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RESEARCH ARTICLE
Year : 2003  |  Volume : 20  |  Issue : 1  |  Page : 50-53
 

Endourological interventions in the diagnosis and management of upper urinary tract fungal infections - our experience


1 Department of Urology, Kasturba Medical College, Manipal, India
2 Department of Pathology, Kasturba Medical College, Manipal, India

Correspondence Address:
S Joseph Philipraj
Department of Urology, KMC, Manipal - 576 119
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Objectives: We have analyzed the incidence and man­agement options of upper urinary tract obstructions caused by fungal infections during January 2000-December 2001.
Methods: Four patients with upper urinary tract fun­gal infections underwent endourological interventions and received antifungal therapy.
Results: All 4 patients underwent double J stenting, of which one patient underwent bilateral stenting. Percuta­neous nephrostomv to irrigate was done in one patient in whom the filling defect caused by the fiungal ball persisted even after 4 weeks of oral antifungal therapy.
Nephroureterectomy was done in 1 patient as the renal function did not recover even after 4 weeks of appropriate therapy. Three patients had good recovery of renal func­tion.
Conclusions: Endourological interventions help in re­lieving and treating obstructions caused by fungal infec­tions.


Keywords: Fungal infections, endourological interventions.


How to cite this article:
Philipraj S J, Thomas M J, Bhat S. Endourological interventions in the diagnosis and management of upper urinary tract fungal infections - our experience. Indian J Urol 2003;20:50-3

How to cite this URL:
Philipraj S J, Thomas M J, Bhat S. Endourological interventions in the diagnosis and management of upper urinary tract fungal infections - our experience. Indian J Urol [serial online] 2003 [cited 2019 Jul 17];20:50-3. Available from: http://www.indianjurol.com/text.asp?2003/20/1/50/37125



   Introduction Top


Upper urinary tract fungal infections are rare and are usually associated with diabetes, chronic renal failure, long term antibiotic usage and terminal malignancy. Diagno­sis is based on microscopic examination of urine and spe­cific fungal culture. Histopathological examination of fungal balls will demonstrate the fungus. Appropriate imaging studies of the pelvicalyceal system and ureter and prompt institution of measures to relieve obstruction and antifungal therapy will help in preserving the renal unit. We present our experience of 4 cases with fungal infec­tions during 2 years: January 2000-December 2001.


   Patients and Methods Top


This is a retrospective study involving 4 patients who were treated in our department during the 2-year period between January 2000-December 2001. The inpatient records were reviewed for the clinical details, pathology and the microbiology reports. The details of the patients and the management are given in the [Table - 1].


   Results Top


The patients were of the age group 50-65 years with the mean age of 57.5 years. There were 3 females and 1 male. All 4 patients were diabetics on oral antidiabetic agents. Two patients had renal failure. The commonest present­ing symptom was fever with ipsilateral loin pain and dysu­ria. One patient who had bilateral obstructed renal units presented with oliguria. None of the patients had any his­tory of prior instrumentation/catheterisation of the urinary tract.

Laboratory evaluation showed leucocytosis and uncon­trolled diabetes. Serum creatinine levels were elevated in 2 patients. One was a female patient with serum creati­nine of 3.5 mg/dl who had features of diabetic nephropa­thy with unilateral obstruction. The other was a male patient with serum creatinine of 8 mg/dl who had bilateral obstructed renal units and had to be dialysed before inter­vention. Urine examination revealed pyuria in all patients and in 3 cases yeast cells were seen. Ultrasonography in all patients revealed mild to moderately dilated pelvicaly­ceal system with internal echoes, suggestive of infected hydronephrosis. Intravenous urography (IVU) was done in the 2 patients with normal renal function which revealed unilateral non-visualization in both patients. Double J stenting was done in all 4 cases. Percutaneous nephrostomy was planned only if stenting was not effective in alleviat­ing the symptoms. Fever subsided in all 4 patients. After 2 days of antibiotic (cefaperazone and sulbactam) therapy, a diagnostic cystoscopy and retrograde ureterogram was done which showed filling defects in the ureter [Figure - 1] and pelvis - unilateral in 3 and bilateral in one. Uretero­scopy revealed fungal accretions in the ureter and pelvis, most of which were removed. Culture of urine on Sabou­rauds dextrose agar showed fungus - Candida in 2 pa­tients and Aspergillus in one. Histopathology confirmed candida infection in the 2 cases [Figure - 2]. In the patient who had a negative urine culture for the fungus, the his­topathological examination of the fungal ball demonstrated Mucormycosis [Figure - 3]. Hepatitis antigen (HBsAg) and human immunodeficiency virus (HIV) antigen were nega­tive in all the patients. Oral antifungal therapy with 400 mg/day of itraconazole was started with stent in situ. Af­ter 4 weeks of oral therapy patients were reassessed. Two patients showed good recovery of the renal units. One patient was found to have a non-functioning unit on iso­tope renogram and underwent nephroureterectomy. His­topathological examination of the specimen demonstrated multiple abscess with acute inflammatory cell infiltration. The abscess cavity also demonstrated mycelia which were dichotomously branching similar to the ones found in the ureter (Aspergillus). Two patients did not show any resi­dual filling defects and were continued on oral itracona­zole (400 mg/day) for a period of 8 weeks with regular check on the renal parameters and peripheral white blood cell count. Double J stents were removed after 8 weeks of therapy.

