Peritonitis caused by Candida albicans: Rare presentation of a refluxing ureteral stump

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Ped Urol Case Rep 2017; 4(4):346-349 DOI: 10.14534/PUCR.2017428032
Peritonitis caused by Candida albicans: Rare presentation of a
refluxing ureteral stump
Ada Molina Caballero, Alberto Pérez Martínez, Sara Hernández Martín
Pediatric Surgery Department. Complejo Hospitalario de Navarra, Pamplona, Spain.
AB ST RA C T
Ureteral stump syndrome is a medical condition caused by a refluxing distal ureteral remnant left
after nephrectomy. Fungal colonization of the ureteral stump is uncommon and distant site infection
is exceptional. We present a unique case of fungal peritonitis in a 13-year-old boy who had a right
lower-moiety heminephro-ureterectomy at age three with a ureteral stump that served as reservoir for
Candida resulting in the subsequent spontaneous fungal passage to the peritoneum.
Key Words: Candida albicans; peritonitis; ureteral stump, cystoscopy; vesicoureteral reflux.
Copyright © 2017 pediatricurologycasereports.com
Corresponding Author: Dr. Ada Molina Caballero
Pediatric Surgery Department. Complejo Hospitalario
de Navarra. Irunlarrea Street, 3. 31008 Pamplona,
Spain.
Email: adyemoca@yahoo.com
Accepted for publication: 10 May 2017
Introduction
The ureteral stump (US) is a distal segment of
ureter left in situ after total or partial
nephrectomy. Majority of patients are
asymptomatic but when reflux into the stump
produces recurrent febrile urinary tract
infections, bacteriuria or hematuria, empyema,
stones or even malignancy, the condition is call
ureteral stump syndrome [1,2]. It is a rare
entity with an incidence of 1.1-10% usually
occurring many years after surgery [3]. Fungal
colonization of the stump is uncommon and
distant site infection is exceptional [4]. We
present a unique case of fungal peritonitis
resulting from a US that served as reservoir for
Candida albicans.
Case report
13-year old boy operated on for suspected
peritonitis of sudden onset. During surgery, no
cause of peritonitis was found but Candida
albicans was isolated in the peritoneal fluid. He
had an antecedent of right lower-pole
heminephrectomy and proximal ureterectomy
at age 3, for a nonfunctional moiety due to
vesicoureteral reflux in a duplex system.
Ultrasound controls were normal with no
subsequent symptomatology to date.
Antifungal treatment (fluconazole and
caspofungin) was initiated. At seventh
postoperative day, suspecting a possible
complicated US, CT scan and MRI were
performed showing a right subphrenic abscess
and no abnormalities of the US [Fig. 1].
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Caballero et al. Ped Urol Case Rep 2017;4(4):346-349 347
Fig. 1. CT scan and MRI showing a large right
subphrenic abscess (arrows).
The immunity-host defense study and blood
and urine cultures were negative. Evolution
was torpid despite CT-guided drainage of the
intra-abdominal abscess by Candida, requiring
laparoscopic debridement with improvement
afterwards [Fig. 2].
Fig. 2. CT-guided drainage of the intra-
abdominal abscess by Candida.
Failing to find a source of infection and
suspecting the US might be acting as reservoir
despite negative urine cultures, a cystoscopy
was performed encountering a wide ureteral
remnant. Mucosa biopsy showed Candida
colonization and after 6 month of antifungal
medication, the stump was treated
endoscopically with mucosal fulguration and
antireflux technique by subureteric injection of
a synthetic bulking agent [Fig. 3].
Fig. 3. Cystoscopy. A. Wide ureteral remnant.
B. Final aspect of the ureteral orifice after
mucosal fulguration and antireflux technique.
Over 2 years follow-up, the patient has
remained asymptomatic with a practically
inappreciable US in echography [Fig. 4].
Fig. 4. Echography showing the unstructured
US (arrow).
Discussion
In general, a poorly or nonfunctional kidney
connected to a refluxing, obstructed or
dysplastic ureter is manage with (hemi)
nephrectomy and total or proximal
ureterectomy [4]. Following nephrectomy, US
with good drainage eventually undergo

Caballero et al. Ped Urol Case Rep 2017;4(4):346-349 348
muscular atrophy. If the US continues to suffer
repeated episodes of urinary reflux, it may lead
to gross dilatation with urine not effectively
drained [2,5,6]. However, Escolino et al. [4]
found that even a relatively short US (3 cm)
could become symptomatic due to reflux. In
addition, previous surgery or subsequent
periureteritis may damage the nerve supply of
the US, rendering it adynamic and favoring
urinary stasis [4].
There is no literature regarding fungal
peritonitis due to translocation to peritoneum
from a colonized US. Candida albicans is the
most common fungus colonizing and infecting
the urinary tract (50-70% in most series) [7],
but urine rarely yields Candida in persons who
do not have specific risk factors: increased age,
female sex, antibiotic use, urinary drainage
devices, prior surgical procedures, and
diabetes mellitus. These allow the organism to
gain access and colonize the bladder mucosa
or, in our case, the US mucosa [7,8]. Candida
peritonitis may present with vague
symptomatology or as a bacterial-like
peritonitis. Infection is suspected when the
organism is cultured from fluid samples.
Drainage of any abscess (surgically or
percutaneously) and antifungal therapy are
vital [8]. Our patient had an important risk
factor for Candida colonization prior surgical
procedure of the urinary tract but we ignore
what could have triggered the passage of the
fungus to peritoneum years after the initial
surgery, in an otherwise healthy patient.
Traditionally, the treatment of symptomatic
US was open surgical excision of the stump
[1,3]. With the advent of minimally invasive
surgery, less invasive options have been
reported [3,9]. Both laparoscopic excision and
endoscopic electrofulguration or occlusion of
the stump with bulking agents have shown to
be effective [3,9,10]. We opted for an
endoscopic treatment given the multiple
abdominal surgeries and possible peritoneal
adherences that could have hinder the
laparoscopic excision of the stump. Bullock et
al. [10] were the first to successfully treat a
refluxing US by endoscopic subureteric
injection of Teflon. Failure in endoscopic
treatment has been attributed to ectopically
ureteral orifices [3]. When faced with
complications associated with residual US,
minimally invasive techniques should be
considered the treatment of choice.
Here, the insistence in finding the fungus,
despite repeated negative urine cultures and
imaging studies, allowed for the etiological
diagnosis and resolution of our case.
Acknowledgements
The author(s) declare that they have no
competing interest and financial support.
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