Skeletal and renal manifestations of Candida tropicalis within a diabetic patient (2005:2b)

Abstract

This interpretation corner case in a 22-year-old diabetic with a painful foot and right flank pain highlights the value of investigating incidental urinary tract findings on skeletal scintigram further. The skeletal scintigram revealed increased up in the left 3rd TMT joint and a distended right sided renal collecting system. The subsequent ultrasound revealed multiple fungal balls in this distended system. Urine culture grew C. tropicalis a rarer but recognised cause of fungal ball infection in diabetics this enabled consideration of haematogenous spread of the candidal infection to the foot. Systemic antifungal treatment was commenced with resolution of the fungal balls on ultrasound and resolution of symptoms within the right foot.Keywords Diabetes mellitus . Candida tropicalis . Tc-99 m MDP . Skeletal scintigram . Ultrasound Case reportA 22-year-old man with a 14-year history of insulin dependent diabetes mellitus and a past history of intravenous drug abuse was admitted with painful swelling of the right foot and pain in the right flank. Initial investigations revealed mild renal impairment with a serum creatine of 122 mmol/l, confirmed poor diabetic control with a HbA1C of 10.3% and elevated inflammatory markers with neutrophilia of 8.43×10 9 cells/l, ESR of 97 mm/h and a C reactive protein of 316 mg/l. Plain radiographs of the foot demonstrated osteolysis at the 3rd tarsometarsal joint (TMT) with a well defined sclerotic margin (Fig. 1); subsequently a dual phase skeletal scintigram following administration of Tc-99 MDP was performed (Fig. 2a, b) which demonstrated increased uptake in both phases at the right 3rd TMT joint and a distended right pelvicalyceal system (Fig. 2c). An ultrasound confirmed a distended right pelvicalyceal system and revealed multiple round hyperechoic masses within the renal pelvis (Fig. 3). A subsequent Tc-99 m HMPAO labeled white cell study demonstrated low grade uptake at the right 3rd TMT joint confirming low grade infection at this site. Fig. 1 Oblique radiograph of the left foot