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Case Report |
lu1
1
Department of Radiology, Akdeniz University Medical Faculty, Arapsuyu,
Antalya, 07070 Turkey.
2
Department of Pediatric Nephrology, Akdeniz University Medical Faculty,
Arapsuyu, Antalya, 07070 Turkey.
3
Department of Pediatric Surgery, Akdeniz University Medical Faculty, Arapsuyu,
Antalya, 07070 Turkey.
Received May 12, 2000;
accepted after revision August 7, 2000.
Address correspondence to A.
Kabaaliolu.
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We report the case of a premature infant in whom refractory fungus balls in the urinary system were cleared by streptokinase that was infused through ureteral catheters.
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At admission, a physical examination revealed loss of newborn reflexes and bilateral large palpable kidneys. Remarkable laboratory findings were as follows: blood urea nitrogen level, 62 mg/dL; serum creatinine level, 3.24 mg/dL; renal failure index, 6.8; elevated level of C-reactive protein; and leukocytosis. Urinalysis showed candiduria. Sonography showed bilateral renal enlargement and echogenic foci with slight posterior acoustic shadowing in the dilated collecting systems (Fig. 1A). In addition, perirenal and peritoneal fluid that probably reflected urinary ascites was noted.
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Candida albicans was isolated from blood, urine, cerebrospinal fluid, and peritoneal fluid. With the diagnosis of Candida sepsis and renal candidiasis, amphotericin B was started at the dose of 1 mg/kg per day. The patient's renal function deteriorated gradually; therefore, bilateral nephrostomy tubes were placed on the eighth day of treatment and parenteral fluconazole (Triflucan; Pfizer, Istanbul, Turkey) was added. Local irrigation of the tubes with amphotericin B (Ambisome; Nexstar, Helsinn Birex, Ireland) was also started. However, the patient's general condition and sonographic findings did not improve after 10 days of drainage and irrigation by renal and perirenal catheters. Because the amount of fluid drained by the catheters decreased to less than 20 mL/day, percutaneous drainage catheters were removed.
Surgery and other alternative treatments were discussed by the official council composed of pediatric nephrologists, pediatric surgeons, urologists, and radiologists. On the basis of previous experience with percutaneous treatment of septate organized empyemas, the radiologists' suggestion to use streptokinase to lyse the thick organized fungus balls was accepted because open surgery in this patient was considered contraindicated given the condition of his kidneys. Consent from the patient's parents was also obtained. Five milliliters of streptokinase (Kabikinase; Pharmacia & Upjohn, Stockholm, Sweden) at a concentration of 3000 IU/mL was given as a bolus twice daily through transvesically implanted bilateral ureteral catheters that were extended to the renal pelvis. The ureteral catheters were then clamped for 1 hr. Thus, a total amount of 30,000 IU per day streptokinase was initially administered to each renal collecting system. The dose was selected empirically on the basis of the doses used for other interventions, the capacity of a premature infant's renal collecting system, and possibility of hemorrhagic complications. The previous systemic treatment was also maintained.
Four hours after the first dose of streptokinase, sonography showed significant improvement in the left kidney and total disappearance of the fungus balls in the right kidney (Fig. 1B). Because no complications related to treatment with streptokinase were observed, this treatment was continued for 3 days. After 10 days, clinical and sonographic findings were normal, blood urea nitrogen and creatinine levels had also returned to normal values, and the patient was sent home.
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The exact mechanism of action for streptokinase in lysing the fungus balls in our patient is not clear. However, fibrin may adhere to long-standing fungus balls and cause them to become firmer complexes. Therefore, by lysing the fibrin in or around the fungus balls, streptokinase may facilitate their dissolution. To our knowledge, neither streptokinase nor urokinase has been previously used to lyse fungus balls. Further experimental studies are needed to fully explain the pathways of the streptokinase for its effect against fungus balls.
In conclusion, percutaneous streptokinase injection to renal pelvis through catheters, in conjunction with parenteral antifungal agents, may lyse urinary fungus balls that are resistant to medical treatment and percutaneous drainage or irrigation.
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