< Case presentation > The
patient was a 38-year-old man who had hepatitis B and C
virus-related liver cirrhosis, Child class B and type 2
diabetes mellitus under oral hypoglycemic agent control for
five years. On April 13, 2003, he noted that his urine became
dark-colored and contained whitish debris. This was
accompanied by a sudden onset of low back pain and followed by
anuria. He suffered from fever, chills, and general myalgia
three days later.
In our emergency department on
April 21, his consciousness was clear. His temperature was
36.8oC,
pulse rate was 88 beats/min, respiration rate was 20/min, and
blood pressure was 160/108 mmHg.. Renal sonography showed
bilateral enlarged kidneys and hydronephrosis, air in renal
parenchyma, and hyperechoic foci in the medullary pyramids (Fig 1
). Abdominal MRI revealed enlargement of both
kidneys and loss of the corticomedullary junctions. The renal
calyces and bilateral ureters were dilated down to the
uretero-vesicular junction level, which was obstructed by
debris. Coronary T2W image demonstrated ring shadows in the
midportion of medullary pyramids and classic filling of clefts
originating from fornices of the superior caliceal group,
which suggested papillary necrosis in situ. Some air pockets
in the right renal pelvis were also noted.
< Course and Treatment
> The blood cultures on
April 17 and April 21, and urine culture on April 21 all
yielded Candida tropicalis. Fluconazole 200 mg/day was
instituted starting on April 22. However, anuria followed by
fever and chills developed on April 25, 2003. Renal sonography
showed outflow obstruction by debris and bilateral
hydronephrosis. Therefore, he received bilateral percutaneous
nephrostomy (PCN). The urine output recovered later up to 3000
mL /day.
He was
afebrile after the fifth hospitalization day. The hemogram
revealed a leukocyte count of 8,530 (/μL). The BUN and
creatinine also returned to 23.2 mg/dL and 1.21 mg/dL,
respectively which were within normal ranges. Fluconazole was
increased to 400 mg/day. One month later, anterograde
pyelography showed improvement of hydronephrosis, and PCN was
removed on June 6 smoothly, and urine output was adequate
thereafter. Intravenous fluconazole had been administered for
four weeks and then shifted to the oral form for another week.
He was followed up regularly with adequate urine output and
stable renal function.
< Laboratory and Image Study
>
1. CBC/DC
Date |
WBC |
RBC |
Hb |
Hct |
MCV |
MCHC |
Plt |
|
/ul |
M/ul |
g/dl |
% |
fL |
% |
K/ul |
Apr. 21 |
14620 |
2.96 |
8.5 |
25.3 |
85.5 |
33.6 |
128 |
Date |
Seg |
Eos |
Baso |
Mono |
Lym |
Apr 21 |
80.5 |
2.3 |
0.8 |
6.8 |
9.6
|
2. Biochemistry
BUN |
Cre |
UA |
Na |
K |
Cl |
Ca |
P |
Mg |
Glu |
Mg/dL |
Mg/dL |
Mg/dL |
mM |
mM |
mM |
Mg/dL |
mM |
mM |
Mg/dL |
55.1 |
7.97 |
10.39 |
129.8 |
3.9 |
103 |
1.82 |
3.44 |
0.81 |
438 |
Alb |
Glo |
AST |
ALT |
T-bil |
CK |
ALP |
GGT |
LDH |
g/dL |
g/dL |
U/L |
U/L |
Mg/dL |
U/L |
U/L |
U/L |
U/L |
2.1 |
4.8 |
29 |
10 |
0.6 |
25 |
900 |
459 |
718 |
3. Urinalysis
App. |
pH |
Pro |
Glu |
Ket |
OB |
Urobi |
|
|
Mg/dL |
Mg/dL |
|
|
EU/dL |
Y/T |
6.0 |
- |
100 |
- |
2+ |
0.1 |
Bil |
WBC |
RBC |
Epi |
Cast |
Crystal |
Others |
- |
22-28 |
15-20 (morphology negative) |
3-6 |
- |
- |
Yeast
(1+) |
< Analysis
>
C. tropicalis infection has been most often seen in
persons with cancer and diabetes mellitus [1]. It appears to
be more virulent than C. albicans in patients with
hematological malignancies, and disseminated infection is
associated with higher mortality rates than infection with
C. albicans and C. parapsilosis [2].
Fungal infiltration at the tips of
the renal papillae may also cause papillary necrosis [3]. Like
in our patient, less resistant individuals with severe fungal
infection develop microabscesses in the renal parenchyma.[3]
The coexistence of liver cirrhosis and diabetes mellitus
supports the contention, at least partly, for the severity
coexistence of bilateral EPN and RPN.
The diagnosis of papillary
necrosis usually relies on destructive changes involving the
tips of the pyramids shown on excretory urography (IVP) [4].
To avoid the contrast related nephropathy in this patient with
acute renal failure, we looked for “ring signs” consistent
with papillary necrosis in MRI.
In our patent, infection was
controlled, and renal function preserved after PCN drainage
and fluconazole treatment. As in our patient, it was reported
that the presence of loculated gas pattern and presence of
exudates in EPN or the presence of gas in the collecting
system reflect a better prognosis than mottled gas pattern.[5]
We suggest that if appropriate diagnostic studies demonstrate
evidence of urinary obstruction in bilateral EPN and RPN,
intensive medical treatment and surgical drainage is
necessary.
In conclusion, disseminated
candidiasis could result in severe bilateral EPN and RPN,
especially in diabetic and cirrhotic patients. Treatment
should attempt to eradicate the fungus and relieve the
obstruction by surgical drainage of the
lesions.[6]
< Legends to Figures
>
Fig
1. Ring signs consistent
with papillary necrosis. Longitudinal sonogram of the left
kidney showed an enlarged kidney (13.9cm). Echogenic papillae
(arrows) in a medullary pyramid and hydrocalyces were noted.
Surrounding the echogenic region were echolucent rims,
consistent with fluid dissection into and around necrotic
papillae.
< Reference
>
- Kao, A.S., M.E. Brandt, W.R. Pruitt, et al. The
epidemiology of candidemia in two United States cities:
results of a population-based active surveillance. Clin
Infect Dis 1999; 29: 1164-70.
- Leung, A.Y., C.S. Chim, P.L. Ho, et al. Candida
tropicalis fungaemia in adult patients with haematological
malignancies: clinical features and risk factors. J Hosp
Infect 2002; 50: 316-9.
- Kale, H., R.S. Narlawar, and K. Rathod. Renal fungal
ball: an unusual sonographic finding. J Clin Ultrasound
2002; 30: 178-80.
- Tomashefski, J.F., Jr. and C.R. Abramowsky.
Candida-associated renal papillary necrosis. Am J Clin
Pathol 1981; 75: 190-4.
- Wan, Y.L., S.K. Lo, M.J. Bullard, et al. Predictors of
outcome in emphysematous pyelonephritis. J Urol
1998; 159: 369-73.
- Wu, V.C., C.C. Fang, W.Y. Li, et al. Candida
tropicalis-associated bilateral renal papillary necrosis and
emphysematous pyelonephritis. Clin Nephrol
2004; 62:
473-5.
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