Indian Journal of Medical Specialities

CASE REPORT
Year
: 2021  |  Volume : 12  |  Issue : 4  |  Page : 228--231

Fungal ball obstructive uropathy in an elderly female with nil comorbidity: A case report and review of literature


Vijoy Kumar Jha, Debasish Mahapatra 
 Department of Nephrology, Command Hospital Air Force Bangalore, Bengaluru, Karnataka, India

Correspondence Address:
Dr. Vijoy Kumar Jha
Department of Nephrology, Medical Division, Command Hospital Air Force, Bengaluru, Karnataka
India

Abstract

Fungal balls in the upper urinary tract are a rare cause of obstructive uropathy. We describe a case of renal fungal ball in an immunocompetent lady with extreme of age and gender as risk factors. The patient presented with recurrent renal colic and complicated urinary tract infection. She had complete resolution of symptoms with spontaneous passage of fungal ball and systemic antifungal therapy.



How to cite this article:
Jha VK, Mahapatra D. Fungal ball obstructive uropathy in an elderly female with nil comorbidity: A case report and review of literature.Indian J Med Spec 2021;12:228-231


How to cite this URL:
Jha VK, Mahapatra D. Fungal ball obstructive uropathy in an elderly female with nil comorbidity: A case report and review of literature. Indian J Med Spec [serial online] 2021 [cited 2022 Oct 2 ];12:228-231
Available from: http://www.ijms.in/text.asp?2021/12/4/228/329464


Full Text



 Introduction



Invasive fungal infections have usually been described in the setting of immunosuppression medication, malignancy, diabetes mellitus, or extremes of ages. Invasive candidiasis of the urinary tract has been described in preterm neonates and in patients with diabetes mellitus. In preterm neonates, it presents as obstructive uropathy due to fungal balls. We describe an uncommon condition of urinary tract fungal balls in an elderly woman without comorbidities.

 Case Report



A 71-year-old woman with no known comorbidity presented initially with bilateral flank pain, high-grade fever, and history of passage of fleshy mass in urine. She was initially managed at a different center. Contrast-enhanced computed tomography imaging was suggestive of bilateral pyelonephritis with hydroureteronephrosis. She was managed with bilateral Double J stenting (DJS) and intravenous antibiotics, as a case of bilateral pyelonephritis with papillary necrosis. Mid-course to treatment, the patient came to our center. She complained of intense dysuria, however, she had partial relief in flank pain and fever at this time. Right DJS was removed as it had migrated to urinary bladder. Intravenous antibiotics were continued. Urine analysis showed protein 1+, 5–6 white blood cells/HPF. Urine culture was sterile. HIV antibody and tests for blood sugar came normal. Serum creatinine values decreased from 2.1 to 0.75 mg/dl. She had gradual relief of symptoms and left DJS was removed. Antibiotics were given for a total of 4 weeks.

She again presented after 3 months with history of recurrent, bilateral, and alternating ureteric colic and recurrent urinary passage of “muddy green” mass with relief of colic. Computerized tomography (CT) scan showed filling defects in bilateral renal pelvis and calyces [Figure 1] and bilateral perinephric fat stranding. One such mass was sent to laboratory for analysis. The mass was friable and showed nonseptate pseudohyphae and ovoid budding yeast forms suggestive of Candida species [Figure 2]. Urine culture showed no growth. The mass could not be cultured as it had been sent in formalin. Blood sugars were normal. She was treated with a course of antibiotic and fluconazole. On discharge, she was advised to continue oral fluconazole. She remained asymptomatic for the next 3 months and then was lost to follow-up. She reported back after 6 months with fever, right flank pain, and reduction in urine output. There was no history of passage of mass in urine. Investigations showed neutrophilic leukocytosis, azotemia (serum creatinine: 2.51 mg/dl), and pyuria. Ultrasound showed hydroureteronephrosis on the right side with abrupt cutoff at the mid-ureter. CT kidneys, ureters, and bladder showed bulky appearance of the right kidney with perinephric fat stranding, uniform reduction in enhancement in postcontrast images with hydronephrosis and dilatation of the right ureter till the level of L4; hyperdense content was noted within ureter at this level with abrupt narrowing of the ureter; the left kidney was normal size with hypodense filling defect in the middle calyx and no hydroureteronephrosis [Figure 3]. She was started on broad-spectrum intravenous antibiotic and liposomal amphotericin B (AmpB). Subsequently, urine culture showed Escherichia coli. There was improvement in symptoms. She had an episode of ureteric colic on the right side followed by passage of a fleshy mass in urine confirming to the shape of a tube and relief of pain. The fleshy mass was sent to laboratory in normal saline and was found to be necrotic tissue. Staining and cultures from the tissue were negative. She was given a total of 2.1 g of AmpB. Leukocytosis and azotemia normalized. At discharge, she was started on oral fluconazole which was continued for 3 months. She remains asymptomatic and has completed 1-year of follow-up.{Figure 1}{Figure 2}{Figure 3}

