Huge fungal perinephric abscess masquerading as malignancy:
A 60-year-old woman with diabetes, hypertension for the past 15 years, with two episodes of complicated urinary tract infection in last 6 months treated with broad-spectrum antibiotics (imipenem) in a local hospital, presented with complaints of fever, vomiting, loin pain and breathlessness.

On examination, she had tachycardia, tachypnoea, hypotension (blood pressure (BP) of 90/60mm Hg), O2 saturation of 84% on room air, decreased breath sounds on left hemithorax and a large non-tender, palpable mass in the left lumbar region of abdomen, measuring around 10×10cm.

On evaluation, she had anaemia (haemoglobin (Hb) 8.4g/dL with microcytic hypochromic blood picture), polymorphonuclear leucocytosis of 22750 cells/mm3 and thrombocytosis. Serum creatinine was 5.1mg/dL. Urine microscopy showed the full field of WBCs and yeast cells.

The patient was started on empirical broad-spectrum antibiotics (Meropenem with modified dose according to creatinine clearance) after sending blood and urine for culture and antibiotic susceptibility testing. She was supported with inotropes, mechanically ventilated and received one session of haemodialysis. Chest x-ray was suggestive of left massive pleural effusion. Pleural fluid aspiration revealed neutrophilic exudative pleural fluid.

Non-contrast CT of kidneys, ureters and bladder (KUB) revealed a large heterogeneous lobulated collection 8.6×6.5×10.3cm in the perinephric region which was drained with image-guided pig tail insertion and the aspirate was also sent for culture. Both the BacT bottles signalled positive for Candida kefyr. In urine, it was 10000 colony forming unit/mL and in the pleural fluid and perinephric collection, there was a heavy growth of C. kefyr.

C. kefyr was identified by Matrix Assisted Laser Desorption Ionization Time-of-Flight (MALDI-TOF) VITEKMS and antimicrobial susceptibility testing for the isolates was done by VITEK2 system. The isolated C. kefyr was sensitive to echinocandins, amphotericin and fluconazole. But the patient had the septic shock which was refractory and succumbed to the illness within 48 hrs of hospital stay.

Read more here: https://casereports.bmj.com/content/11/1/e226753
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