Treatment of Renal Fungal Ball with Fluconazole Instillation Through a Nephrostomy Tube: Case Report and Literature Review.

BACKGROUND Urinary tract candida infection can be due either to hematogenous dissemination of the organism or a retrograde infection. In debilitated or immunosuppressed septic patients, who have upper urinary tract obstruction with renal filling defect, fungal infection should be considered. We report on a patient with sepsis and renal fungal ball who was treated with percutaneous nephrostomy and intravenous antifungal agent, but the patient did not respond so instillation of fluconazole through nephrostomy was given. CASE REPORT A 60-year-old male patient with a known case of diabetes mellitus with refractory urine retention underwent transurethral resection of the prostate. Postoperatively, the patient developed recurrent high-grade fever with left loin pain, and elevated septic parameters; urine and blood culture were positive for Candida albicans. Computed tomography urography showed left hydronephrosis with filling defect in the left renal pelvis with suspected renal fungal ball. Left percutaneous nephrostomy was performed and intravenous fluconazole started but the fever did not subside, therefore, the treatment was changed to anidulafungin. The patient improved but urine from both the bladder and the nephrostomy remained positive for candida. Instillation of fluconazole at 300 mg in 500 mL normal saline was applied through the nephrostomy tube over 12 hours at 40 mL/hour for 7 days. CONCLUSIONS Renal fungal ball is rare but can be serious, especially in immunocompromised patients. Management options for renal fungal ball include intravenous antifungal agents and percutaneous nephrostomy with antifungal instillation of antifungal agents. The objective of this case report was to document treatment success with the use of fluconazole instillation through a nephrostomy tube.