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Percutaneous Management of Systemic Fungal Infection Presenting As Bilateral Renal Fungal Ball

View Article: PubMed Central - PubMed

ABSTRACT

Background:: Zygomycoses are uncommon, frequently fatal diseases caused by fungi of the class Zygomycetes. The majority of human cases are caused by Mucorales (genus—rhizopus, mucor, and absidia) fungi. Renal involvement is uncommon and urine microscopy, pottasium hydroxide mount, and fungal cultures are frequently negative.

Case presentation:: A twenty-one-year-old young unmarried lady presented to our emergency department with bilateral flank pain, fever, nausea, and decreased urine output of one-month duration. She was found to have azotemia with sepsis with bilateral hydronephrosis with a left renal pelvic obstructing stone. Even after nephrostomy drainage and broad spectrum antibiotics, her condition worsened. She developed disseminated fungal infection, and timely systemic antifungal followed by bilateral nephroscopic clearance saved the patient.

Conclusion:: Although renal fungal infections are uncommon, a high index of suspicion and early antifungal and surgical intervention can give favorable outcomes.

No MeSH data available.


(a) Histopathology of the nasal sinus mucosa (silver methenamine stain) showing broad aseptate hyphae. (b) Intraoperative nephroscopic view of necrotic material within the pelvicaliceal system.
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f2: (a) Histopathology of the nasal sinus mucosa (silver methenamine stain) showing broad aseptate hyphae. (b) Intraoperative nephroscopic view of necrotic material within the pelvicaliceal system.

Mentions: She was started on broad spectrum parenteral antibiotics, and received hemodialysis with blood transfusion followed by bilateral percutaneous nephrostomy drainage. After showing some initial clinical improvement, her condition continued to deteriorate. Both nephrostomies drained flakes with necrotic debris, for which repeated cultures, microscopy, and KOH mounts were negative. She was extensively evaluated for immunocompromised state, but no underlying cause could be found. She was planned for bilateral nephroscopic removal of stone and necrotic debris, but developed fever and signs of sepsis with metabolic acidosis, and creatinine increased. Despite antibiotics and bilateral wide bore nephrostomy drainage, her condition deteriorated progressively. We had two options, nephroscopic removal of debris and stone or bilateral nephrectomy in an unstable patient or to start systemic antifungal drugs empirically without any microscopic evidence at a creatinine of 3.5 mg/dL and oliguria, on the basis of NCCT findings of hyperdense material in the right pelvicaliceal system. She developed concomitant right maxillary swelling for which nasal endoscopy was done, which revealed necrotic nasal sinus mucosa with necrotic bone. Microscopy of the same was suggestive of mucor (Fig. 2a). Liposomal amphotericin B was then initiated. But by now she was already on mechanical ventilator. She showed dramatic response to amphotericin B and was extubated on day 2 of amphotericin. Nasal debridement and a total cumulative dose of 3.5 g of amphotericin B for 25 days resulted in stabilization of the patient's condition. Her general condition and urine output improved. On repeat NCCT scan of abdomen, both kidneys showed improvement and reduction in parenchymal gas (Fig. 1b). Bilateral sequential nephroscopic removal of stone and necrotic material was done; intraoperative picture is shown in Figure 2b. Postoperative NCCT scan of the abdomen is shown in Figure 1c. She was discharged on bilateral Double-J stents, no external drainage tubes, serum creatinine stable at 2.0 mg/dL, and a urine output of 2.5 L/day. After a 2 months of follow-up, her condition is stable with both the stents removed. Follow-up imaging shows no evidence of residual disease.


Percutaneous Management of Systemic Fungal Infection Presenting As Bilateral Renal Fungal Ball
(a) Histopathology of the nasal sinus mucosa (silver methenamine stain) showing broad aseptate hyphae. (b) Intraoperative nephroscopic view of necrotic material within the pelvicaliceal system.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5035836&req=5

f2: (a) Histopathology of the nasal sinus mucosa (silver methenamine stain) showing broad aseptate hyphae. (b) Intraoperative nephroscopic view of necrotic material within the pelvicaliceal system.
Mentions: She was started on broad spectrum parenteral antibiotics, and received hemodialysis with blood transfusion followed by bilateral percutaneous nephrostomy drainage. After showing some initial clinical improvement, her condition continued to deteriorate. Both nephrostomies drained flakes with necrotic debris, for which repeated cultures, microscopy, and KOH mounts were negative. She was extensively evaluated for immunocompromised state, but no underlying cause could be found. She was planned for bilateral nephroscopic removal of stone and necrotic debris, but developed fever and signs of sepsis with metabolic acidosis, and creatinine increased. Despite antibiotics and bilateral wide bore nephrostomy drainage, her condition deteriorated progressively. We had two options, nephroscopic removal of debris and stone or bilateral nephrectomy in an unstable patient or to start systemic antifungal drugs empirically without any microscopic evidence at a creatinine of 3.5 mg/dL and oliguria, on the basis of NCCT findings of hyperdense material in the right pelvicaliceal system. She developed concomitant right maxillary swelling for which nasal endoscopy was done, which revealed necrotic nasal sinus mucosa with necrotic bone. Microscopy of the same was suggestive of mucor (Fig. 2a). Liposomal amphotericin B was then initiated. But by now she was already on mechanical ventilator. She showed dramatic response to amphotericin B and was extubated on day 2 of amphotericin. Nasal debridement and a total cumulative dose of 3.5 g of amphotericin B for 25 days resulted in stabilization of the patient's condition. Her general condition and urine output improved. On repeat NCCT scan of abdomen, both kidneys showed improvement and reduction in parenchymal gas (Fig. 1b). Bilateral sequential nephroscopic removal of stone and necrotic material was done; intraoperative picture is shown in Figure 2b. Postoperative NCCT scan of the abdomen is shown in Figure 1c. She was discharged on bilateral Double-J stents, no external drainage tubes, serum creatinine stable at 2.0 mg/dL, and a urine output of 2.5 L/day. After a 2 months of follow-up, her condition is stable with both the stents removed. Follow-up imaging shows no evidence of residual disease.

View Article: PubMed Central - PubMed

ABSTRACT

Background:: Zygomycoses are uncommon, frequently fatal diseases caused by fungi of the class Zygomycetes. The majority of human cases are caused by Mucorales (genus—rhizopus, mucor, and absidia) fungi. Renal involvement is uncommon and urine microscopy, pottasium hydroxide mount, and fungal cultures are frequently negative.

Case presentation:: A twenty-one-year-old young unmarried lady presented to our emergency department with bilateral flank pain, fever, nausea, and decreased urine output of one-month duration. She was found to have azotemia with sepsis with bilateral hydronephrosis with a left renal pelvic obstructing stone. Even after nephrostomy drainage and broad spectrum antibiotics, her condition worsened. She developed disseminated fungal infection, and timely systemic antifungal followed by bilateral nephroscopic clearance saved the patient.

Conclusion:: Although renal fungal infections are uncommon, a high index of suspicion and early antifungal and surgical intervention can give favorable outcomes.

No MeSH data available.