Fungal bezoar arising as complication after forgotten double
The present case has been reported in BMJ. A 38-year-old man presented with intermittent right flank pain, dysuria, passage of turbid urine and low-grade fever for the last 1 year. He revealed a history of right-sided laparoscopic Anderson-Hynes dismembered pyeloplasty with double J (DJ) stenting performed for right pelviureteric junction obstruction 5 years back at other centre.

The discharge card given to the patient advised for DJ stent removal, but the patient was lost to follow-up and never underwent DJ removal.

Urine analysis showed 40–50 pus cells/high power field (HPF), 20 red blood cells/HPF and presence of fungal hyphae and spores. Urine culture revealed >105 colony counts of Candida albicans per mL.

On evaluation with kidney, ureter and bladder X-ray there was presence of right DJ stent without encrustation and radiopaque shadow in left renal region. Ultrasonography of abdomen revealed severely dilated right kidney showing multiple hyperechoic rounded lesions (15–25 mm) with a DJ stent in situ and left renal pelvic calculus (21 mm).

Further evaluation with contrast-enhanced CT scan of abdomen showed presence of isodense non-enhancing multiple intraluminal filling defects with tiny peripheral calcifications in massively dilated right renal pelvis (suggestive of fungal balls). The patient underwent ureteric stent removal followed by placement of right-sided percutaneous nephrostomy (PCN).

After proper counselling and consent, he underwent right nephrectomy followed by left percutaneous nephrolithotomy. At 3 months of follow-up, he was doing well with no residual stone or hydronephrosis on ultrasound abdomen on left side.

Learning points
• Fungal bezoar is a rare upper urinary tract infection mostly seen in immunocompromised individuals.

• In rare cases, fungal bezoar may develop in immune competent individuals as a complication of forgotten double J stent.

• The urinary tract obstruction, urosepsis, hydronephrosis and secondary renal damage are very rare complications of fungaluria.

• The preferred treatments of upper tract fungal infections are systemic and local antifungal administration, urinary drainage with percutaneous nephrostomy or ureteric stent and removal of foreign body.

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