Indian Journal of Dermatology
  Publication of IADVL, WB
  Official organ of AADV
Indexed with Science Citation Index (E) , Web of Science and PubMed
 
Users online: 4151  
Home About  Editorial Board  Current Issue Archives Online Early Coming Soon Guidelines Subscriptions  e-Alerts    Login  
    Small font sizeDefault font sizeIncrease font size Print this page Email this page


 
Table of Contents 
E–CASE REPORT
Year : 2013  |  Volume : 58  |  Issue : 5  |  Page : 408
Nosocomial urinary tract aspergilloma in an immunocompetent host: An unusual occurrence


1 Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, University of Delhi, Delhi, India
2 Department of Microbiology, University College of Medical Sciences and GTB Hospital, University of Delhi, Delhi, India
3 Department of Surgery, University College of Medical Sciences and GTB Hospital, University of Delhi, Delhi, India

Date of Web Publication30-Aug-2013

Correspondence Address:
Archana Singal
B-14 Law Apartments, Karkardooma, Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.117346

Rights and Permissions

   Abstract 

Fungal infections of the urinary tract are usually encountered following prolonged antibiotic use, instrumentation and indwelling urinary catheters. Candida is the most frequent causative fungus. However, infections with Aspergillus flavus have been reported previously in immune-compromised hosts. We, hereby, report a 32-year-old immunocompetent man diagnosed to have urinary tract infection caused by Aspergillus flavus following instrumentation for the removal of a ureteric stone. The infection was symptomatic, associated with abdominal pain and subsequent passage of fungal masses per urethra. Patient was treated successfully with a prolonged course of broad spectrum antifungal agent itraconazole.


Keywords: Aspergillosis, immuncompetent, nosocomial, urinary tract


How to cite this article:
Singal A, Grover C, Pandhi D, Das S, Jain BK. Nosocomial urinary tract aspergilloma in an immunocompetent host: An unusual occurrence. Indian J Dermatol 2013;58:408

How to cite this URL:
Singal A, Grover C, Pandhi D, Das S, Jain BK. Nosocomial urinary tract aspergilloma in an immunocompetent host: An unusual occurrence. Indian J Dermatol [serial online] 2013 [cited 2020 Jul 14];58:408. Available from: http://www.e-ijd.org/text.asp?2013/58/5/408/117346

What was known?
1. Candidal fungal infections of urinary tract following prolonged antibiotics, indwelling catheters and instrumentation are well known and symptoms vary from asymptomatic infections to fatal fungemia.
2. Urinary aspergillosis generally occurs in immunocompromised host and amphotericin B has been reported to be the treatment of choice for symptomatic infections.



   Introduction Top


Fungal infections of the urinary tract are becoming increasingly becoming common due to overuse of antibiotics, urinary tract instrumentation or loss of immunocompetency in the host. [1] Most of the cases are a result of candidal infection. [1] Other rarer reported causes include Aspergillus or Cryptococcus. Fungal infections of the urinary tract tend to be symptomatic and also carry a significant risk of dissemination. We present an interesting case of an immunocompetent male who presented with nosocomially acquired aspegillus bezoars of the urinary tract, which were symptomatic and also favorably responded to oral antifungal therapy.


   Case Report Top


A 32-year-old man of average built, visited a private hospital for surgical consult, with the complaints of recurrent, colicky abdominal pain of 6 months duration. On the basis of radiological investigations, he was diagnosed to have a right sided ureteric stone of 0.5 cm at the junction of upper 1/3 rd and lower 2/3 rd of the right ureter. He was also found to have significant bacteriuria with E. coli, for which he was treated with norfloxacin and amikacin. The ureteric stone was extracted by trans-urethral approach.

