Intermittent renal graft obstruction by fungal ball—case report

Sir, The saprophytic colonization of a cavity by fungal hyphae, without the invasion of the adjacent tissue, is referred to as ‘fungal ball’ [1]. Fungal balls causing intermittent graft obstruction have not been previously reported. We managed a renal graft case that was characterized by intermittent graft obstruction. The patient was a recipient of a live unrelated renal graft. At 4 months after transplantation, he presented with a history of fever for 7 days and did not pass urine for 1 day. He had diabetes and had been treated for right psoas hematoma 2 months previously. Upon presentation, he was in shock (blood pressure 90/60mmHg) and the graft was tender. His clinical evaluation showed many pus cells in the urine, a dilated pelvicalyceal system (PCS) with nonshadowing echogenic strands in the graft, suggesting fungal ball or clots on ultrasound, (Figure 1) and deranged renal function (serum creatinine: 5.3 mg/dL). He was stabilized with vasopressors and given one session of hemodialysis. From the next day onwards, his urine output increased without surgical intervention and renal function returned to normal by the fourth day; however, he developed anuria again on Day 5. Because repeat ultrasound revealed again the same findings, we performed percutaneous nephrostomy, and a white cheesy material was removed through the nephroscope. Histopathology confirmed it as a Candida species and urine culture grew Candida non-albicans. Due to the partial success of the procedure (nephroscopic removal of fungal ball), local irrigation with amphotericin-B was started. This treatment resulted in complete disappearance of the fungal ball, a return of renal function and a disappearance of graft PCS dilatation by Day 14. Fig. 1. Ultrasound picture of renal allograft showing nonshadowing echogenic foci in pelvis—fungal bezoars.