Ferari Christopher, Crigger Chad, Morley Chad
Department of Urology, West Virginia University School of Medicine, Morgantown, WV 26505, USA.
Case Rep Urol. 2020 Sep 28;2020:8828289. doi: 10.1155/2020/8828289. eCollection 2020.
Fungemia due to obstructive urinary tract fungal ball is exceedingly rare. These patients often have multiple predisposing conditions, including diabetes or antimicrobial exposure. While candiduria can be relatively common in this population, urinary tract fungal balls are a rare entity. Hospitalists should be aware of this rare complication in patients presenting with funguria. . We present a case of a 44-year-old male with type II diabetes, chronic hepatitis C secondary to injection drug use, and chronic kidney disease who developed a urinary tract fungal ball leading to fungemia and subsequent bilateral chorioretinitis, additionally complicated by emphysematous cystitis and pyelonephritis. Additional invasive treatment options beyond typical antifungals are often required in the case of urinary tract fungal ball, and in this case, bilateral nephrostomy tubes and micafungin were employed. Hospital course was complicated by fungemia with subsequent bilateral fungal chorioretinitis on dilated fundus exam. This was effectively treated with cyclogyl and prednisolone drops along with bilateral voriconazole injections. Follow-up imaging and cultures showed resolution of fungemia, urinary tract masses, and chorioretinal infiltrates; however, recurrent polymicrobial UTIs continue to be an issue for this patient.
Special multidisciplinary management is required in the treatment of urinary tract fungal balls with subsequent fungemia, including nephrostomy tubes, antifungal irrigation, ureterorenoscopy, and more powerful antifungals such as amphotericin B and 5-flucytosine. This management draws from a myriad of specialties, including urology, infectious disease, and interventional radiology. Additionally, the literature has demonstrated that only approximately half of patients with fungemia receive an ophthalmologic evaluation. Ophthalmologic and urologic cooperation is essential in the case of obstructive uropathy leading to fungemia as the obstructive uropathy must be relieved and these patients should receive a dilated fundus exam.
梗阻性尿路真菌球引起的真菌血症极为罕见。这些患者通常有多种易感因素，包括糖尿病或抗菌药物暴露。虽然念珠菌尿在该人群中可能相对常见，但尿路真菌球是一种罕见的病症。住院医生应意识到在出现真菌尿的患者中存在这种罕见并发症。我们报告一例44岁男性患者，患有II型糖尿病、因注射吸毒继发慢性丙型肝炎和慢性肾脏病，他发生了尿路真菌球，导致真菌血症及随后的双侧脉络膜视网膜炎，此外还并发气肿性膀胱炎和肾盂肾炎。对于尿路真菌球病例，通常需要除典型抗真菌药物之外的其他侵入性治疗选择，在本病例中，采用了双侧肾造瘘管和米卡芬净。住院期间病情因真菌血症而复杂化，散瞳眼底检查发现随后出现双侧真菌性脉络膜视网膜炎。使用环喷托酯和泼尼松龙滴眼液以及双侧伏立康唑注射有效地治疗了该病。随访影像学检查和培养显示真菌血症、尿路肿块和脉络膜视网膜浸润消退；然而，复发性多种微生物尿路感染仍是该患者的一个问题。
治疗伴有真菌血症的尿路真菌球需要特殊的多学科管理，包括肾造瘘管、抗真菌灌洗、输尿管肾镜检查以及更强效的抗真菌药物，如两性霉素B和5-氟胞嘧啶。这种管理涉及众多专业领域，包括泌尿外科、传染病科和介入放射科。此外，文献表明，只有大约一半的真菌血症患者接受眼科评估。在梗阻性尿路病导致真菌血症的情况下，眼科和泌尿外科的合作至关重要，因为必须解除梗阻性尿路病，并且这些患者应接受散瞳眼底检查。
