Successful Endoscopic Management of a Renal Fungal Ball using Flexible Ureterorenoscopy

Unilateral renal fungus ball caused by Candida glabrata

A 46-year-old diabetic woman with unilateral renal fungus ball was successfully treated with antifungal therapy, endoscopic extraction and ureteral stent placement. The patient was initially treated for a right staghorn calculus, thereafter developed urinary symptoms. Imaging revealed distal left ureter filling defects and a previous stent at the ureteropelvic junction. Urine culture confirmed Candida glabrata sensitive to Micafungin. Bilateral ureteroscopy facilitated the extraction of a left renal pelvis fungus ball. This case underscores the challenges in diagnosing fungal UTIs in patients with predisposing factors, and highlights a combined medical and surgical approach for effective treatment of renal fungus balls.

Urological Tract Infection with Candida Bezoars in a Woman with Diabetes Type 2

The aim of this report is to describe a case of fungal bezoar obstruction of the kidney and our experience in managing it endoscopically. A 61-year-old woman presented with flank pain. On CT scan, a proximal stone and secondary dilatation was seen. After placing a DJ stent and administering antibiotics, there was persistent pain, sickness, and kidney dilatation on CT scan. URS showed soft tissue bezoars surrounding the stent and the stone. We managed to remove all the fungal balls mechanically and endoscopically. This report showed that endoscopic removal of the bezoars is a good alternative for antifungal installation.

Long-Term Passive Ureteral Dilatation with Double-J Stent: Possibly an Effective Treatment for Recurrent Renal Colic Caused by Papillary Renal Necrosis

Background: An uncommon cause of recurrent renal colic is mucous tissue passage secondary to renal papillae necrosis. Because of its low prevalence, the correct management of recurrent obstructive uropathy produced by renal papillary necrosis (RPN) is not well defined. Case Presentation: We present a case of recurrent renal colic associated with the expulsion of mucous tissue in a young woman's urine with a history of excessive consumption of nonsteroidal anti-inflammatory drugs (NSAIDs). The patient required multiple admissions to the emergency department because of recurrent episodes of renal colic. A retrograde pyelogram and histopathologic study of the expulsed tissue supported the diagnosis of RPN. The patient was managed with Double-J stents for 12 months, complete withdrawal of NSAIDs, and large volume intake of water. A satisfactory outcome was seen radiologically and endoscopically after treatment. The patient stopped experiencing new renal colic episodes because of the passive ureteral dilatation despite still presenting the mucous tissue expulsion in the urine. Conclusions: Passive ureteral dilatation with Double-J stents could possibly be an effective treatment for patients with recurrent renal colic secondary to persistent renal papillae necrosis.

A Rare Case of Urinary Tract Fungal Ball Leading to Fungemia and Bilateral Chorioretinitis

Background

Fungemia due to obstructive urinary tract fungal ball is exceedingly rare. These patients often have multiple predisposing conditions, including diabetes or antimicrobial exposure. While candiduria can be relatively common in this population, urinary tract fungal balls are a rare entity. Hospitalists should be aware of this rare complication in patients presenting with funguria. Case Presentation. We present a case of a 44-year-old male with type II diabetes, chronic hepatitis C secondary to injection drug use, and chronic kidney disease who developed a urinary tract fungal ball leading to fungemia and subsequent bilateral chorioretinitis, additionally complicated by emphysematous cystitis and pyelonephritis. Additional invasive treatment options beyond typical antifungals are often required in the case of urinary tract fungal ball, and in this case, bilateral nephrostomy tubes and micafungin were employed. Hospital course was complicated by C. tropicalis fungemia with subsequent bilateral fungal chorioretinitis on dilated fundus exam. This was effectively treated with cyclogyl and prednisolone drops along with bilateral voriconazole injections. Follow-up imaging and cultures showed resolution of fungemia, urinary tract masses, and chorioretinal infiltrates; however, recurrent polymicrobial UTIs continue to be an issue for this patient.

Conclusions

Special multidisciplinary management is required in the treatment of urinary tract fungal balls with subsequent fungemia, including nephrostomy tubes, antifungal irrigation, ureterorenoscopy, and more powerful antifungals such as amphotericin B and 5-flucytosine. This management draws from a myriad of specialties, including urology, infectious disease, and interventional radiology. Additionally, the literature has demonstrated that only approximately half of patients with fungemia receive an ophthalmologic evaluation. Ophthalmologic and urologic cooperation is essential in the case of obstructive uropathy leading to fungemia as the obstructive uropathy must be relieved and these patients should receive a dilated fundus exam.