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Case Reports Indian Pediatrics 2002; 39:769-772 |
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Renal Failure from Obstructive Fungal Mycetoma and Fungal Sepsis in an Infant |
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Mohan Abraham Tonny Mampilly Joseph Prem Paul Johny V.F.
The incidence of fungal sepsis is on the increase in NICUs of tertiary centers especially in VLBW babies(1). Broad spectrum antibiotics especially third generation cephalosporin, prematurity, low birth weight, central venous access, intravenous lipids and total parenteral nutrition have been shown to be risk factors for fungal sepsis(1-4). We report a case of renal fungal mycetoma associated with fungal meningitis, which was successfully treated. Case Report The patient was born at 30 weeks gestation with a birth weight of 1.26 kg to non-consanguineous parents. He was conceived after treatment for infertility and was the lone survivor of a quadruplet. The neonatal period was complicated with hyaline membrane disease and pyogenic meningitis which was treated with mechanical ventilation for 3 days and parenteral antibiotics for 21 days. The patient was discharged at 30 days of life. He presented to us at 3 months (corrected age: 2 weeks) with persistent vomiting, fever and lethargy of 3 days duration associated with oliguria. Physical examination showed a sick, dehydrated and irritable baby with temperature of 101.2ºF. The weight was 2.63 kg, length 46 cms and head circumference 32.9 cm (all less than 50th percentile). The anterior fontanel was bulging, but there was no focal neurological deficit. Bilateral renal masses were palpable per abdomen with no hepatosplenomegaly or ascites. Investi-gations showed hemoglobin level of 11 g/dL, white cell count 13100/cu mm, neutrophils 64%, lymphoytes 32% and eosinophils 4% and platelet count of 75,000/cu mm. The blood level of urea was 60 mg/dL), creatinine 1.9 mg/dL, sodium 135 mEq/l, potassium 6.1 mEq/1 and CRP 192 mg/l. Blood culture was sterile. CSF analysis showed 240 white cells/cu mm with 86% neutrophils, protein 192 mg/dl and sugar 32 mg/dl (blood sugar 98 mg/dl). Gram stain of CSF did not reveal any organism and the culture was sterile. The patient was treated with a provisional diagnosis of recurrent meningitis and acute renal failure.
Initially fluid challenge followed by parenteral frusemide was given to correct renal failure. The patient was also given keyexalate resin (1 g/kg daily), intravenous sodium bicarbonate and calcium gluconate. However oliguria persisted and potassium and creatinine levels increased to 7 meq/l and 3.1 mg/dL respectively. Peritoneal dialysis was done for 72 h. An ultrasound of the abdomen showed increased echogenicity of both kidneys and bilaterally dilated renal pelvis filled with echogenic material. The left ureter was dilated upto the bladder and filled with similar material (suggestive of obstructive uropathy). A percutaneous nephrostomy tube was placed bilaterally to bypass the obstruction, which drained pus like material that on microscopy and culture showed candida. Nephrostomogram showed dilated pelvis on both sides with radiolucent filling defects (Fig. 1). On intermittent irrigation through nephrostomy tube with normal saline, the baby passed cheese - like material per urethra after 2 days, which on microscopy showed fungal hyphae. Repeat nephrostomogram showed free flow of dye into the bladder. The patient started voiding urine and renal parameters normalized following which percutaneous nephrostomies were removed. The patient was initially treated with ceftriaxone at a dose of 100 mg/kg, ampicillin 200 mg/kg and fluconazole 6 mg/kg daily. CSF studies showed rising protein and cells; fungal cultures of CSF and urine grew Candida albicans resistant to fluconazole and sensitive to amphotericin B. Treatment was changed to amphotericin B (1 mg/kg/day IV) for 3 weeks. CT scan of the brain showed moderate hydrocephalus and a small focus of calcification in the right frontal horn. The patient developed progressive hydro-cephalus, which required external ventricular drainage till the CSF became normal, followed by ventriculoperitoneal shunt. At 10 months of age, the baby feeds well, has gained weight, head circumference is 44 cm and has normal development. An ultrasound abdomen does not show any evidence of obstructive uropathy or mycetoma. The blood levels of urea and creatinine are normal and urine albumin is negative. Discussion Fungal sepsis in infants of VLBW is fatal in 25-55% cases(3,5). In a study from India, 3.2% NICU admissions were diagnosed to have acquired systemic candidiasis. The mean age at onset was 10.4 days(3). In a study by Fernandez et al out of 106 neonates with systemic candidiasis, 23 had candidial meningitis(6). CSF analysis showed varying pleocytosis and hypogly-corrhachia; gram staining was negative and CSF culture grew Candida in 74%. The infants were treated with amphotericin B; 5 also received flucytosine therapy. Timely initiation of amphotericin monotherapy was associated with excellent outcome(6). Narang, et al reported that fluconazole was the most used antifungal agent but 24% of Candida isolates were resistant(3). In a retrospective chart review of systemic candidiasis with sonographic evidence of renal mycetoma only one of 14 patients required surgical intervention with nephrostomy tube placement(9). Blood levels of creatinine were normal on follow up. A sustained decline in platelet count of 10% or more per day in a neonate on broad spectrum antibiotics may suggest fungal sepsis(7,8). Hari et al reported a case of an infant who developed acute renal shutdown due to bilateral candidial bezoars causing obstruction at the pelviureteric junction. Recovery from renal failure followed bilateral nephrostomy tube placement and parenteral administration of amphotericin B(9). Of 1213 newborns admitted to our NICU during July 1999 to June 2001, 38 had positive fungal cultures (3.1%). Fungi were isolated from blood in 4, urine in 29, stool in 2, and CSF, endotracheal tube and pus in one case each. The present patient was the first fungal mycetoma during this period. Since the coil of the usual pigtail catheter is too big for the renal pelvis of the newborn, we managed with percutaneous placement of cavafix, which is used for central venous catheterisation. Some authors have reported treatment of fungal venous catheterisation with systemic antifungal and irrigation of the renal tract through nephrostomy catheter using amphotericin B(10). We used isotonic saline for irrigation in the present case. Fungal sepsis is a recognized complication in NICU babies especially following prolonged use of broad-spectrum antibiotics. Systemic candidiasis (and meningitis) needs treatment with systemic amphotericin. Parentenal treatment with fluconazole is probably inadequate. Acknowledgments We thank Dr. Unnikrishnan M, Neurosurgery Division, Amrutha Institute of Medical Sciences and Research Center, Elamakkara (Ernakulam District, Kerala), for the surgical management of hydrocephalus Contributors: All authors were involved in patient management. MA, JVF, JPP helped in drafting, supervising and revising the data critically. TA will act as the guarantor for the manuscript. Funding: None. Competing interests: None stated.
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