Case Presentation:
An 80 yo African-American female with past medical history of hypertension, uterine cancer s/p radiation and mild cognitive impairment presented to the hospital with fatigue and non-specific symptoms for 2 weeks. On examination, vital signs were within normal limits and no acute findings were noticed except impaired vision and mild cognitive impairment. Initial labs were significant for serum Urea of 101, Creatinine of 5.3, pyuria and funguria on urinalysis.
An ultrasound of the kidneys and bladder revealed bilateral hydronephrosis and heterogeneous echogenic material in the bladder. Urine culture was positive for Candida albicans. Ureteral stenting was performed and bilateral nephrostomy tubes were placed which reversed renal failure. Cystoscopy confirmed the diagnosis of fungal bezoar in urinary bladder, which was positive for abscess on pathology and Candida species on staining. As patient was considererd not fit for surgery, she was treated conservatively with systemic fluconazole and amphotericin B bladder irrigation. Urine analysis, culture and follow-up ultrasound after anti-microbial therapy demonstrated successful treatment of the fungal ball.
Discussion:
Fungal bezoars in urinary bladder are rarely seen in clinical practice. Our review of literature since1966 showed 9 cases of fungal bezoars in urinary bladder, usually in patients with predisposing risk factors. We report a rare case of medically managed fungal bezoar in urinary bladder causing obstructive hydronephrosis and acute renal failure in an elderly patient with no predisposing risk factors. Systemic therapy with an antifungal agent is imperative in the management. Debulking by extraction of the fungus ball through the catheters and lavage should be attempted. After debulking, irrigation via the catheters until urine cultures are negative and there is no radiologic evidence of persistent disease.
Conclusions:
Candiduria is generally a benign infection commonly occurring in hospitalized patients. Risk factors for candiduria include urinary tract drainage devices, prior antibiotic therapy, diabetes, urinary tract pathology, and malignancy. Most patients with candiduria are asymptomatic, and the yeasts merely represent colonization. Invasive fungal infection of the urinary tract is uncommon, and rare complications like perinephric abscess and fungal ball formation can develop. We report a rare challenging case of candidial fungal bezoar in urinary bladder in a patient with no risk factors complicated with hydronephrosis and acute renal failure and describe its successful medical management and outcome.