LAUSR

Dear Editor, With interest, we read the clinical quiz by Aksoy et al. [1] describing a premature infant with bilateral obstructing candida fungus balls demonstrated by antegrade pyelography. The authors advocate the use of antegrade amphotericin B irrigation via the nephrostomy tubes, which were left in situ for 2 and 8 weeks respectively. Although urinary diversion may be indicated in severe obstruction, the use of amphotericin B irrigation is questionable. We have shown that systemic treatment with fluconazole is effective for the treatment of candida bezoar, even in an anuric patient, owing to its good tissue penetration and high urine concentrations [2]. At the same time, inserting and maintaining nephrostomy tubes in premature infants with candida bezoar is challenging and associated with a high rate of complications such as displacement, urinoma or drain obstruction [3]. We believe that urinary diversion in candida fungus balls should be reserved for the relief of severe obstruction and that the drain be removed as soon as urine production resumes and anatomical obstructions such as ureteropelvic or ureterovesical junction obstruction have been excluded. The candida infection should be treated systemically as it often involves the renal parenchyma, leading to intratubular obstruction and papillary necrosis [3]. If sensitivity permits, fluconazole is the drug of choice and can even be administered orally.