Diabetic ketoacidosis from Candida urosepsis with fungus ball.

A 76‐year‐old man with untreated type 2 diabetes mellitus was presented to the emergency department because of disturbed consciousness. On examination, the patient’s Glasgow Coma Scale was 12/15 (E3V4M5) and his temperature was 37.2°C. Other physical findings revealed no pathology. The laboratory data showed white cell count of 16.4 (normal range 3.5–9.1) × 109/L, C‐reactive protein level of 334.1 (normal range 0–3) mg/L, blood glucose level above 40 (normal range 5.6–6.9) mmol/L, and hemoglobin A1c level of 18.5 (normal range 4.6–6.2) %. Blood gas analysis indicated an elevated anion gap with metabolic acidosis and ketosis (pH 7.35, anion gap 29.5 mmol/L, bicarbonate 9.3 mmol/L, lactate 3.44 mmol/L, and beta‐hydroxybutyrate >7.0 [normal range 0.1–0.6] mmol/L). Abdominal computed tomography showed bilateral ureteral dilatation with right predominance beginning at just above the bladder. Initially, lower urinary tract obstruction was suspected, and an indwelling urinary catheter was inserted. However, abdominal ultrasonography showed that the left ureteral dilatation had improved, but the right ureter remained dilated (Fig. 1A, red arrows), with a mass lesion near the right ureteral orifice (Fig. 1B, red arrowheads). As ureteral obstruction by the mass was suspected, we decided to perform a cystoscopy.

Fig. 1

(A) Abdominal ultrasonography showed dilation of the right ureter (red arrows). (B) Abdominal ultrasonography showed a fungal ball near the right ureteral orifice (red arrowheads). (C) Cystoscopy showed a fungal ball at the right ureteral orifice. (D) Cystoscopic removal of the fungal ball was performed. (E) Gram stain of the urine showed large gram‐positive cocci and pseudohyphae.

Cystoscopy revealed a ball‐shaped material at the right ureteral orifice, while there was no mass around the left ureteral orifice; therefore, the ball‐shaped material was removed cystoscopically (Fig. 1C,D). Then, pyuria was discharged one after another from the ureteral orifice (Video S1), and we placed ureteral stent. Blood and urine culture revealed Candida albicans (Fig. 1E). Thus, he was diagnosed with diabetic ketoacidosis due to Candida urosepsis with fungus ball. He was treated with intravenous fluid, insulin, and antifungal drugs but died 10 weeks after admission.

The clinical presentations of Candida range from colonization to invasive infections. Particularly, fungal balls are crucial clinical manifestation that can obstruct the ureters and require medical and surgical treatment. Although Candida urinary tract infection due to fungal ball obstruction is rare, it should be noted in patients with diabetes mellitus because it is frequently reported in those patients.

DISCLOSURE

Approval of the Research Protocol with Approval No. and Committee Name: N/A.

Informed Consent: Written informed consent was obtained from the patient’s son.

Registry and Registration No. of the Study/Trial: N/A.

Animal Studies: N/A.

Conflict of Interest: The authors declare no conflict of interest in association with the present study.

Video S1. After a fungal ball was removed cystoscopically, pyuria was discharged one after another from the right ureteral orifice.

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