Acute renal failure as a result of bilateral ureteral obstruction by <i>Candida albicans</i> fungus balls

Fungus ball and fungal emphysematous cystitis are two rare complications of fungal urinary tract infection. A 53-year-old male patient presented with these complications caused by Candida tropicalis simultaneously. The predisposing factors were diabetes mellitus and usage of broad-spectrum antibiotics. The fungus ball, measuring 3.5 × 2.0 cm on the left wall of the urinary bladder, shrank significantly to 1.6 × 0.8 cm after 5 days of intermittent irrigation with saline before surgery. With transurethral removal of the fungus ball and antifungal treatment with fluconazole, the patient fully recovered. We conclude that a bladder fungus ball and fungal emphysematous cystitis should always be suspected in patients with diabetes mellitus with uncontrolled funguria and abnormal imaging. Treatment should include a systemic antifungal therapy and thorough surgical removal of the fungus ball. A systemic antifungal therapy combined with a local irrigation with saline or antifungal drugs might help decrease the dissemination of fungemia during an invasive manipulation. Case reportA 53-year-old male was referred to our department in February 2015 with intermittent, but recently aggravated cloudy urine. The symptom had been ongoing for 9 years, sometimes with frequency and urgency. No blood urine or fever was ever reported. To control the symptoms of cystitis, the patient underwent multiple treatments with broadspectrum antibiotics during this 9-year period. Twice, fungus was found in his urine (9 years and 6 years ago).The patient had uncontrolled type II diabetes mellitus for more than a decade. He also suffered from a right kidney stone and underwent a percutaneous nephrolithotomy 18 years ago. Physical examination was unremarkable. A routine urine test showed significantly elevated red blood cells (56.1/HP, normal <4.5/HP) and white blood cells (328.7/HP, normal <5.4/HP). Blood tests were normal, except for an elevated fasting glucose level of 7.7 (range: 3.6-6.1) mmol/L. Sonography revealed a medium-to hypo-echoic bladder tumour, measuring 3.5 × 2.0 cm. It was located on the left wall of the urinary bladder, did not move with posture changes, and had no sign of blood flow (Fig. 1a). A computed tomography (CT) revealed no intravesical mass in either the unenhanced or dual-enhanced phase. Only a very faint filling defect was found in the excretory phase. Moreover, a large round gas collection was found in the bladder, and a 1.1 × 0.9-cm calculus revealed a right distal ureter, leading to mild unilateral hydronephrosis and ureterectasis (Fig. 1b).Urinary cytology showed a large number of hyphae and neutrophil granulocytes. Candida tropicalis was isolated from the urine, but the blood culture was negative. Because a fungus ball secondary to Candida tropicalis was highly suspected at this time, intermittent bladder washouts with saline (2 L per time and 3 times per day) were performed via an indwelling three-cavity urinary catheter. A mass of floccules were flushed out during early irrigation. A rechecked sonography ...

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“…11 Bladder fungus balls, also called fungus bezoars, 2,7 are extremely rare and were described as an amorphous mass that could grow to as …”

Section: Discussionmentioning

confidence: 99%

Fungus ball and emphysematous cystitis secondary to Candida tropicalis: A case report

Wang

Sun

et al. 2015

CUAJ

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“…1 The most described therapeutic approach is urinary drainage by a nephrostomy and/or a ureteral catheter with systemic and local antifungal administration. 1,[7][8][9] Nephrostomy also provides access to percutaneously remove the fungus ball 1,[7][8][9] and manually drain it via ureteroscopy. 4 The most commonly used antifungal agents are fluconazole and amphotericin B (AmpB) deoxycholate, because other drugs have extremely low urine concentrations.…”

Section: Discussionmentioning

confidence: 99%

Fungal ball in urinary tract, a rare entity, which needs a specific approach

Praz

Burruni

Meid

et al. 2014

CUAJ

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A fungal mass in the urinary tract (fungus ball), mainly occurring in compromised patients, is a rare and dangerous complication of candiduria. We report 2 cases of fungus ball associated with hydronephrosis and sepsis. As reported in the literature, we treated the first patient by prompt relief of obstruction by nephrostomy and local and systemic antifungal agent. The second patient failed to respond to this treatment due to a distal ureteral stenosis and required open surgery with fungus ball removal and ureteral reimplantation. Despite a large success in urinary tract drainage with antifungal treatments, some cases need a modified approach due to anatomical modification.

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“…Th e most common causes of fungal bezoars are C. albicans and C. tropicalis (3)(4)(5)(6)(7). C. glabrata may have inherent resistance to azoles, which are typically fi rst-line agents for treatment of candidal urinary tract infections.…”

Section: Discussionmentioning

confidence: 99%

Management of a Renal Fungal Bezoar Caused by Multidrug-Resistant Candida Glabrata

Berlanga

Machen

Lowry

et al. 2016

Baylor University Medical Center Proceedings

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Acute renal failure as a result of bilateral ureteral obstruction by Candida albicans fungus balls

Cited by 26 publications

References 6 publications

Fungus ball and emphysematous cystitis secondary to Candida tropicalis: A case report

Fungus ball and emphysematous cystitis secondary to Candida tropicalis: A case report

Fungal ball in urinary tract, a rare entity, which needs a specific approach

Management of a Renal Fungal Bezoar Caused by Multidrug-Resistant Candida Glabrata

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