Obstructive anuria due to fungal bezoars in a renal graft recipient

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... Infection may disseminate from the respiratory tract to other sites including the brain, eyes, liver, spleen, intestine, skin, bones, and urinary tract (4). A ''fungus ball'' formation of Aspergillus in the bladder has seldom been reported, mainly in renal transplant patients (5,6). ...
... Aspergilloma in renal transplantation is a rare and dangerous fungal infection. Fungal bezoars of the urinary tract can obstruct the excretory system, leading to oligoanuria, worsening graft function and risk of graft loss (5). ...
... Several studies have indicated that CMV infection may predispose renal transplant recipients to other serious complicating infections such as IFI (5). Our patient suffered from retinal CMV disease, which is an unusual presentation after HSCT. ...
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Aspergillosis is an important cause of mortality in allogeneic HSCT. A "fungus ball" formation of Aspergillus in the bladder has seldom been reported. We report a child that underwent HSCT and developed possible disseminated aspergillosis with an intravesical "fungus ball," diagnosed by genitourinary MRI and PCR of the mass that was removed from the bladder. It is important to consider this complication in a patient with HC after HSCT. The treatment included a combination of systemic antifungal therapy along with intravesical voriconazole and surgical removal.
... After year 2011, some more cases of candidiasis in newborns have been described in the literature [40][41][42][43] , with no standardized treatment at the moment [44] . Of course, transplant recipients must be considered at high risk for opportunistic pathogens [45,46] and obstructive anuria due to fungal bezoars has been described [47] . ...
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Bilateral ureteral obstruction in children is a rare condition arising from several medical or surgical pictures. It needs to be promptly suspected in order to attempt a quick renal function recovery. In this paper we concentrated on uncommon causes of obstruction, with the aim of giving a summary of such multiple, rare and heterogeneous conditions joint together by the common denominator of sudden bilateral ureteral obstruction, difficult to be suspected at times. Conversely, typical and well-known diseases have been just run over. We considered pediatric cases of ureteral obstruction presenting as bilateral, along with some cases which truly appeared as single-sided, because of their potential bilateral presentation. We performed a review of the literature by a search on PubMed, CrossRef Metadata Search, internet and reference lists of single articles updated to May 2014, with no time limits in the past. Given that we deal with rare conditions, we decided to include also papers in non-English languages, published with an English abstract. For the sake of clearness, we divided our research results into 8 categories: (1) urolithiasis; (2) congenital urinary tract malformations; (3) immuno-rheumatologic causes of ureteral obstruction; (4) ureteral localization of infections; (5) other systemic infective causes of ureteral obstructions; (6) neoplastic intrinsic ureteral obstructions; (7) extrinsic ureteral obstructions; and (8) iatrogenic trigonal obstruction or inflammation. Of course, different pathogenic mechanisms underlay those clinical pictures, partly well-known and partly not completely understood.
... Obstructive uropathy is second only to urinary leaks as the most frequent urological complication in a transplanted kidney [5] and usually occurs after 1 year following transplantation [6]. While the usual causes of obstruction are ureteral stenosis and calculi, unusual causes include granulomatous disease [7] and fungal bezoars [8]. In the past, a significant proportion of patients with renal transplant underwent open surgical procedures for the treatment of obstruction [9]. ...
Obstructive uropathy is the second most common urological complication in a transplanted kidney. The usual causes of obstruction are ureteral stenosis and calculi. Papillary necrosis as a cause of obstruction in a transplant kidney is extremely rare with only one prior report published. Moreover, percutaneous removal of sloughed papilla in a transplant kidney has not previously been reported. We report an unusual case of a sloughed papilla causing hydronephrosis of a transplant kidney and its successful percutaneous removal. The recognition of renal papillary necrosis is important, not only because it can be a sign of acute rejection but also it because it can lead to obstruction, infection and potentially the loss of the transplant as exemplified by our case. Rapid diagnosis and meticulous retrieval technique are the crucial factors in minimizing the complications due to obstruction of a transplanted kidney by sloughed papilla.
Kidney transplant is the most common type of organ transplantation worldwide. In preparation for transplantation, appropriate infectious disease testing of the donor and recipient is required. In the posttransplant period, infections within the first 1 month generally include urinary tract infection, pneumonia, and wound infections. There is increasing prevalence of multidrug-resistant bacterial infections after kidney transplantation. Syndromes of specific interest in kidney transplant recipients include asymptomatic bacteriuria, recurrent UTI, and candiduria. Kidney transplant recipients are predisposed to several opportunistic viral infections including cytomegalovirus, BK virus, adenovirus, and parvovirus. There are also increasing number of HIV-positive recipients undergoing kidney transplant and there needs to be special attention to drug interactions in this population. Finally, infection prevention for kidney transplant recipients includes chemoprophylaxis and vaccinations.
Les “fungus balls” sont une cause rare d'obstruction du haut appareil urinaire. Moins de 60 cas ont été rapportés dans la littérature. Nous décrivons trois cas d'anurie obstructive secondaire à une infection candidosique du haut appareil urinaire. Le premier est survenu chez une greffée du rein, le deuxième chez un patient diabétique et le troisième chez un insuffisant rénal chronique. Le traitement consiste en un drainage des urines, l'identification de l'agent infectieux et le traitement antifongique approprié. Fungus balls as a cause of upper urinary tract obstruction are rare, with less than 60 cases reported in the literature. We herein describe three cases pf secondary anuria caused byCandida infection of the upper urinary tract. The first case was observed in a patient with a transplanted kidney, the second in a diabetic patient and the third in a patient suffering from chronic kidney failure. The treatment consisted of urinary drainage, identification of the infectious organism and appropriate antifungal treatment.
