This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited. © 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada. Key Words Competing Interests Article Information Malakoplakia, urinary tract infections, urinary bladder, lower urinary tract symptoms None declared. Patient Consent: Obtained. Received on December 3, 2021 Accepted on December 11, 2021 Soc Int Urol J.2021;3(4):281–282 DOI: 10.48083/QFCW5582 FIGURE 1. Cystoscopy showing (A) malakoplakia nodules in the bladder and surrounding a severely dilated ureteric orifice (B) 281SIUJ.ORG SIUJ • Volume 3, Number 4 • July 2022 CLINICAL PICTURE Malakoplakia Causing Poor Bladder Compliance and Bilateral Hydroureteronephrosis Cecile T. Pham,1,2 Melanie Edwards,3 Amanda S.J. Chung,1,2 Venu Chalasani1,2 1 Department of Urology, Northern Beaches Hospital, Frenchs Forest, Australia 2 North Shore Urology Research Group, St Leonards, Australia 3 Department of Anatomical Pathology, Douglass Hanley Moir Pathology, Macquarie Park, Australia An 81-year-old female presented with lower urinary tract symptoms (LUTS) including frequency, urgency and urge incontinence. She had a 2-year history of recurrent urinar y tract infections (UTI) with Escherichia coli of varying susceptibility. Background history included rheumatoid arthritis treated with long- term corticosteroids, and stage-4 chronic kidney disease due to hypertensive nephrosclerosis. Non-contrast CT imaging showed severe bilateral hydroureteronephrosis to the level of the vesicoureteric junction and circumferential bladder wall thicken- ing. The patient had a creatinine level of 221 μmol/L and eGFR rate of 18mL/min/1.73m2. Cystoscopy revealed diffuse erythema and white-yellow nodules (Figure  1). Histopathological examination of bladder biopsies demonstrated numerous Michaelis-Gutmann bodies, pathognomic for the rare chronic inf lamma- tory condition malakoplakia (Figure 2)[1–5]. There was no evidence of dysplasia or malignancy. Urody- namic assessment revealed increased bladder sensation and poor bladder compliance with impaired detrusor contractility. Malakoplakia is usually associated with recurrent UTI, particularly Escherichia coli, Staphylococcus aureus, Proteus, and Klebsiella[4]. The patient was commenced on trimethoprim/sulfamethoxazole 150/100mg daily http://SIUJ.org https://orcid.org/0000-0002-5954-565X mailto:cecile.pham%40icloud.com?subject=SIUJ https://orcid.org/0000-0002-0111-4961 https://orcid.org/0000-0003-1356-9610 prophylaxis, which was switched to cephalexin 500mg daily prophylaxis due to poor tolerance. She was also commenced on methenamine hippurate, supplemental vitamin C, and completed a course of Uromune for UTI prophylaxis. The nodules had largely resolved on progress cystos- copy four months later. At this time, she was treated with intravesical antibiotic wash using gentamicin 480mg diluted in 1L 0.9% sodium chloride. This case demonstrates that malakoplakia can cause obstructive uropathy. It serves as a reminder to consider malakoplakia as a differential, particularly in women with recurrent UTI and immunosuppression. References 1. Kogulan PK, Smith M, Seidman J, Chang G, Tsokos M, Lucey D. Malakoplakia involving the abdominal wall, urinary bladder, vagina, and vulva: case report and discussion of malakoplakia- associated bacteria. Int J Gynecol Pathol.2001;20:403-406. doi: 10.1097/00004347-200110000-00016 2. Bylund J, Pais VM Jr. A case of acute renal failure caused by bilateral, multifocal malacoplakia lesions of the bladder and ureters. Nat Clin Pract Urol.2008;5(9):516-519. doi:10.1038/ncpuro1173 3. Sanchez LM, Sanchez SI, Bailey JL. Malacoplakia presenting with obstructive nephropathy with bilateral ureter involvement. Nat Rev Nephrol.2009;5(7):418-422. doi: 10.1038/nrneph.2009.86 4. Cavallone B, Serao A, Audino P, Di Stasio A, Tiranti D, Vota P. Bilateral hydroureteronephrosis with renal failure caused by malacoplakia. Urologia.2017;85(1):36-37. doi: 10.5301/uj.5000268 5. Stamatiou K, Chelioti E, Tsavari A, Koulia K, Papalexandrou A, Efthymiou E, et al. Renal failure caused by malakoplakia lesions of the urinary bladder. Nephrourol Mon.2014;6(4). doi: 10.5812/ numonthly.18522 FIGURE 2. Histopathological images at x40 magnification with white arrows demonstrating the Michaelis-Gutmann bodies on (A) H&E stain and (B) von Kossa calcium stain 282 SIUJ • Volume 3, Number 4 • July 2022 SIUJ.ORG CLINICAL PICTURE http://SIUJ.org