Case Report 127Urology Journal Vol 6 No 2 Spring 2009 Aspergillus Fungal Balls Causing Ureteral Obstruction Ashish Ahuja, Baldev S Aulakh, Deepinder Kaur Cheena, Ravi garg, Sandeep Singla, Sushil Budhiraja Urol J. 2009;6:127-9. www.uj.unrc.ir Keywords: Aspergillus, urinary tract infections, ureteral obstruction Dayanand Medical College and Hospital, Ludhiana, Punjab, India Corresponding Author: Sandeep Singla, MD H No 265, Sector-10, Panchkula (Haryana), India Tel: +91 98 7277 7620 E-mail: drsandeepdmch@yahoo. co.in Received January 2008 Accepted May 2008 INTRODUCTION Fungal bezoar of the kidney is a rare clinical entity, usually seen in a diabetic, immunocompromised, or chronic alcoholic patient who has prolonged catheterization.(1) Angio-invasive fungal infections such as aspergillosis are associated with severe renal lesions and kidney failure with high morbidity and mortality rates.(2) We describe a patient who developed complete obstruction of the left ureter as a result of Aspergillus fungal balls which were successfully removed ureteroscopically. CASE REPORT A 48-year-old diabetic woman presented with a dull pain in the left flank, recurrent urinary tract infections, and passage of small particles during urination for the past 2 years. Urine microscopic examination showed a field full of pus cells. Diagnosis of aspergillosis was confirmed by urine culture (Figure 1). Intravenous urography showed left hydroureteronephrosis. No invasion to the renal parenchyma was detected on abdominal computed tomography (Figure 2). Preoperative retrograde pyelography and ureteroscopy showed complete obstruction in the pelvic ureter (Figure 3). The fungal balls were removed ureteroscopically from the left ureter and the renal pelvis and sent for microbiological examination. Microscopic examination of the wet mount preparation revealed hyaline septate hyphae with branching at acute angles. The lactophenol cotton blue mount from the Figure 1. Lactophenol cotton blue mount of Aspergillus culture shows septate hyphae and conidiophores ending in a vesicle (× 400). Figure 2. Contrast-enhanced abdominal computed tomography shows a bulky left kidney with normal enhancement of the renal parenchyma. Fungal Balls Causing Ureteral Obstruction—Ahuja et al 128 Urology Journal Vol 6 No 2 Spring 2009 fungal culture demonstrated septate hyphae with conidiophores terminating in a vesicle. The features were consistent with the diagnosis of Aspergillus infection. The patient received oral itraconazole, 400 mg, for 1 month, and irrigation through ureteral catheter with amphotericin B was done for 7 days. Retrograde urography on the 10th postoperative day showed good drainage of contrast medium from the left kidney (Figure 4). The patient’s recovery period was uneventful. DISCUSSION Opportunistic pathogens such as Candida, Aspergillus, Mucor, Cryptococcus, and Histoplasma are known to infect the kidneys in patients with serious complications.(2) Typically, fungal diseases involve the urinary drainage system.(3) The usual locations of involvement by Aspergillus include the lungs, central nervous system, sinuses, and skin.(3-5) In immunocompromised patients, disseminated infections with involvement of kidney may occur. Aspergillosis of the kidney may present as any of the following patterns: disseminated aspergillosis with renal involvement resulting from hematogenous spread of the fungi to the kidneys, leading to formation of multiple focal abscesses; aspergillus cast of the renal pelvis; and ascending panurothelial aspergillosis of the urethra, bladder, pelvis, and kidney.(2) A fungal bezoar causing ureteral obstruction is extremely rare. Only about 50 cases of such fungal balls have been reported.(5) Most fungal bezoars causing ureteral obstruction are due to Candida species. Only about 12 cases of ureteral obstruction by aspergillosis have been reported to date.(6) Most of ureteral obstructions are unilateral. Bilateral ureteral obstruction due to fungal bezoars is extremely rare.(6,7) Fungal infections of the urinary tract must be diagnosed quickly and treated aggressively. If they remain untreated, they can cause urinary obstruction through formation of accretions called fungal balls resulting in hydronephrosis, oligu ria or anuria, destruction of the renal parenchyma, wide-spread Figure 4. Postoperative retrograde urography shows normal drainage of the left ureter. Figure 3. Retrograde urography shows complete obstruction of pelvic ureter. Fungal Balls Causing Ureteral Obstruction—Ahuja et al Urology Journal Vol 6 No 2 Spring 2009 129 dissemination of the organism, and death of the patient.(2,8) Unfortunately, excretory urography, computed tomography, and even retrograde urography have been reported to be unreliable in diagnosis of this condition.(6-8) Otherwise, endourological procedures including percutaneous nephrostomy, ureteroscopy, nephroscopy, and ureteral stents are valuable in the diagno sis and management of fungal infections in the urogenital system and offer better ways of han dling these patients to the urologist.(7) At the same time, percutaneous irrigation permits administration of highly toxic antifungal drugs to the patients with localized infection and as a result, minimizes systemic side effects.(8) Endourological procedures along with oral and topical antifungals can be successfully used to manage patients with disseminated fungal infection. CONFLICT OF INTEREST None declared. REFERENCES 1. 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