Geriatric Nephrology and Urology8: 137–139, 1998.© 1998Kluwer Academic Publishers. Printed in the Netherlands.

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Original article

Renal aspergillosis giving rise to obstructive uropathy and recurrentanuric renal failure

R. Krishnamurthy, C. Aparajitha, Georgi Abraham, S. Shroff, U. Sekar & S. KuruvillaDepartments of Nephrology, Urology, Microbiology and Pathology, Sri Ramachandra Medical College andResearch Institute, Porur, Chennai – 600 116, India

Accepted 26 October 1998

Key words: Aspergillus fumigatus, obstruction, renal failure

Abstract

A sixty-year-old previously healthy male patient presented with anuric renal failure of sudden onset. He wasdetected to haveAspergillus fumigatusfungal balls in the renal pelvis, ureters and bladder which were removedand his renal function improved. He was treated with itraconazole and sent home. Three weeks later he againpresented with anuria and renal failure. He had recurrence of the obstruction with the same fungus. The fungalball was removed, a double ‘J’ stenting was performed and he was treated with amphotericin B and itraconazole.Hence we report a previously healthy patient with no evidence of immunosuppression presenting an obstructiveanuric renal failure due to isolated renal aspergillosis.

Introduction

Bilateral obstructive uropathy, which is not an uncom-mon cause of renal failure, may be due to a disparategroup of diseases. As this is a potentially reversibleform of renal failure, early recognition and treatmentare essential as the outcome is related to the dura-tion and completeness of obstruction [1]. We present apatient with acute renal failure with obstructive uropa-thy due to isolatedAspergillus fumigatusinfection ofthe renal pelvis and the ureters who was previouslyhealthy.

Case report

A 60-year-old male who was apparently normal pre-sented to us with complaints of anuria of nineteenhours duration. On examination he was anemic, other-wise normal.

Investigations at the time of admission were:serum creatinine 3.6 mg/dL, potassium 7.4 mmol/L,sodium 124 mmol/L, chloride 115 mmol/L, bicar-

bonate 19 mmol/L, hemoglobin 6.0 gm/dL, WBCcount 22,500/cumm, HbsAg, anti-HCV, VDRL, HIV1 & 2 were negative. Chest x-ray was normal. Anultrasound examination showed bilateral hydro ureteronephrosis with a cortical thickness measuring 9 mm oneither side.

Hyperkalemia was conservatively treated andwhen the potassium came down to 6.5 mmols/L. Anemergency right percutaneous nephrostomy was per-formed which drained an average of 4.0 litres/day.Once his electrolytes stabilized and creatinine camedown, bilateral ureteroscopy was done which revealedthe ureters and bladder filled with cotton-like mate-rial. This was sent for histopathological examina-tion and culture which showedAspergillus fumigatus.Patient was initiated on itraconozole 400 mg OD anddischarged. On discharge his BUN was 13 mg/dL,creatinine 1.5 mgl/dL, sodium 138 mmol/L, potas-sium 5.3 mmol/L, chloride 110 mmol/L, and bicar-bonate 20 mmol/L. He returned after three weekswith another episode of anuria and on question-ing he admitted that he was noncompliant with thetreatment.

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Figure 1. Tissue section showing septate acute angle branching hypha of aspergillus – GMS stain (40× magnification).

Investigations revealed serum BUN 73 mg/dL,creatinine 6.1 mg/dL, sodium 116 mmol/L, potas-sium 6.19 mmol/L, chloride 99 mmol/L, WBC count19,500/cumm, hemoglobin 7.3 g/dL, random bloodsugar 95 mg/dL. A repeat ultrasound showed bilat-eral hydro uretronephrosis. The cystoureteroscopyrevealed ureters filled with cotton flakes and this waswashed out.

