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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~ Conclusions
 ~ Acknowledgement
 ~  References
 ~  Article Figures

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  Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 33  |  Issue : 2  |  Page : 316-318
 

Aspergillus infection in urinary tract post-ureteric stenting


Department of Microbiology, Narayana Health Multispeciality Hospital, Ahmedabad - 382 424, Gujarat, India

Date of Submission10-Feb-2014
Date of Acceptance21-Mar-2014
Date of Web Publication10-Apr-2015

Correspondence Address:
P Rao
Department of Microbiology, Narayana Health Multispeciality Hospital, Ahmedabad - 382 424, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.154895

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 ~ Abstract 

Fungal infections of the urinary tract are usually encountered following prolonged antibiotic use, instrumentation and indwelling urinary catheters. These type of infections are mostly seen in immuno-compromised patients. Candida is the most common among the fungal infections of urinary tract followed by Aspergillus infection. Here is a case report of a 26 year old diabetic female who presented with abdominal pain, fever, nausea and vomiting. She had undergone double-J stenting 15-20 days back. The cause of the symptoms was not detected till the patient underwent C.T Scan-KUB with excretory urography which showed the displaced D-J stent. Then on performing replacement of D-J stent, cystoscopy was done and the tissue sample was sent for microbiological and histopathological examination. On Microbiological examination, Aspergillus flavus was isolated from the tissue, which was culprit behind the disease. Patient was then treated with anti-fungal drugs, following which she gradually improved.


Keywords: Aspergillus, cystoscopy, Candida, immunocompromised


How to cite this article:
Rao P. Aspergillus infection in urinary tract post-ureteric stenting. Indian J Med Microbiol 2015;33:316-8

How to cite this URL:
Rao P. Aspergillus infection in urinary tract post-ureteric stenting. Indian J Med Microbiol [serial online] 2015 [cited 2019 Aug 20];33:316-8. Available from: http://www.ijmm.org/text.asp?2015/33/2/316/154895



 ~ Introduction Top


Fungal infections of the urinary tract are becoming increasingly becoming common due to overuse of antibiotics, urinary tract instrumentation or in case of immunocompromised condition 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 a diabetic female who presented with severe urosepsis with severe symptoms but for cause not known.


 ~ Case Report Top


A 26-year-old diabetic female presented to our hospital with complaints of abdominal pain, fever, urinary retention, nausea and vomiting with Right Double-J stent in situ.

This patient was admitted previously about 15 days back elsewhere with complain of bilateral flank pain with chills. On investigation she was found to be suffering from bilateral hydronephrosis with impaired renal function for which she underwent Bilateral Double-J ureteric stenting. Following this she improved symptomatically as well as her serum creatinine level normalized. After this left D-J stent was displaced it was removed subsequently within 5-6 days. Again after a week, the patient presented to our hospital with above-mentioned complaints.

Patient was investigated which showed raised total leucocyte count, creatinine levels, potassium levels and plenty of pus cells in urine. Patient was suspected to be suffering from urosepsis and so urine culture was followed. This showed the presence of infection with  Escherichia More Details coli. She was then treated with appropriate antibiotic as per the culture and sensitivity report. Then also there were no signs of improvement. Repeated urine analysis revealed plenty of pus cells. Then repeated cultures did not show any bacterial growth and Z-N stain also did not show presence of acid-fast bacilli. So, it was decided to go for Multislice C.T scan of kidney-urinary bladder with excretory urography. C.T scan showed changes of pyonephrosis with ureteric inflammation suggestive of some chronic infection and narrowing with normal excreting left kidney with D-J stent in urinary bladder i.e. displaced stent. Patient then underwent cystoscopy with ureteric biopsy with D-J stent removal and replacement. Then urine and bladder tissue samples were sent for microbiological examination.

