RECURRENT URINARY CANDIDIASIS COMPLICATED BY FUNGAL BEZOARS IN AN IMMUNOCOMPETENT PATIENT
Zahedi S, Chao S, Almajed MR, Ibrahim AM, and Brar I. RECURRENT URINARY CANDIDIASIS COMPLICATED BY FUNGAL BEZOARS IN AN IMMUNOCOMPETENT PATIENT. J Gen Intern Med 2023; 38:S525.
J Gen Intern Med
CASE: A middle-aged man with a past medical history of uncontrolled diabetes, urinary retention requiring temporary use of an indwelling foley catheter, and prior urinary tract infection, presented for evaluation of resistant hyperglycemia. Patients hyperglycemia had been occurring for a week and was not responsive to insulin use. On further questioning, the patient also endorsed increased urinary frequency, urinary urgency, and dysuria. The indwelling foley catheter was removed 3 months prior to this presentation and was in place for 2 weeks. Initial testing was significant for hyperglycemia with glucose of >500 mg/dL with normal beta- hydroxybutyrate and normal anion gap. Urinalysis showed large leukocyte esterase, >182 white blood cells, and few budding yeasts. Urine culture was positive for Candida tropicalis. A computed tomography of his abdomen and pelvis was obtained and showed bilateral hydroureteronephrosis as well as approximately 40 fungal bezoar balls measuring 1 to 4 cm each located throughout his urinary bladder lumen. Urology evaluated the patient, and he underwent cystoscopy with transurethral resection of extra-large fungal bezoar burden in addition to amphotericin B irrigation (Figure 1). Intraoperative cultures also grew Candida tropicalis. The patient was initially treated with intravenous fluconazole and later transitioned to oral fluconazole.
IMPACT/DISCUSSION: Fungal bezoars, also known as fungus balls, are rare complications of recurrent fungal urinary tract infections. Only a few case reports of Candida spp. Fungal bezoars have been reported in the literature. Risk factors for these infections include diabetes, prolonged bladder catheterization, antibiotic usage, and malignancy (1). In this patient's case, his uncontrolled diabetes and prolonged bladder catheterization likely placed him at higher risk for development of fungal bezoars (2). Foley catheters are ubiquitously used in hospital setting despite their propensity towards fungal growth and proliferation, prompting more cognizant use of foley catheters. Furthermore, promptly establishing diagnosis in cases of fungal bezoars is paramount as treatment differs from those of typical fungal urinary tract infections, requiring both medical and surgical approaches. If left untreated, fungal bezoars can lead to urinary tract obstruction, urosepsis, renal damage, and even bladder rupture.
CONCLUSION: This is a very rare case of intravesical bezoar infection in a patient with recurrent fungal urinary tract infections. The patient was previously treated in an outpatient setting with fluconazole. This case highlights the importance of further investigation for underlying etiologies in patients with recurrent infections. Failure to identify fungal bezoar may result in life-threatening complications.