The removal of the stone led to subsidence of his symptoms. However, 3 weeks later, patient had recurrence of abdominal pain with low grade fever and malaise. He then presented to the department of surgery in our hospital. The pain was milder in intensity and accompanied by the passage of small, pinkish white soft balls per urethra during the process of urination. The pain subsided significantly following passage of these masses. The episodes of pain and subsequent passage of masses were intermittent, varying from twice a day to twice per week. His repeated urine cultures were sterile despite 2-3 neutrophils per high power field on microscopic examination. There were no signs of uretric obstruction, renal compromise or sepsis. He was reassured and prescribed antispasmodics with only temporary relief. He was then referred for dermatology opinion. The patient was asked to urinate in an open container to visualize the masses. On examination, these masses appeared fleshy, of variable size and shape, maximum being 2 cm in length and soft in consistency [Figure 1]. These masses were subjected to microscopic examination in 10% potassium hydroxide (KOH), fungal culture and histopathological examination. KOH examination revealed dense collection of septate hyaline hyphae with dichotomous branching at places [Figure 2]. For fungal culture, the specimen was inoculated on sabouraud dextrose agar (SDA) medium with antibiotics (chloramphenicol-0.4 gm/l, gentamicin-0.04 gm/l) and without cyclohexamide at 25°C. After 3-4 days, growth of colonies was observed which were green to grey in colour with a mat - like surface. Microscopically on lacto phenol cotton blue (LPCB) mount hyaline septate, relatively broad hyphae with long conidiophores were seen [Figure 3]. Vesicles were spherical, large with biseriate phialides bearing chains of conidia over most of the surface morphologically correlating with Aspergillus flavus. Histopathology too, was corroborative and revealed dense masses of interweaving septate filamentous hyphae.
Figure 1: Linear fleshy mass of fungus passed per urethra

Click here to view
Figure 2: Mass of septate hyaline hyphae with dichotomous branching on KOH microscopy

Click here to view
Figure 3: Greenish grey, hyaline septate relatively broad hyphae with long conidiophores seen on LPCB mount. Note: Large, spherical vesicles with biseriate phialides bearing chains of conidia characteristic of Aspergillus flavus

Click here to view


The patient underwent hematological investigations to rule out underlying diabetes, HIV or any other cause of immunodeficiency. His renal functions were within normal limits. Blood sample for bacterial and fungal cultures were sterile and X-ray chest did not reveal any focus of infection. He was started on oral itraconazole at a dose of 200 mg twice a day. Patient became afebrile and reported a feeling of well being within two weeks of therapy. The last fungal mass was passed 12 days after start of therapy but the treatment was continued for a period of three months. The patient has been well and asymptomatic for more than 6 months after discontinuation of therapy.


   Discussion Top


Fungal infections of the urinary tract are increasing in incidence, mostly due to the increasing use of antibiotics, instrumentation and indwelling urinary catheters. [1] They may be symptomatic or may remain asymptomatic. A spectrum of clinical manifestations varying from asymptomatic colonization (most common), cystitis, pyelonephritis, renal infection, sepsis and fungemia have been reported. [1] There is a predilection for drainage structures rather than the renal parenchyma. [2] Funguria may become pathologic depending on host factors, thus the management depends on the patient's underlying health status. Candida is the most common fungus infecting the urinary tract. [1] However, other fungi may be involved depending on previous antifungal treatment and previous hospitalization.

Aspergillus is not a common cause of fungal urinary tract infections (UTI's). Primary aspergillus infection of the urinary tract is sufficiently rare, even more so in immunocompetent patients. [3] Bibler et al., reviewed 11 patients with aspergillomas of the renal system. [4] Ten of these were men and all had an underlying disease that predisposed to the fungal infection. In immunocompromised patients, varying manifestations in the form of aspergillus balls or bezoars, [3],[5] ureteric obstruction, [4] ureteric colic, renal failure, [3] sepsis [3] or disseminated aspergillosis have been reported. Except for mild spasmodic pain and discomfort, our patient did not manifest any fever or severe constitutional symptoms. Disseminated aspergillosis in the form of pulmonary aspergillomas or prostatic involvement [6] has been reported even in immunocompetent patients. This can occur due to corticosteroid use or surgical intervention. [6] No signs of dissemination were seen in our patient. Visible passage of aspergillus balls in urine is an interesting and frightening symptom for the patient. This has rarely been reported previously in a patient with acute myelocytic leukemia. [7] To the best of our knowledge, our patient is the first immunocompetent host to develop aspergillus bezoars.

