Nosocomial Urinary Tract Aspergilloma in an Immunocompetent Host: An Unusual Occurrence
A 32-year-old man of average built, visited a private hospital for surgical consult, with the complaints of recurrent, colicky abdominal pain of 6 months duration. On the basis of radiological investigations, he was diagnosed to have a right sided ureteric stone of 0.5 cm at the junction of upper 1/3rd and lower 2/3rd of the right ureter. He was also found to have significant bacteriuria with E. coli, for which he was treated with norfloxacin and amikacin. The ureteric stone was extracted by trans-urethral approach.\nThe removal of the stone led to subsidence of his symptoms. However, 3 weeks later, patient had recurrence of abdominal pain with low grade fever and malaise. He then presented to the department of surgery in our hospital. The pain was milder in intensity and accompanied by the passage of small, pinkish white soft balls per urethra during the process of urination. The pain subsided significantly following passage of these masses. The episodes of pain and subsequent passage of masses were intermittent, varying from twice a day to twice per week. His repeated urine cultures were sterile despite 2-3 neutrophils per high power field on microscopic examination. There were no signs of uretric obstruction, renal compromise or sepsis. He was reassured and prescribed antispasmodics with only temporary relief. He was then referred for dermatology opinion. The patient was asked to urinate in an open container to visualize the masses. On examination, these masses appeared fleshy, of variable size and shape, maximum being 2 cm in length and soft in consistency []. These masses were subjected to microscopic examination in 10% potassium hydroxide (KOH), fungal culture and histopathological examination. KOH examination revealed dense collection of septate hyaline hyphae with dichotomous branching at places []. For fungal culture, the specimen was inoculated on sabouraud dextrose agar (SDA) medium with antibiotics (chloramphenicol-0.4 gm/l, gentamicin-0.04 gm/l) and without cyclohexamide at 25°C. After 3-4 days, growth of colonies was observed which were green to grey in colour with a mat – like surface. Microscopically on lacto phenol cotton blue (LPCB) mount hyaline septate, relatively broad hyphae with long conidiophores were seen []. Vesicles were spherical, large with biseriate phialides bearing chains of conidia over most of the surface morphologically correlating with Aspergillus flavus. Histopathology too, was corroborative and revealed dense masses of interweaving septate filamentous hyphae.\nThe patient underwent hematological investigations to rule out underlying diabetes, HIV or any other cause of immunodeficiency. His renal functions were within normal limits. Blood sample for bacterial and fungal cultures were sterile and X-ray chest did not reveal any focus of infection. He was started on oral itraconazole at a dose of 200 mg twice a day. Patient became afebrile and reported a feeling of well being within two weeks of therapy. The last fungal mass was passed 12 days after start of therapy but the treatment was continued for a period of three months. The patient has been well and asymptomatic for more than 6 months after discontinuation of therapy.