One patient had persistent filling defect on repeat IVU and a percutaneous nephrostomy was done to irrigate the system with antifungal agent. Amphotericin B 50 mg in one litre of dextrose water was irrigated over 24 hrs with adequate bladder drainage. This was done on alternate days for 5 instillations. After 10 days nephrostogram was done which did not reveal any filling defect. Nephrostomy cath­eter was removed and patient remained afebrile.

Follow-ups ranged from 12-24 months with regular check on renal function and urine examination. Repeat urine ex­amination did not show any evidence of fungus either by direct microscopy or by culture. Serum creatinine values had stabilized at 1.1 mg% - 2.5 mg% [Table - 1]. Repeat IVU in 3 patients showed good function and drainage.


   Discussion Top


In recent years, there has been an increasing awareness of the significance of infections caused by fungus. [1] Diag­nosis typically depends on the discovery of pyuria with high colony candida counts in the urine. Treatment deci­sions are influenced by the symptoms and anatomic site of infections. [2] Recently polymerase chain reaction is used to detect candidemia in patients with candiduria and to detect candiduria before the culture reports are available. [3],[4] The infections are of 2 types, the first, which is the most significant from the urologist's point of view, is the op­portunistic type caused by Candida and Aspergillus. The infections are especially common in patients debilitated by chronic disease, neoplasm or drug treatment. Fungal infection may be systemic with secondary involvement of the urinary system or originate in the urinary tract and then disseminate hematogenously. The use of indwelling urethral catheter and administration of multiple antibiot­ics increases the risk of dissemination of urinary fungal infections.

The second type of fungal infection is acquired as a result of contamination by a person who often is other­wise healthy.

Fungal infections of the urinary tract must be diagnosed quickly and treated aggressively. Untreated, they can cause urinary obstruction through formation of accretions called fungal balls. [5],[6],[7] The results can be hydronephrosis, oligu­ria or even anuria, [8] destruction of renal parenchyma, wide spread dissemination of the organism and death of the patient. A case of bladder rupture due to fungal ball has been reported. [9]

Endourological procedures are valuable in the diagno­sis and management of genitourinary fungal infections. [6],[7],[10] Percutaneous nephrostomy, [8] ureteroscopy, nephroscopy and ureteral stents offer the urologist better ways of han­dling these often seriously ill patients. At the same time, percutaneous irrigation [9],[10] permits administration of highly toxic antifungal drugs to patients with localized infection thereby minimising systemic side effects.

In years to come there will be an increase in the number of patients who are immunocompromised due to human immuno deficiency virus infection and chronic disease like diabetes, malignancy and chronic renal failure. Enhanced longevity due to better medical technology and antibacte­rial agents will place these patients at greater risk for sec­ondary fungal infections. Awareness of disease patterns associated with fungal infections will help the urologist to recognize and treat these super infections.

Some of the measures which can be taken to prevent these opportunistic infections are to avoid long term ind­welling urethral/venous catheters. The indiscriminate us­age of multiple antibiotics for longer durations should be avoided.

Even though it is difficult to prevent the fungal infections it is prudent to be aware of the possibility of opportunistic infections especially when dealing with immunocompromised individuals. The possibility of fungal balls as an etiology of obstructive uropathy should be kept in mind.


   Conclusions Top


Endourological interventions help in relieving and treat­ing obstructions caused by fungal infections.

 
   References Top

1.Lundstrom T, Sobel J. Nosocomial Candiduria : a review. Clin In­fect Dis 2001; 1: 32(11): 1602-7.  Back to cited text no. 1    
2.Fisher JF. Candiduria : when and how to treat it. Curr Infect Dis Rep 2000; 2(6): 523-530.  Back to cited text no. 2    
3.Talluri G, Mangone C, Freyle J et al. Polymerase chain reaction used to detect candidemia in patients with candiduria. Urology 1998: 51(3): 501-5.  Back to cited text no. 3    
4.Muncan P, Wise GJ. Early identification of Candiduria by polymer­ase chain reaction in high risk patients. J Urol 1996: 156(1): 154-6.  Back to cited text no. 4    
5.Benchekroun A, Alarm M, Ghadouan M et al. Urinary candidiasis revealed by ureteral obstruction : report of 2 cases. Ann Urol (Paris) 2000; 34(3): 171-4.  Back to cited text no. 5    
6.Krcmery S, Dubrava M, Krcmery V Jr. Fungal urinary tract infec­tions in patients at risk. Int J Antimicrob Agents 1999; 11(3-4): 289-91.  Back to cited text no. 6    
7.Mendez Lopez V, Elia lopez M, Llorens Martinez FJ et al. Treat­ment of pelvis fungus balls with ureteral catheterisation, fluconazole and urine alkalinisation. Actas Urol Esp 1999: 23(2): 167-70.  Back to cited text no. 7    
8.Visser D, Monnens L, Feitz W, Semmekrot B. Fungal bezoars as a cause of renal insufficiency in neonates and infants - recommended treatment strategy. Clin Nephrol 1998; 49(3): 198-201.  Back to cited text no. 8    
9.Comitzer CV, Mcdonald M, Minton J, Yalla SV. Fungal bezoar and bladder rupture secondary to Candida tropicalis. Urology 1996; 47(3): 439-4.  Back to cited text no. 9    
10.Clark MA, Gaunt T. Czachor JS. The use of fluconazole as a local irrigant for nephrostomy tubes. Mil Med 1999; 164(3): 239-41.  Back to cited text no. 10    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]
 
 
    Tables

  [Table - 1]



 

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    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    Conclusions
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