Localized Renal Pelvic Fungal Ball in a Patient Undergoing Bone Marrow Transplantation

Dr. Y.K. Keung, 1441 Eastlake Avenue, Room 162, Norris Kenneth Jr Cancer Hospital, Los Angeles, CA 90033 (USA) In patients with prolonged neutropenia, candidiasis is well described. It usually presents as candidemia or shortly after neutrophil recovery as hepatosplenic abscesses. ‘Fungal ball’ arising in renal pelvis has been described in the literature [1-3], especially in neonates [4, 5]. Its pathogenesis is not well understood. We would like to report the first case of renal pelvic fungal ball with obstructive uro-pathy in a patient undergoing autologous bone marrow transplantation. The sequence of events could also give some clues to the mechanism of this rare infection. A 61-year-old Caucasian female was diagnosed with stage IV follicular small cleaved, follicular center cell malignant lymphoma (Lukes-Collin classification) and bone marrow involvement in 1986. She had no history of renal stones. She was treated successfully with chlorambucil and later by vincristine, cyclophosphamide and prednisone. In November 1990 her disease transformed to a higher grade, i.e. diffuse mixed small and large cell lymphoma. Chemotherapy was changed to adriamycin, etoposide, vincristine and prednisone with good initial response. However, in February 1991, the disease progressed and she received two cycles of decadron, high-dose ara-c and cisplatin (DHAP) leading to nearly complete response. Peripheral stem cells were harvested during the neutrophil recovery period after each cycle of DHAP. Bone marrow which was histologically free of tumor was harvested in May 1991. In June her disease rapidly progressed and she was given two cycles of mitoxantrone, ifosfamide, mesna and etoposide with an almost complete response. In July she received total body irradiation 12 Gy in 8 fractions over 4 days followed by high-dose etoposide 60 mg/kg given over 6 h on day -A, cyclophosphamide 100 mg/kg over 1 h on day -2 with equal dose of mesna over 24 h, and reinfusion of autologous bone marrow and peripheral stem cells on day 0. Oral norfloxacin 400 mg twice daily, acyclovir 200 mg thrice daily and fluconazole 100 mg daily were given pro-phylactically since admission. She developed severe nausea, mucositis and odynophagia requiring frequent morphine injection. On day 4 after stem cell reinfusion, a vaginal swab grew Candida albicans which was treated with topical miconazole. On the same day she spiked a temperature of 38 °C. She was treated empirically with ceftazi-dime and vancomycin and her fever subsided 2 days later. Her urine grew α-hemolytic streptococcus and group D nonenterococcus. Blood cultures were sterile. At about the same time, she also developed urinary retention secondary to