Fungal

2. Introduction
• SARS-CoV-2 is associated with variety of opportunistic bacterial and
fungal infections.
• Candida and Aspergillus main fungal co-infection.
• Low oxygen, high blood glucose levels (DM and Steroid induced),
acidic medium, high iron levels, decreased phagocytic activity of
leucocytes – favorable platform for fungal spores
• Mortality rate of post-covid-mucormycosis – 49%
• Urology – Fungal pyelonephritis

3. Objective
•To evaluate the outcome
•To study the factors predicting the
outcome

4. MATERIALS AND METHODS
• Observational prospective study from May 1 to Dec 31 2021
• No of cases: 7
• Inclusive criteria:
• All patients with c/f s/o pyelonephritis with sepsis with prior history of covid positivity.
• Data Collected
• Basic demographics,
• History:
• Severity based on NIH guidelines
• Investigations
• Use of steroids, toclizumab, anticoagulants, supplemental oxygen.
• Admission
• Creatinine, CBP, D Dimer, Platelet count, Urine for fungus, blood and urine cultures
• USG KUB, Color doppler, CT KUB

5. • All patients received ICU care
• Specific antifungals based on urine fungal C/S report
• Specific treatment: DJ stenting for hn and nephrectomy
• Endpoints: Discharge or mortality

6. RESULTS
Mean age of presentation 42 years ( 20 – 63 years)
Male : Female 6 : 1
Diabetic 1
No comorbidities 6
Asymptomatic COVID 19 2
Mild COVID 1
Severe COVID 4
Requiring oxygen supports, steroids and anticoagulants 4
Elevated d dimer, CRP and TLC All
USG – bulky kidney ALL
Color Doppler – main renal arterial thrombosis 2
Segmental arterial thrombosis 1
CT KUB fat stranding Side Left in all

7. • –
3 arterial thrombosis Initial Simple Nephrectomy
4 others 1. systemic antifungal based on sensitivity
2. DJ Stenting
3. Subsequently nephrectomy in all
Open Vs Lap 5 : 2
Meantime between admission & nephrectomy 6 days
Meantime between admission and death 14 days
Meantime between COVID infection to onset of
pyelonephritis
34 days
Final HPE report Necrotizing fungal inflammation in all
Complications Local wound discharge post nephrectomy in 2 (1
survived, 1 succumbed), re-exploration for bleeding in 2
Endpoints
Discharge
Death
4
3

9. Gross specimen • Doppler and CT

10. DISCUSSION
• Post COVID fungal infection – multifactorial and multiorgan
• Isolated renal fungal infection – common in immunocompromised, rare
in immunocompetent
• 14 % renal involvement in 129 case series (Chakroborty et al)
• COVID induced renal injury – direct vessel injury due to increased
expression of ACE 2 in renal tissues, defective host immune clearance,
endothelial dysfunction, thrombus formation, glucose and lipid
metabolism disorder and hypoxia

11. Fungal pyelonephritis
• Medical challenge
• Mucormycosis or invasive aspergillosis – Amphotericin B
(nephrotoxic) so liposomal amphotericin B (relatively less
nephrotoxic) – efficacy – equal
• Prehydating with 1 litre of NS prevent renal damage
• Continue antifungal even after nephrectomy with long term drain
placement until negligible output.

12. • Final HPE in all 7 patients – necrotizing fungal inflammation with
presence of microthrombi.
• Hypothesis: Microthrombi prevents adequate tissue concentration of
drugs further deteriorating the status leading to nephrectomy.
• Lap nephrectomy- 2 , Difficulties - dense adhesions, more operative time
• Open nephrectomy – 5, retroperitoneal, ease of wide debridemnt, lesser
operative time.
• Hence open should be preferred in post covid fungal pyelonephritis
nephrectomy.

13. Conclusion
• PN in post covid – requires aggressive workup for fungal PN due to high
mortalit rate.
• Imaging, Perfusion defect and Elevate D-dimer levels can guide us to
the existence of this uncommon entity and after confirming diagnosis,
early nephrectomy should be warranted.