Clinical practice

Abstract

Renal candidiasis is an increasingly common condition affecting predominantly premature infants receiving neonatal intensive care or term infants with urogenital tract anomalies. Multiple risk factors are usually present. Although rare, some infants develop an obstructive uropathy due to fungal balls, and this requires prompt detection and intervention to preserve kidney function. The management of obstructive renal bezoars is challenging and not well summarised in the past. This is mainly due to scarce literature confined to case reports or case series only. This review clarifies various definitions used in relation to renal candidiasis and identifies infants particularly at risk of obstruction. Clinical presentation, diagnosis and the role of imaging are discussed. A summary of the recent literature is provided to outline the range of existing treatment options available with published drug dosages and mode of delivery used. No single approach is successful in all cases and clinicians need to be aware of the different options available: apart from adequate urinary drainage and use of systemic +/- local antifungal agents, additional treatment with fibrinolytic agents and/or endoscopic or open surgical removal may be required. A new simplified algorithm for use in management is proposed. We hope this review will help clinicians in their management of patients presenting with this complex and challenging diagnosis.

Ultrasound Diagnosis and Follow-Up of Neonate Renal Candidiasis

“…Fungal skin infection is common in newborns. However, it rarely progresses to a systemic form, unless certain risk factors are present [ 1 ]. Candida albicans is the most frequently implicated agent in systemic candidiasis [ 2 ].…”

“…Parenchymal involvement is associated with increased volume and hyperechoic renal cortex, similar to pyelonephritis. Involvement of the cortex is focal or global [ 1 ]. Septate cavities may be present in the cortex corresponding to abscesses caused by ischemia resulting from obstruction by fungal balls.…”

“…They result from the aggregate of mycelial fragments [ 5 ] and can obstruct the urinary tract. Fungal balls must also be found in the ureters, bladder and urethra [ 1 ]. Once treated they often calcify and gradually disappear, as in this case [ 1 5 ].…”

“…Fungal balls must also be found in the ureters, bladder and urethra [ 1 ]. Once treated they often calcify and gradually disappear, as in this case [ 1 5 ]. They can be confused with necrotic papillae, blood clots, nephrocalcinosis or tumor, and clinical information is crucial.…”

“…The treatment can be extended from three to six weeks in case of parenchymal disease [ 3 ]. It should be emphasized that ultrasound appearance is not correlated with the healing, and fragmented or calcified sterile fungal balls can still be seen at the end of treatment [ 1 3 ]. The kidney ultrasonography objective is to exclude obstructive syndrome, possibly requiring drainage or surgery [ 3 4 ].…”