Emphysematous Pyelonephritis due to Candida glabrata and Candida tropicalis Bezoar: A Case Report

Emphysematous pyelonephritis (EPN) is a severe, necrotizing infection that can affect the renal parenchyma, collecting system, or perinephric tissue. Although typically caused by enteric Gram-negative bacteria, infections secondary to Candida occur rarely. We present the case of a 72-year-old female who was transferred from an outside hospital with a chief complaint of abdominal pain in the setting of dislodged percutaneous nephrostomy tube for chronic hydronephrosis. Clinically, she presented without evidence of septic shock but was found to have elevated creatinine (6.04), concerning for acute renal failure. Urology was consulted and performed cystoscopy that showed a large bilateral mass consistent with fungal ball formation. Subsequent urine cultures speciated Candida tropicalis and Candida glabrata. Per infectious disease recommendations, the patient was initially started on treatment with fluconazole and flucytosine; however, fluconazole was switched to amphotericin B deoxycholate after sensitivities reported resistance to fluconazole for Candida tropicalis. Additionally, urology performed a bilateral percutaneous nephroscopy with ultrasonic lithotripsy for removal of her fungal bezoar on Day 22 of her hospitalization with subsequent nephrostograms that showed a patent genitourinary system. This case demonstrates successful treatment of EPN secondary to azole-resistant Candida species using combined systemic antifungal therapy and an endourologic approach. This avoided the use of percutaneous nephrostomy irrigation with amphotericin deoxycholate as recommended in current guidelines and prevented potential complications this procedure carries.