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To describe a cluster of donor-transmitted cases of invasive aspergillosis. Case series of epidemiologically linked cases of invasive aspergillosis. Two tertiary care centers with solid-organ transplant programs. Two kidney recipients, one heart recipient, and the single donor. Routine clinical, microbiological, and pathologic investigation as dictated for patient care. Epidemiologic analysis to establish linkage among cases. Three allografts (two kidneys and a heart) from a single donor transmitted invasive aspergillosis to the recipients. Three weeks after transplantation, the two kidney recipients had fever and urine cultures positive for Aspergillus fumigatus. The infected kidneys had multiple Aspergillus abscesses and had to be removed to cure the patients. The heart recipient had a negative workup when a diagnosis of aspergillosis was made for the kidney recipients but presented three months later with aspergillus endocarditis with hematogenous spread to the eyes and to the skin. Treatment included eye surgery, aortic valve replacement, and antifungal therapy; control of infection ensued. The donor was intensely immunosuppressed (17 days post-liver transplantation with death from intracerebral bleeding) but had no clinical or autopsy evidence of aspergillosis. Donor tracheal secretions obtained at the time of organ harvest later grew A fumigatus. Expanded criteria for organ donation have to be balanced against infectious risk to organ recipients. A fumigatus can be transmitted from a subclinically infected donor to solid-organ transplant recipients.
Thirty-five renal allograft recipients were studied concerning the relationship between cytomegalovirus (CMV), herpes simplex virus (HSV), and opportunistic bacterial and fungal infections. The incidence of opportunistic infections was determined for patients whose tests prior to transplantation were seronegative in complement fixation and indirect hemagglutination assays of CMV antibody and for those patients whose tests were seropositive. Among the six seronegative patients with seronegative tests, four (66%) experienced active CMV infection within two months, and four died of Candida or Aspergillus infection within six months after transplantation. Among the 22 patients with seropositive tests, only one (4%) had a fungal infection and it was nonfatal (P less than .05). The increased morbidity and mortality due to fungal and bacterial infections in transplant recipients with seronegative CMV tests appears, therefore, to be related to primary CMV infection rather than to generalized immunodeficiency.
Although fungal urinary tract infections occur less frequently than bacterial urinary tract infections their incidence has increased during the last several decades and their clinical importance to the urologist should not be underestimated. Herein the pertinent literature on fungal urinary tract infections is reviewed, with emphasis on the predisposing factors, pathogenesis, host defense mechanisms and the clinical spectrum of the disease. An approach to the evaluation of positive cultures and therapy is presented.
Murine cytomegalovirus (CMV) causes depression of cell mediated immunity. Skin graft survival is significantly prolonged across the strong H 2 and weak H Y histocompatibility barriers in mice previously infected with CMV. Maximum prolongation of skin graft survival across the H 2 barrier occurred in mice infected on the day of grafting and survival was significantly prolonged in mice infected up to 5 days before grafting. CMV also inhibited uptake of tritiated thymidine by spleen cells in response to phytohemagglutinin (PHA) or in mixed lymphocyte culture. Inhibition of responsiveness to PHA occurred for up to 26 days after infection. Uptake of tritiated thymidine was significantly elevated over controls 5 days after infection but not after this time.
The incidence of infection in the renal transplant patient is directly related to the net immunosuppressive effect achieved and the duration of time over which this therapy is administered. A second major factor in the causation of infections in this population is the nosocomial hazards to which these patients are exposed, ranging from invasive instrumentation to environmental contamination with Aspergillus species, Legionella pneumophila, Pseudomonas aeruginosa and other microbial pathogens. Careful surveillance is necessary to identify and eliminate such nosocomial sources of infection. The major types of infection observed can be categorized according to the time period post-transplant in which they occur: postsurgical bacterial infection in the first month after transplantation; opportunistic infection, with cytomegalovirus playing a major role, and transplant pyelonephritis in the period one to four months post-transplant; and a mixture of conventional and opportunistic infections in the last post-transplant period. Conventional infection in this late period occurs primarily in patients with good renal function who are receiving minimal immunosuppressive therapy; opportunistic infection occurs primarily in patients with poor renal function who are receiving higher levels of immunosuppression.
During a 31-month period in 1979–1981, nine patients at a renal transplant center in Tennessee developed invasive infections with Aspergillus species. Despite an extensive search, no common environmental source of contamination was found. A matched case-control study of host risk factors showed that leukopenia, prior administration of antibiotics, and treatment with azathioprine and antilymphocyte serum were not significantly related to the development of aspergillosis. In contrast, the administration of high-dose corticosteroids posed a significant risk. An average daily dose of ⩾ 1.25 mg of prednisone/kg per day for the entire interval studied was the best predictor of subsequent invasive infection with Aspergillus.
Fig 2 Antegrade pyelography showing a patent ureter. OBSTRUCTIVE ANURIA 2693
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