황성조, 박정완, 유시내, 이은영, 길효욱, 박삼엘, 조남준

506

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Renal Fungus ball infection case report

순천향대학교 천안병원

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황성조, 박정완, 유시내, 이은영, 길효욱, 박삼엘, 조남준

Introduction: Renal fungal infections are uncommon medical situation, especially among immunocompetent patients. Fungus ball or fungus bezoar is a colony preformed by fungal hyphae without invading adjacent tissues. Risk factors for fungus ball were diabetic mellitus, prolonged usage of antibiotics, or indwelling catheters. Herein, we described the patient who experienced a fungus ball in the ureter. 110 Case description The patient was 76 year old woman. She diagnosed for diabetes mellitus at 1990, and applied insulin aspart 40/36IU due to poor blood glucose control. She already had a history of re- current urinary tract infection (UTI) treatment. The patient visited a local clinic for fever, myalgia and urinary frequency symptoms which occurred three days ago. At that clinic, a physician impressed with UTI and gave her 3rd generation cephalosporin. However, she felt symptoms were aggravated so admit- ted our hospital through emergency room. When we performed fever study, Candida tropicalis was identified in blood culture and urine culture. So we ap- plied fluconazole 200mg once daily, and confirmed that the blood cultures were negative conversion. However, because her urinary symptom persisted, we planned the abdomen pelvic computed tomography (APCT) scan. We could find multiple air density in left renal pelvis and upper ureter dilatation at APCT scan. When we discussed with the radiologist, we concluded that lesion was fungal ball. She received Lt. percutaneous nephrostomy (PCN), underwent am- photericin B irrigation via nephrostomy and foley catheter for 2 months, and fluconazole was maintained for 6 months. After treatment the patient stated that her urinary symptoms were improved. Conclusions: We have experienced a case that we have successfully treated with fungus ball. If there is a fun- gal infection in a patient with a risk factor and there is a persistent urinary symptom, it may be necessary to perform an aggressive image test to determine whether a fungus ball is present.

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A misdiagnosed case of tinea capitis as cellulitis of scalp

서울의료원 내과

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황선미, 안미영, 오동현, 최재필, 전재현, 임은빈, 이예현

Tinea capitis is a fungal infection of the scalp that most often presents with pruritic, scaling areas of hair loss. It is more common in pubertal populations, diagnosis and appropriate treatment are often delayed in elderly. We meet a case of tinea capitis in an older patient that was misdiagnosed as scalp cellulitis caused by seborrheic dermatitis or psoriasis vulgaris superimposed infection. A 95-years-old female residing in a nursing home visited the clinic for scalp pain and redness suspected inflammation. She was diagnosed with psoriasis vulgaris of the abdomen and scalp 6 years ago and being followed up by dermatologist. Three weeks ago the erythema and pain of the skin of the nape and scalp was developed and worsened three days before. Initial laboratory exam revealed elevated hs-CRP of 13.34 mg/dL, and the patient had fever upto 39 ℃. Blood and wound culture was performed and ampicillin-sulbactam was started as an empirical antibiotic under suspicion of cellulitis of the scalp. 3 days later, Methicillin sensitive Staphylococcus aureus (MRSA) was iden- tified in wound culture, then teicoplanin was added based on this result. In HD 15, we performed scalp biopsy to obtain appropriate specimens for culture and rule out the tumorous condition and 3 days later biopsy result showed active inflammation with

microabscess. Despite the use of susceptible antibiotics for almost 3 weeks, the fever persisted and the scalp inflammation was not improved. In HD 21, fungus culture revealed the Trichophyton menta- grophytes, we started administering terbenafin 250mg once a day and planed to continue for 6 weeks.

After 7days of medication, the scalp condition was significantly improved and the fever was subsided.

Because it is difficult that early diagnosis for tinea capitis in older patient, it leads to delay in the ini- tiation appropriate treatment. The systemic antifungal agents must be required for tinea capitis treat- ment because the topical agents cannot penetrate to infected hair follicles. We should suspect a diag- nosis of tinea capitis and have to do fugus culutre when we meet a patient with treatment failure of se- borrheic dermatitis or psoriasis.