 Discussion



Invasive fungal infections are common in clinical practice and majority are caused by Candida and Aspergillus species.[1] The presence of Candida in urine or candiduria is uncommon in healthy subjects. Mere presence does not define infection, and controversy exists about management of patients with colonization.[2],[3] Candida infection of the urinary tract is mainly ascending due to catheterization or instrumentation and sometimes due to hematogenous spread. Candida colonization and infection of the urinary tract are associated with diabetes mellitus, solid organ transplantation, extremes of age, female sex, concomitant bacteriuria, intensive care unit admission, prolonged hospitalization, broad-spectrum antibiotics, congenital and structural abnormalities of the urinary tract, indwelling urinary tract devices, instrumentation of the urinary tract, bladder dysfunction, bladder stones, urinary stasis, and nephrolithiasis.[3]

Candida infections are caused by over 30 different species, of which Candida albicans, Candida glabrata, Candida parapsilosis, Candida tropicalis, etc., are common. Albicans candida are azole sensitive, and widespread use of azoles has led to the emergence of nonalbicans candida species in clinical practice which are variably resistant to the available antifungal agents including polyenes and echinocandins.[4],[5]

Fungal ball or bezoar formation is an uncommon manifestation of Candida urinary tract infection. Fungal balls may present with or without obstruction to urinary tract and renal dysfunction. Although mere presence of candiduria cannot be construed as infection, the presence of Candida fungal ball warrants treatment. Candida appears as budding yeast under microscopy and is easily identifiable in Gram stain. Other yeasts appear similar under microscopy and can cause clinical infection.[6] Candida can be grown on blood agar, with the exception of Candida glabrata which grows slowly and may be missed if agar is discarded.[6] Ultrasound, intravenous pyelogram, and CT scan all can show fungal ball as filling defect within the excretory tract. However, CT urogram has emerged as the imaging of choice because of greater sensitivity in visualization of pyelonephritis, perinephric abscess, air in tissue, and presence of obstruction.[6],[7] The suspicion of fungal ball lesion was made in view of filling defects in the excretory tract, nonseptate pseudohyphae in the mass sent for histopathological examination, and recurrent urinary tract infections in the present case.

The use of systemic antifungals is the mainstay of therapy. However, problem remains with susceptibility of Candida to antifungals. Azoles given orally are variably absorbed, and bioavailability is affected by postprandial state and presence of acid. Except for fluconazole, other azoles are not excreted in urine in unchanged or metabolically active form, limiting the use of intravenous formulations. However, this does not preclude their use when renal parenchyma is involved.[8] Echinocandins do not achieve significant concentration in urine.[8] AmpB has the broadest antifungal cover and is not absorbed when given orally. Excretion of AmpB in urine is better than echinocandins but less than fluconazole. However, it may be active even in lesser concentrations. Cost of newer azoles such as voriconazole and posaconazole is also an issue. With these concerns, fluconazole and AmpB remain the pharmacological treatment of choice, either given orally or via intravenous route or by irrigation into the renal pelvis through a nephrostomy tube.[9] However, only pharmacological treatment may not suffice, and removal of fungal balls by surgical or interventional methods may be needed for faster clearance of fungus load, especially when with obstruction. In the index case, the patient was treated with AmpB with no requirement of surgical intervention due to spontaneous passage of fungal ball.

