A 63 y.o. male presents with painful urination
what do you see in his bladder?
The pt is altered due to fentanyl and cannot give more history
You notice his kidney is abnormal on the L
Our patient had emphysematous pyelonephritis(EP) caused by E. Coli and also a fungal infection of the urine leading to a bladder fungus balls with Candida tropicalis. EP is found mainly in patients with diabetes and is a rare complication of pyelonephritis. It is a necrotizing infection of the kidney with a mortality of 25% due to overwhelming sepsis. Before 1980, the treatment was nephrectomy but currently broad spectrum antibiotics and limited surgery are the first line.
There are four things necessary for this condition to occur
1. There must be a gas forming organism
2. There should be high tissue glucose
3. Impaired tissue perfusion causes tissue ischemia which makes the condition more likely.
4. A defective immune response contributes to the infection.
a fungus ball in the bladder on cystoscopy
Fungus balls or mycetomas are also a relatively rare problem but are important to recognize because they can cause urinary obstruction. The fungal infection usually starts in the renal pelvis and then extends to the bladder. Candida is the most common cause of mycetomas. This is probably because candida is found in the urine of 20% of hospitalized patients. Diabetes and urinary tract anomalies make fungal infections more likely.
US is very useful for detecting mycetomas
Our patient underwent removal of a fungus ball from the renal pelvis and on the current admission was treated with antifungals. He has been lost to follow up multiple times and again left ama.
Tang H, et al. Clinical characteristics of emphysematous pyelonephritis. J Microbiol Immunolol Infect 2001 Jun 34(2):125-30.
Huang J, Tseng C. Emphysematous pyelonephritis: clinicoradiological classification management prognosis, and pathogenesis. Arch Internal Med 2000 March 27 160(6)797-805.
Hameed T, Jain S, Ansari F, Dua A. Isolated fungal balls in urinary bladder presenting as acute retention of urine. Molume 2020 Article ID 4601474 https://doi.org/10.1155/2020/461474
Irby P, Stoller M, McAninch J. fungal bezoars of the upper urinary tract. The Journal of Urology, 1990. vol 143, no 3.pp447-451.