4:10 PM Abstract No. 50 - Pharmacomechanical pulverization of mycetoma in the renal collecting system

Abstract

Purpose Renal mycetomas are rare manifestations of candidia infection in children, which if untreated may lead to urinary tract obstruction (UTO), renal failure and high mortality. We report successful use of an AngioJet device to pulverize an obstructing renal pelvis candida mycetoma resistent to conventional nephrostomy tube (NT) drainage in a small child with UTO and renal failure. Materials and Methods Case history : A 2.5 year old, 10.5 kg, former 26 wk premature girl was admitted with recurrent candida urinary tract infection and fungal balls within the right pelvicalyceal system leading to UTO, oliguria and renal failure (serum Cr 2.7 mg/dL). NT placement and administration of IV Amphotericin B (AmB) failed to improve urine output or renal failure. Ultrasound and antegrade pyelogram showed persistent dilatation of an obstructed right collecting system plugged with fungal balls. Technique : The in situ 8.5F NT catheter was exchanged for a vascular sheath through which a 6-French AngioJet Spiroflex catheter (AngioJet ® Ultra thrombectomy system, Medrad International ® ) with a 15-mm active tip was advanced into the renal pelvis and calyces under ultrasound and fluroscopic monitoring. Fungal balls were drawn into the catheter,fragmented by saline pressure jets from the active tip and aspirated simultaneously. The saline in the AngioJet system was replaced with AmB solution and pharmacomechanical pulverization of the fungal balls was performed followed by upsizing of the NT to 10F. Results After mycetoma pulverization, NT urine output improved from 0 to 490mL in the first 12 hr, and serum Cr decreased to 1.65 within 24 hr. The patient had no complications from the AngioJet therapy. She completed a 21 day course of systemic and transcatheter AmB and NT was removed. At 2 week follow-up, serum Cr was 0.6 mg/dL, and ultrasound and antegrade studies showed reduced hydronephrosis with no recurrence of fungal balls. At 12 month follow- up, patient had no recurrence of candida infection, no imaging recurrence of mycetoma and serum Cr 0.5 mg/dL. Conclusion Pharmacomechanical pulverization using an AngioJet thrombectomy system is an effective treatment option for refractory renal collecting system mycetoma.