In microbiology laboratory, bacterial, fungal and mycobacterial culture was done. Bacterial and mycobacterial culture were negative but fungal examination revealed positive findings. On KOH examination of urine deposits and tissue, plenty of septate, branched hyphae were seen [Figure 1]. On culture on Saboraud's dextrose agar, after 24 hours of incubation at 25°C, greenish mat-like colony was observed [Figure 2]. Surface pigment was yellowish green and obverse was colourless. Lacto-phenol-cotton blue preparation showed narrow septate hyphae, long, hyaline conidiophores with large and globose vesicles. Also uniseriate phialides were seen with unicellular and globose phialoconidia. Foot cells were also seen. This picture was suggestive of Aspergillus flavus [Figure 3] and [Figure 4]. On histopathological examination also H & E stain showed features suggestive of Aspergillosis [Figure 5].
Figure 1: Branched septate hyphae on KOH examination

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Figure 2: Greenish mat like colony on SDA

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Figure 3: Aspergillus head

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Figure 4: Aspergillus head with conidiophores and hyphae

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Figure 5: Histopathological picture of aspergillosis on H and E stain

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Isolation of Aspergillus flavus finally lead to correct diagnosis. Then she was given I.V. Liposomal Amphotericin B (3 mg/kg for 1 week) following which the patient gradually improved and was finally asymptomatic.


 ~ 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]

The rate of urinary tract infection following ureteric stenting is around 3-5% and is mainly due to Gram-negative bacteria. [2],[3],[4] Aspergillus infection following ureteric stenting is very rare. Aspergillosis of urinary tract may occur by three ways namely, by ascending infection from the lower tract, from haematogenous dissemination or due to Aspergillus cast in renal pelvis. [5] Renal aspergillosis due to haematogenous dissemination is the most common while localized infection is rare. [5],[6] Co-existing conditions include malignancy, use of chemotherapeutic and immunosuppressive agents, transplantation, liver diseases, AIDS and diabetes. [6],[7] However, primary renal aspergillosis in diabetic patients is rare. [8],[9]

In our case, no history of urinary tract infectionprior instrumentation suggest that the Aspergillus was introduced into the urinary tract duringplacement of stent in the ureter. Probably, fungal spores contaminated the instrument during the procedure or the sterilization of the equipment was inadequate. The infection was a primary and localized aspergillosis of the urinary tract as no other known focus of fungal infection was present elsewhere in the body. Displaced stentand underlying diabetes facilitated the localized infection. Initial routine urine analysis and culture failed to detect fungal hyphae and isolate Aspergillus until the samples were sent post-cystoscopy and stent removal.

Recently, improved outcome in invasive aspergillosis has been reported by sequential therapy with amphotericin B and itraconazole. [7] In our case, we planned monotherapy with amphotericin B and the patient then gradually improved.


 ~ Conclusions Top


The present case emphasizes the possibility of iatrogenic urinary fungal infection secondary to instrumentation. A high index of suspicion in such patients and careful investigations are needed to establish the diagnosis.


 ~ Acknowledgement Top


I gratefully acknowledge the support of the consulting doctors, staff and the institute for the study of this case.

 
 ~ 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
    
2.
Zeng GQ1, Zhong WD, Cai YB, Dai QS, Hu JB, Wei HA. Extracorporeal shock-wave versus pneumatic ureteroscopic lithotripsy in treatment of lower ureteral calculi. Asian J Androl 2002;4:303-5.  Back to cited text no. 2
    
3.
Yalçin O, Firdolaº F. Comparison of ureteroscopic lithotripsy and extracorporeal shock-wave in the treatment of urethral calculi. Med J Kocatepe 2004;5:73-76.  Back to cited text no. 3
    
4.
Nabi G, Cook J, N'Dow J, McClinton S. Outcomes of stenting after uncomplicated ureteroscopy: Systematic review and meta-analysis. BMJ 2007;334:572.  Back to cited text no. 4
    
5.
Gupta KL. Fungal infections and the kidney. Indian J Nephrol 2001;11:147-54.  Back to cited text no. 5
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6.
Piérard GE, Arrese JE, Quatresooz P. Comparative clinicopathological manifestations of human aspergillosis. Exog Dermatol 2004;3:144-53.  Back to cited text no. 6
    
7.
Steinbach WJ, Stevens DA, Denning DW. Combination and sequential antifungal therapy for invasive aspergillosis: Review of published in vitro and in vivo interactions and 6281 clinical cases from 1966 to 2001. Clin Infect Dis 2003;37:S188-224.  Back to cited text no. 7
    
8.
Comings DE, Turbow BA, Turbow BA, Callahan DH, Waldstein SS. Obstructing aspergillus cast of the renal pelvis. Report of a case in a patient having diabetes mellitus and Addison's disease. Arch Intern Med 1962;110:255-61 .  Back to cited text no. 8
    
9.
Irby PB, Stoller ML, McAninch JW. Fungal bezoars of the upper urinary tract. J urology 1990;143:447-51.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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