Fungus ball and emphysematous cystitis secondary to Candida tropicalis: A case report

Abstract

Fungus ball and fungal emphysematous cystitis are two rare complications of fungal urinary tract infection. A 53-year-old male patient presented with these complications caused by Candida tropicalis simultaneously. The predisposing factors were diabetes mellitus and usage of broad-spectrum antibiotics. The fungus ball, measuring 3.5 × 2.0 cm on the left wall of the urinary bladder, shrank significantly to 1.6 × 0.8 cm after 5 days of intermittent irrigation with saline before surgery. With transurethral removal of the fungus ball and antifungal treatment with fluconazole, the patient fully recovered. We conclude that a bladder fungus ball and fungal emphysematous cystitis should always be suspected in patients with diabetes mellitus with uncontrolled funguria and abnormal imaging. Treatment should include a systemic antifungal therapy and thorough surgical removal of the fungus ball. A systemic antifungal therapy combined with a local irrigation with saline or antifungal drugs might help decrease the dissemination of fungemia during an invasive manipulation.

Fig. 1a.

An ultrasound image illustrating a mass on the left wall of the urinary bladder (arrow), measuring 3.5 × 2.0 cm with a medium- to hypo- echogenicity.

Fig. 1b.

Axial section of enhanced computed tomography (excretory phase) revealed round gas collections and a faintly filling-defect (black arrow) on the left wall of the urinary bladder. Right distal ureter was dialated (white arrow) due to the calculus lied beneath (not shown).

Fig. 2a.

An ultrasound image revealed a significantly shrinkage of the bladder mass (arrow), measuring 1.6 × 0.8 cm, after intravesical irrigation with saline for a week.

Fig. 2b.

An intraoperative image illustrating a pale, amorphous, immobile mass adhering to the left wall of the urinary bladder (arrows). The nearby mucosa was covered with sporadic fungal biofilms (arrowheads).

Fig. 3a.

Histopathologic sections demonstrating the mass to be composed of Candida spores, hyphae, keratosic substances and inflammatory exudate.

Fig. 3b.

Bladder mucosa (from the base of the fungus ball) manifested chronic inflammation, squamous metaplasia and hyperkeratosis. There were no fungal elements within the bladder wall.