|Year : 2003 | Volume
| Issue : 1 | Page : 50-53
Endourological interventions in the diagnosis and management of upper urinary tract fungal infections - our experience
S Joseph Philipraj1, M Joseph Thomas1, Sudha Bhat2
1 Department of Urology, Kasturba Medical College, Manipal, India
2 Department of Pathology, Kasturba Medical College, Manipal, India
S Joseph Philipraj
Department of Urology, KMC, Manipal - 576 119
Source of Support: None, Conflict of Interest: None
| 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 May 26];20:50-3. Available from: http://www.indianjurol.com/text.asp?2003/20/1/50/37125
| Introduction|| |
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|| |
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|| |
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|| |
In recent years, there has been an increasing awareness of the significance of infections caused by fungus.  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.  Recently polymerase chain reaction is used to detect candidemia in patients with candiduria and to detect candiduria before the culture reports are available. , 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. ,, The results can be hydronephrosis, oliguria or even anuria,  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. 
Endourological procedures are valuable in the diagnosis and management of genitourinary fungal infections. ,, Percutaneous nephrostomy,  ureteroscopy, nephroscopy and ureteral stents offer the urologist better ways of handling these often seriously ill patients. At the same time, percutaneous irrigation , 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|| |
Endourological interventions help in relieving and treating obstructions caused by fungal infections.
| References|| |
|1.||Lundstrom T, Sobel J. Nosocomial Candiduria : a review. Clin Infect Dis 2001; 1: 32(11): 1602-7. |
|2.||Fisher JF. Candiduria : when and how to treat it. Curr Infect Dis Rep 2000; 2(6): 523-530. |
|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. |
|4.||Muncan P, Wise GJ. Early identification of Candiduria by polymerase chain reaction in high risk patients. J Urol 1996: 156(1): 154-6. |
|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. |
|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. |
|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. |
|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. |
|9.||Comitzer CV, Mcdonald M, Minton J, Yalla SV. Fungal bezoar and bladder rupture secondary to Candida tropicalis. Urology 1996; 47(3): 439-4. |
|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. |
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1]