Therapeutic approach to Candida bezoar in children
| Autor: | Arend Bökenkamp, T.P.V.M. de Jong, Caroline F. Kuijper, H. J. R. van der Horst, L. L. de Wall, M.M.C. van den Heijkant |
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| Přispěvatelé: | Other Research, Paediatric Urology, Urology, Pediatric surgery, ICaR - Circulation and metabolism |
| Rok vydání: | 2015 |
| Předmět: |
Male
Antifungal Agents medicine.medical_treatment Pediatrics Bezoars Cohort Studies Tertiary Care Centers chemistry.chemical_compound Kidney Pelvis Candida Netherlands Kidney education.field_of_study Combined Modality Therapy Perinatology and Child Health Multicenter Study medicine.anatomical_structure Treatment Outcome Child Preschool Drainage Female medicine.medical_specialty Urinary system Candida bezoar Urology Population Renal function Risk Assessment Rare Diseases medicine Journal Article Humans Complications nephrostomy tube Renal replacement therapy Pediatrics Perinatology and Child Health education Retrospective Studies Creatinine business.industry Infant Newborn Candidemia Infant Ultrasonography Doppler medicine.disease Surgery Treatment chemistry Pediatrics Perinatology and Child Health Nephrostomy Pyonephrosis business |
| Zdroj: | Journal of pediatric urology, 11(2), 81.e1-81.e7. Elsevier BV Journal of Pediatric Urology, 11(2), 81.e1. Elsevier BV Journal of Pediatric Urology, 11(2), 81.e1-81.e7. Elsevier BV de Wall, L L, van den Heijkant, M M C, Bokenkamp, A, Kuijper, C F, van der Horst, H J R & De Jong, T P V M 2015, ' Therapeutic approach to Candida bezoar in children ', Journal of Pediatric Urology, vol. 11, no. 2, pp. 81.e1-81.e7 . https://doi.org/10.1016/j.jpurol.2014.10.015 |
| ISSN: | 1477-5131 1873-4898 |
| Popis: | Summary Introduction Candida bezoar (CB) is a rare finding in neonates and infants with candiduria, presenting as necrotic debris with proliferating mycelia in the collecting system of the kidney. If initial antifungal medical treatment does not result in clearance of candiduria and disappearance of CB on ultrasound in dilated kidneys, invasive interventions like insertion of nephrostomy tubes (NT) or surgical interventions to drain the kidney are sometimes advocated . . However, NT placement can be a technical challenge, especially in pre- and dysmature neonates, and NT displacement or obstruction by the CB can lead to suboptimal treatment. Identification of those children who will benefit from invasive renal drainage is important. Objective This study evaluates the management of patients with CB in three tertiary referral hospitals to determine criteria for intervention. Materials and methods A retrospective multicenter chart analysis was conducted of children with candiduria and ultrasonographic demonstration of CB (diagnosed between March 1995 and August 2012). The indication for invasive renal drainage (if performed) and subsequent clinical outcome, serum creatinine levels and ultrasound findings were assessed. Results A total of 12 children were included, two of which were premature neonates. Eight children had congenital urogenital anomalies. One older child with acute myeloid leukemia had CB during chemotherapy and one ex-premature developed CB following cerebral candidiasis. All children received systemic antifungal medication; in seven children invasive treatment was added. Indications for invasive treatment were clinical deterioration, progressive renal dilation, pyonephrosis, rising creatinine levels and persistence of CB. Two underwent a Y-cutaneous ureterostomy and nephrostomy tubes were inserted in five children. Percutaneous renal drainage by nephrostomy led to complications in 3 of 6 procedures. In all patients, irrespective of therapeutic modality, follow-up ultrasound demonstrated no de novo changes. No additional parenchymal defects or deterioration of split renal function were seen on DMSA or MAG-3 scan. Table . Children with invasive treatment Indication renal drainage Type of drainage & complications Renal follow up Premature 28 wks ♀ Clinical deterioration, pyonephrosis, creatinine ↑ Bilateral NT Displacement right NT Normal US Premature 25 wks ♀ Clinical deterioration, progressive dilation, normal creatinine Right sided NT Urinoma, & JJ placement Normal US Urosepticemia bilateral VUR ♂ Clinical deterioration, progressive dilation creatinine ↑ Left sided NT Obstruction & replacement NT Normal US Ex premature cerebral & renal candidiasis ♂ Clinical deterioration, pyonephrosis, creatinine ↑ Right sided NT – Right sided nephrolithiasis Bilateral VUR ♂ Clinical deterioration, progressive dilation, normal creatinine Left sided NT – Normal US Unilateral kidney agenesis & VUR ♀ MAG3 proven obstruction, creatinine ↑ Unilateral Y uretero-cutaneostomy Unchanged DMSA Obstructive mega ureter ♂ Persistent dilation, normal creatinine Unilateral Y uretero-cutaneostomy Unchanged MAG 3 L 63 %: R 37 % Children with antifungal treatment No renal drainage, CB resolution during antifungal treatment Renal follow up Unilateral kidney agenesis & sepsis ♂ CB during renal replacement therapy for multi organ failure Unchanged DMSA with scars Left sided VUR ♀ Febrile UTI with dilation and left sided CB, initially antibiotics switched to fluconazol Unchanged DMSA L 34 %: R 64 % Bladder exstrophy ♂ CB Postoperatively after primary closure with double J in situ Normal US AML and chemotherapy ♂ Neutropenic fever, UTI and CB initially antibiotics switched to fluconazol Normal US Prune belly syndrome ♂ Bilateral CB postoperatively after ureter reimplantation with stents in situ Unchanged DMSA L 60 %: R 40 % VUR = Vesicoureteral reflux; AML = Acute myeloblastic leukemia; US = Ultrasound; DMSA = Dimercaptosuccinic acid scan; MAG3 = Technetium-99m Mercaptoacetyltriglycine scan. Discussion In the literature renal drainage is suggested in case of complete obstruction. However dilatation is a frequent finding in children as part of the congenital renal anomaly and does not necessarily mean that there is obstruction of the urinary tract. Even in children without candida infections the diagnosis of obstruction is not straightforward, while the results of a MAG 3 scan can be obscured by compromised kidney function, parenchymal bacterial infiltration and neonatal immaturity of the kidney. If candiduria and CB persist despite intensive medical treatment, intensive consultation is required before renal drainage, because NT insertion might be a surgical challenge. Complications such as displacement of the NT, urinoma development, or NT obstruction can occur and was seen in three of six procedures. Premature neonates seem to be more prone to complications due to their small anatomical proportions, requiring medical equipment with small diameters prone to displacement and obstruction. Some studies describe successful pharmaceutical management in the majority of patients with CB. Other studies describe unilateral surgical intervention in children with bilateral CB where unilateral drainage did not influence overall renal outcome. This is in line with our results. A limitation of the present study is its retrospective design. In this population, the motivation for invasive renal drainage or conservative management was not well documented in all cases, and was mainly based on clinical and diagnostic parameters like creatinine levels and radiographic findings. Conclusion Renal drainage should be considered in selected cases after failure of systemic antifungal treatment. Inserting and maintaining a nephrostomy tube in young children is associated with a high rate of complications; conservative treatment is likely to be sufficient in the majority of patients with candiduria and CB. |
| Databáze: | OpenAIRE |
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