It is recommended that asymptomatic funguria in hospitalized patients may not be treated as treatment does not impact morbidity and mortality. It may be only a sickness indicator like bacteriuria in elderly. [8] Treatment is recommended only when funguria is symptomatic or in case where host factors increase the risk of fungemia. [1] Reduction of risk factors like removal of indwelling catheters and optimising antibiotic usage should be tried. In immunocompromised patients, a combined approach with topical and systemic antifungal agents and endourological access for extraction, lavage and debulking may be required. [9] However, in immunocompetent, surgical therapy is not necessary. Infact asymptomatic prostatic aspergillosis has been reported to disseminate after a routine transurethral resection procedure. [6] Aspergillosis is reported to behave more malignantly than candidiasis of urinary tract. [9] Treatment with amphotericin B has previously been recommended. [10] However, itraconazole treatment has proven effective even in amphotericin B resistant cases. [9] Our patient was healthy, immunocompetent and refused hospitalization; hence, we tried this as the first line therapy in our case with successful outcome.

The present case emphasizes the possibility of iatrogenic urinary fungal infection secondary to instrumentation in an otherwise immunocompetent patient. A high index of suspicion in such patients and careful investigations are needed to establish the diagnosis. Oral itraconazole may be recommended as a first line therapy.

 
   References Top

1.Etienne M, Caron F. Management of fungal urinary tract infections. Presse Med 2007;36:1899-906.  Back to cited text no. 1
[PUBMED]    
2.Morris BS, Chudgar PD, Manejwala O. Primary renal candidiasis: Fungal mycetomas in the kidney. Australas Radiol 2002;46:57-9.  Back to cited text no. 2
[PUBMED]    
3.Smaldone MC, Cannon GM, Benoit RM. Case report: Bilateral ureteral obstruction secondary to Aspergillus bezoar. J Endourol 2006;20:318-20.  Back to cited text no. 3
[PUBMED]    
4.Bibler MR, Gianis JT. Acute ureteral colic from an obstructing renal aspergilloma. Rev Infect Dis 1987;9:790-4.  Back to cited text no. 4
[PUBMED]    
5.Vuruskan H, Ersoy A, Girgin NK, Ozturk M, Filiz G, Yavascaoglu I, et al. An unusual cause of ureteral obstruction in a renal transplant recipient: Ureteric aspergilloma. Transplant Proc 2005;37:2115-7.  Back to cited text no. 5
[PUBMED]    
6.Ludwig M, Schneider H, Lohmeyer J, Ermert L, Sziegoleit A, Lommel D, et al. Systemic aspergillosis with predominant genitourinary manifestations in an immunocompetent man: What we can learn from a disastrous follow-up. Infection 2005;33:90-2.  Back to cited text no. 6
[PUBMED]    
7.Torrington KG, Old CW, Urban ES, Carpenter JL. Transurethral passage of Aspergillus fungus balls in acute myelocytic leukemia. South Med J 1979;72:361-3.  Back to cited text no. 7
[PUBMED]    
8.Simpson C, Blitz S, Shafran SD. The effect of current management on morbidity and mortality in hospitalised adults with funguria. J Infect 2004;49:248-52.  Back to cited text no. 8
[PUBMED]    
9.Irby PB, Stoller ML, McAninch JW. Fungal bezoars of the upper urinary tract. J Urol 1990;143:447-51.  Back to cited text no. 9
[PUBMED]    
10.Khan ZU, Gopalakrishnan G, al-Awadi K, Gupta RK, Moussa SA, Chugh TD, et al. Renal aspergilloma due to Aspergillus flavus. Clin Infect Dis 1995;21:210-2.  Back to cited text no. 10
[PUBMED]    

What is new?
Iatrogenic fungal infection is a possibility secondary to invasive procedures even in an immunocompetent patients that should be confirmed on culture. Oral itraconazole should be used as first line of treatment.


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
Print this article  Email this article
 
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (1,145 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Case Report
   Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed2849    
    Printed47    
    Emailed0    
    PDF Downloaded35    
    Comments [Add]    

Recommend this journal