Fungal balls in the urinary excretory tract are most commonly caused by Candida species; Aspergillus and mucormycosis also have been implicated. Lechmiannandan et al. have described a case of urinary bladder fungal ball in a 73-year-old male with only hypertension, caused by Candida tropicalis, and observed that clinical outcome was worse in cases of Candida tropicalis fungemia versus fungemia due to other Candida, which could be due to higher antifungal resistance of Candida tropicalis.[10],[11],[12] Berlanga et al. described a case of renal fungal ball in a 57-year-old woman with diabetes mellitus and hemoglobinopathy, caused due to Candida glabrata, and observed that the organism was resistant to fluconazole in initial cultures and quickly developed resistance to micafungin, which was managed with intravenous AmpB and AmpB irrigation through nephrostomy tube.[13] Irby et al. described six cases of upper urinary tract fungal bezoars, of which three were caused by Aspergillus and the rest by Candida. He observed that cases with Aspergillus were more morbid, and required nephrectomy in two cases, while all cases of Candida bezoar responded well to drug therapy.[14] Palacio-Bedoya et al. described a case of renal bezoar caused by Rhizopus in a young male with diabetes mellitus and IV drug user, who was managed with endourological removal of fungal mass, IV AmpB, and irrigation of AmpB through nephrostomy.[15]

Premature infants are at high risk of invasive fungal infection because of several factors such as immaturity immunodeficiency, break in natural barrier due to catheters and endotracheal tube, use of broad-spectrum antibiotic and steroid, parenteral alimentation, H2-receptor antagonists, congenital urinary tract abnormalities, indwelling bladder catheter, obstruction, urinary stasis, and hyperglycemia. The most important factors for fungal balls are low urinary pH, urinary stasis due to poor urine output, congenital renal anomalies, and administration of frequent courses of broad-spectrum antibiotics and most commonly caused due to Candida albicans.[16] Ultrasonography, though operator dependent, is a very good modality to diagnose, follow-up for resolution, or progression of obstruction. Acute kidney injury may be associated and complete resolution happens with successful treatment. Long-term sequel is not known, though hydronephrosis may not resolve completely. Mortality in preterm infants is high (34%).[17] Suboptimal renal function may be a sequela.[18] Optimal management in these small babies is not known. Nonobstructive fungal balls respond well to pharmacological therapy, and surgical intervention is rarely necessary.[19] Surgical intervention may be needed in cases of obstructive fungal ball with deteriorating renal function, nonresolution with pharmacological therapy, and abscess formation.[18],[20] Insertion of nephrostomy tubes for irrigation with antifungal agents such as fluconazole or AmpB is the most common surgical procedure employed. A variety of endourological procedures may be employed in adults but are technically challenging in children and neonates. Cystourethroscopic removal of fungal ball, percutaneous nephrostomy, percutaneous endoscopic dilatation of nephrostomy tract and removal of fungal ball, and percutaneous removal through mechanical thrombectomy device have been described.[21]

 Conclusion



Fungal ball or bezoar in the renal excretory tract is an uncommon clinical manifestation even in the presence of fungal urinary tract infection. The cases have been described in adult patients with risk factors and premature infants. The management is challenging and needs to be individualized. A combination approach through both pharmacological and surgical means when necessary is desirable. Few mistakes in management need to be highlighted. The mass should have been sent as such or in normal saline. Nonavailability of culture and sensitivity affected treatment. AmpB should have been used in the first instance, which could have avoided recurrence and further complication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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