[45-47] However, majority of the patients (75%) suffering from isolated renal mucormycosis in India are apparently healthy individuals;[4-6] in contrast, in China, majority of the reported cases possess risk factors for developing mucormycosis, except the paediatric population.[45-47] These patients with isolated renal mucormycosis had acute presentations. They developed fever, flank pain, haematuria or anuria.[4] Although renal tuberculosis, rapidly progressive glomerulonephritis

and acute pyelonephritis may present similarly, enlarged unilateral or bilateral infarcted non-functioning kidneys (no contrast Cobimetinib supplier excretion) with low attenuation areas on imaging strongly suggest renal mucormycosis.[48] With increased awareness and the combination of clinical and radiological findings at our tertiary-care centre in North India, majority of these cases were diagnosed antemortem, as in 32 (76.2%) of 42 patients in a meta-analysis.[4-6] In spite of antemortem diagnosis, mortality

remained INCB024360 price high (~50%) due to difficulty in managing such patients.[4-6] It is still not clear how the fungus enters the kidney, without developing lesion in other organs in majority of patients. Lungs may be the portal of entry, as an additional focus in lungs has been observed in a few patients on autopsy.[49] Ascending route may also be the portal of entry, as additional lesion in the urinary bladder has been noted in a recent report.[50] Once fungi gain entry into the main vessels of kidney, they can cause cortical and medullary infarction leading to renal failure.[51] A detailed investigation of such patients is required to clarify the unexplained pathogenesis of this mucormycosis. There is a wide spectrum of mucoralean fungi causing human infections. Globally, Rhizopus, Mucor and Lichtheimia (formerly Absidia or Myocladus) spp. represent the most frequent causative agents of this disease, accounting for 70–80% of all cases (Fig. 1).[1, 4, 7, 52] Apophysomyces, Saksenaea, Rhizomucor, Cunninghamella, Cokeromyces, Actinomucor

and Syncephalastrum spp. Florfenicol have also been reported rarely.[1, 4, 7, 52] In India, Apophysomyces elegans is the second most common causative agent, after Rhizopus oryzae (Fig. 1).[4, 5] Although Mucorales are considered opportunistic pathogens, Apophysomyces elegans and Saksenaea vasiformis can initiate disease in apparently normal hosts, following penetrating trauma during accidents in tropical and sub-tropical areas.[1, 7, 27, 52] Majority of these patients present with cutaneous mucormycosis only and do not have any underlying disease; only a few patients manifest rhino-cerebral and pulmonary infections, and have risk factors for developing mucormycosis.[1, 7, 52] Intriguingly, Apophysomyces elegans does not produce spores in the environment easily; its sporulation is induced in the laboratory with care.