested the infection may have been acquired from the donor. Despite antifungal therapy, she suffered from recurrent arterial pseudoaneurysms in the surgical bed. She died 91 days post-transplant from a ruptured iliac artery mycotic aneurysm.

This case highlights the challenges in diagnosing and managing mucormycosis in pediatric kidney transplant recipients. A high index of suspicion together with early recognition, aggressive surgical management, and appropriate antifungal treatment is essential. Donor derived fungal infections should be considered in cases of early onset disease. Unfortunately, outcomes remain poor.