Successful Treatment of Bilateral-Obstructive Renal Fungal Balls with Continuous Liposomal Amphotericin B Irrigation Using Pairs (Upper and Lower Pole) of Percutaneous Nephrostomy Tubes in an Extremely Low Birth Weight Infant

Abstract

Extremely low birth weight infants (ELBWIs) are at high risk for candidemia, which often involves the kidneys, resulting in obstructive uropathy, for which the management is difficult and challenging. An ELBWI developed a bloodstream Candida albicans infection on the 21st day of life. Candidemia persisted after one week of fluconazole administration. Then, the antifungal agent was changed to liposomal amphotericin B (AmBisome®; LAmB). The blood culture turned negative after three days of LAmB treatment. At the end of the two-week course of LAmB, the patient showed progressive renal failure with a positive fungal culture in the urine. Bilateral obstructive renal fungal balls were identified by ultrasonography. On both sides, we placed two pairs of 5-Fr percutaneous nephrostomy (PCN) tubes (upper and lower pole tube pairs in each kidney). We started direct administration of LAmB through the upper pole tubes and let them drain through the lower pole tubes. Concomitantly, systemic LAmB levels were maintained. The urine culture turned negative after two weeks of continuous irrigation. The PCN tubes were removed sequentially following fungal ball disappearance, while irrigation was continued for seven weeks. Continuous antifungal agent irrigation through paired PCN tubes was effective in ELBWI with bilateral urinary obstruction.