Double “j” stents were placed in both ureters. Hehad a profound diuresis following this. He was ini-tiated on amphotericin 20 mgs and was increased to36 mgs/day as an infusion. Investigations done afterone week of the second admission showed BUN 32mgl/dL, creatinine 2.6 mg/dL, sodium 129 mmol/L,potassium 4.75 mmol/L, chloride 111 mmol/L, bicar-bonate 16 mmol/L.

He was discharged on this regimen. Follow-upafter nine weeks showed BUN 18 mg/dL, creatinine1.6 mg/dL, and an ultrasound abdomen showed arounded shadow in the mid calyx of the right kidneysuggesting a fungal ball. He continues on itraconazole400 mg OD and twice weekly amphotericin Binfusion. The patient comes for a regular followup and the bilateral stents have been removed. Hecontinues on intermittent antifungal therapy afterthe initial episode, with no further recurrence of the

fungus or any other evidence of immunosuppressionor malignancy. His Serum Creatinine is in the range of2–2.1 mgs/dL.

Discussion

Among the fungiAspergillus fumigatusis ubiquitousand the second most common mycotic infection ofthe kidney which is believed to infect debilitatedor immunosuppressed subjects [2–6].Aspergillusinfection spreads via the haematogenous route, bycontiguity and also by the ascending route throughindwelling catheters [2, 3].Aspergillusis a slender,regular, dichotomously branching septate hyphaestaining well with PAS and GMS stains. The fungussecretes a complement inhibiting factor and it alsoinhibits the killing activity of phagocytic cells. It isbelieved that certain isolates ofAspergillus fumigatusare more pathogenic than others. Molecular epidemi-ology tools including restriction fragment lengthpolymerization and random amplified polymorphicDNA analysis were used to characterize the isolates[7]. Analysis of risk factors for significant infectionreveals that cultures with more than 2 colonies, ormore than one site of infection are predictive of

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significant infection and portended a poor prognosiseven with aggressive therapy. Fewer than 2 coloniesfrom a single site represents contamination and maybe followed with repeat cultures [8].

Isolated renal infection in our patient with noobvious immunosuppressive state or other predis-posing conditions is a rare occurrence [9]. Althoughwe attempted a renal biopsy the material obtainedwas perinephric tissue which showed granulomatousreaction with foreign body giant cells suggestive offungal infection [2]. One has to weigh the advantagesand disadvantages of doing a percutaneous renalbiopsy in a kidney obstructed with fungus balls, asthis may lead to dissemination of infection, significanttrauma to the renal parenchyma, hemorrhage andspread of infection along the tract of the biopsy needle.Previous reports described the renal involvement inimmunosuppressed patients and in those with othercomorbid conditions including pulmonary infections,cardiac surgery, and in cirrhotic patients [2]. A autopsyseries done by Raghavan et al. showed fungus ballsin the calyces and renal pelvis, necrotic papillary castand an ascending infection of the entire urinary tract[2]. Invasion of the arcuate and intralobular arteriesleading to thrombosis and resulting in necrosis ofthe cortical and papillary tissue has been reported[2]. There have been instances of transmission ofAspergillus Fumigatusfrom an organ donor (whowas a bone marrow transplant recipient) to a twokidneys recipient leading to multiple abcesses in thetransplanted kidney [10]. The presence of fungus ballsin the pelvis or ureter may lead to obstruction as inour patient [5, 9]. The recurrence of obstruction andrenal failure highlights the facts that both antifungaltherapy with removal of fungus from ureterscombined with double ‘J’ stenting prevented furtherrecurrence [11]. Topical irrigation and systemicuse of itraconazole and amphotericin for prolongedduration of 11 months have been recommended for asuccessful outcome in the treatment of aspergillosis[12, 13]. This patient remains well with reasonablerenal function and no evidence of recurrenceof fungus at eight months follow-up, probably

ruling out the possibility of significant immunosup-pression or underlying malignancy. In conclusion, wehave described a previously healthy patient in whomtwo frequent episodes of anuric renal failure resultedfrom obstruction due toAspergillus fumigatusfungalballs which was relieved by stenting and antifungalagents.

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