Dr.Sruthi Suresh (Resident )Dr.Jayasree (Neo)Dr.C.Jayakumar
AIMS Kochi
Seventy four day old male ba presented due to respiratory distress
She was delivered at 28th week (790gm )to a primi mother an emergency caesarean section due to utero-placental insufficiency.
Ba was not saturating and was initiated on Bubble CPAP initially followed one dose of surfactant. Ba was gradually weaned off to hood oxygen. But Labs showed raised inflammatory markers. Renal and liver functions were within. After taking blood for culture ba was started on intravenous piperacillin- tazobactam, amikacin and oral oseltamivir. Blood culture was found to be sterile. Repeat CRP showed an increasing trend. At this juncture , late onset sepsis in extreme low birth weight ba, investigations were done to rule out fungal sepsis. As Urine examination revealed candiduria and urine culture was suggestive of candida albicans hence started on Fluconazole.Ultrasound of kidney, ureter and bladder showed nodular solid echogenic contents in bilateral dilated pelvicalyceal system suggestive of fungal balls.
For this bilateral Nephrostomy was done on day 77 of life followed installation of Amphotericin B through the nephrostomy tube. Urine culture again sent at the time of nephrostomy showed significant growth of Candida albicans which was pansensitive.Intravenous Micafungin was started.Fungal lodging at other sites were negative,antifungal was continued till repeat urine culture become sterile. Repeat ultrasound showed major improvement.
A vast majority of fungal infections subside with the regular anti-fungal agents but some require higher anti-fungals. However, our case warranted a surgical intervention for the fungal ball in the kidney.
In the current day NICUs urinary candidiasis is a fairly common condition however invasive renal candidiasis leading to fungal ball is uncommon. Occasionally, they can end up as abscesses leading to unilateral or bilateral renal obstruction which may lead to renal failure if not treated promptly.
The diagnosis of fungal sepsis in high-risk neonates is difficult and is often delayed or missed as there are no specific clinical features.
Ultrasound is a very useful investigation for diagnosis of renal fungal balls. In the presence of candidemia and the absence of hematuria or pyuria, the calyces and the non-shadowing echo-dense material in the renal pelvis suggest renal candidiasis even without hydronephrosis.
Initial management of renal fungal ball is medical. However, if they are causing obstruction and not responding to antifungals we need to consider surgical intervention in the form of the form of percutaneous nephrostomy insertion with antifungal irrigation of the pelvis.
Renal candidiasis with fungal balls is a rare but important cause of morbidity and mortality in low-birth weight neonates. We need to have a high degree of suspicion in preterm neonates with persistent fungal sepsis which is not responding to routine antifungals. A timely ultrasound scan can pick up the diagnosis. This case report aims to highlight the need for a prompt diagnosis and aggressive treatment of renal invasive candidiasis.