506

￭

￭

Renal Fungus ball infection case report

순천향대학교 천안병원

*

황성조, 박정완, 유시내, 이은영, 길효욱, 박삼엘, 조남준

Introduction: Renal fungal infections are uncommon medical situation, especially among immunocompetent patients. Fungus ball or fungus bezoar is a colony preformed by fungal hyphae without invading adjacent tissues. Risk factors for fungus ball were diabetic mellitus, prolonged usage of antibiotics, or indwelling catheters. Herein, we described the patient who experienced a fungus ball in the ureter. 110 Case description The patient was 76 year old woman. She diagnosed for diabetes mellitus at 1990, and applied insulin aspart 40/36IU due to poor blood glucose control. She already had a history of re- current urinary tract infection (UTI) treatment. The patient visited a local clinic for fever, myalgia and urinary frequency symptoms which occurred three days ago. At that clinic, a physician impressed with UTI and gave her 3rd generation cephalosporin. However, she felt symptoms were aggravated so admit- ted our hospital through emergency room. When we performed fever study, Candida tropicalis was identified in blood culture and urine culture. So we ap- plied fluconazole 200mg once daily, and confirmed that the blood cultures were negative conversion. However, because her urinary symptom persisted, we planned the abdomen pelvic computed tomography (APCT) scan. We could find multiple air density in left renal pelvis and upper ureter dilatation at APCT scan. When we discussed with the radiologist, we concluded that lesion was fungal ball. She received Lt. percutaneous nephrostomy (PCN), underwent am- photericin B irrigation via nephrostomy and foley catheter for 2 months, and fluconazole was maintained for 6 months. After treatment the patient stated that her urinary symptoms were improved. Conclusions: We have experienced a case that we have successfully treated with fungus ball. If there is a fun- gal infection in a patient with a risk factor and there is a persistent urinary symptom, it may be necessary to perform an aggressive image test to determine whether a fungus ball is present.

￭

￭

A misdiagnosed case of tinea capitis as cellulitis of scalp

서울의료원 내과

*

황선미, 안미영, 오동현, 최재필, 전재현, 임은빈, 이예현

Tinea capitis is a fungal infection of the scalp that most often presents with pruritic, scaling areas of hair loss. It is more common in pubertal populations, diagnosis and appropriate treatment are often delayed in elderly. We meet a case of tinea capitis in an older patient that was misdiagnosed as scalp cellulitis caused by seborrheic dermatitis or psoriasis vulgaris superimposed infection. A 95-years-old female residing in a nursing home visited the clinic for scalp pain and redness suspected inflammation. She was diagnosed with psoriasis vulgaris of the abdomen and scalp 6 years ago and being followed up by dermatologist. Three weeks ago the erythema and pain of the skin of the nape and scalp was developed and worsened three days before. Initial laboratory exam revealed elevated hs-CRP of 13.34 mg/dL, and the patient had fever upto 39 ℃. Blood and wound culture was performed and ampicillin-sulbactam was started as an empirical antibiotic under suspicion of cellulitis of the scalp. 3 days later, Methicillin sensitive Staphylococcus aureus (MRSA) was iden- tified in wound culture, then teicoplanin was added based on this result. In HD 15, we performed scalp biopsy to obtain appropriate specimens for culture and rule out the tumorous condition and 3 days later biopsy result showed active inflammation with

microabscess. Despite the use of susceptible antibiotics for almost 3 weeks, the fever persisted and the scalp inflammation was not improved. In HD 21, fungus culture revealed the Trichophyton menta- grophytes, we started administering terbenafin 250mg once a day and planed to continue for 6 weeks.

After 7days of medication, the scalp condition was significantly improved and the fever was subsided.

Because it is difficult that early diagnosis for tinea capitis in older patient, it leads to delay in the ini- tiation appropriate treatment. The systemic antifungal agents must be required for tinea capitis treat- ment because the topical agents cannot penetrate to infected hair follicles. We should suspect a diag- nosis of tinea capitis and have to do fugus culutre when we meet a patient with treatment failure of se- borrheic dermatitis or psoriasis.