Presented by: Dipak Rajyaguru M Ch urology
UROCARE shanku

Introduction

Novel Corona Virus Disease 2019 (COVID-19) infection has been associated with various bacterial and fungal co-infections. The major and fatal among these infections involves Mucormycosis. In 2021, there has been a huge surge of COVID-19 cases in India, especially the Western India. Post COVID-19 Mucormycosis has been rampant with serious morbidity and mortality rates, involving mainlythe rhino-orbital, oro-facial and maxillary areas of the human body. However, urological complications post COVID-19 are not much reported till date. Mucormycosis has been reported to affect the kidneys. Urinary bladder involvement of Mucormycosis has been reported till now as a single case, in the pre COVID era in an immuno-compromised patient. Isolated urinary bladder involvement as a complication post COVID has not been reported till date.

We report the first single case of Urinary bladder Mucormycosis post COVIDwith resultant Obstructive uropathy and review the literature.The objective is to increase the awareness regarding such a rare diagnosis and its appropriate management in the current pandemic era.

Materials

A 62 year old gentleman was admitted with the symptoms of breathlessness requiring oxygen support. He was diagnosed with COVID by RT PCR and HRCT Thorax andrecent onset of Diabetes Mellitus. He required Injection Remdesevir, steroids, Low Molecular Weight Heparin and Insulin. The patient’s general condition gradually improved. However, on the 20th post COVID day, he developed oliguria, fever and storage Lower Urinary Tract symptoms (LUTS). His blood investigations showed raised Total leucocyte counts, serum Creatinine and C Reactive Protein (CRP). Urine analysis showed plenty of White Blood Cells (WBCs) and fungal KOH stain was positive. Non Contrast CT Scan KUB (NCCT KUB) revealed bilateral Hydroureteronephrosis with cystitis. Suspecting sloughed papillary necrosis to be the cause of Obstructive uropathy, the patient was planned for bilateral Retrograde Pyelography (RGP) and Double J stenting. 

​Under Anaesthesia, Cystoscopy revealed red cherry like ulcerated areas with mass like lesion involving the whole of bladder wall. Bladder biopsies were taken from suspicious areas. Bilateral ureteric orifices could not be identified. Hence, Ultrasound guided bilateral Percutaneous Nephrostomies (PCN) were placed. Post-operative broad spectrum antibiotics and anti-fungal treatment were administered. The histopathology of bladder biopsy showed mononuclear inflammatory infiltrate with broad non-septate fungal hyphae with irregular branching, consistent with Mucormycosis.This was confirmed by the use of special stains such as Hematoxylin and Eosin (H&E) and Periodic acid–Schiff stain (PAS).Infectious disease specialist and Nephrologist opinion were taken and InjectableLiposomal Amphotericin B was administered.

Results

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The patient improved clinically after bilateral PCN and his serum creatinine recovered to normal. He responded well to Liposomal Amphotericin B without any side effects or rise in serum creatinine. The patient is currently under close follow-up for further management.

Conclusion

COVID-19 has unfolded several unknown and rare complications thereby presenting a great challenge for the treating physicians. Mucormycosis has been always very difficult to treat due to the high morbidity and mortality of the fungal disease and the side effects of the treatment itself. Urological Mucormycosis has not been reported post COVID-19. Also, bladder involvement of Mucormycosis has been only a single case till now. Hence, Bladder Mucormycosis as the cause of obstructive uropathy is a diagnosis of exclusion. However, considering the severe spread of Mucormycosis in non-urological cases in the western India, we had a high index of suspicion in this case. The histological diagnosis helped us guide starting the appropriate anti-fungal treatment in the form of Amphotericin B for the treatment of Mucormycosis. Thus, timely diagnosis and specific treatment can help prevent morbidity and mortality due to Mucormycosis in the patients. 

Funding

None

Lead Authors

Hemang Baxi, M Ch urology
Hcg hospital

Krutik Raval, DNB Urology
UROCARE shanku hospital

Co-Authors

Jitendra Amlani, M Ch urology
UROCARE

Vipul Tilva, M Ch urology
Hcg hospital