Candida glabrata fungemia in a diabetic patient with neurogenic bladder: Successful treatment with micafungin

A 69-year-old man was transferred to our hospital because of fever and acute renal failure. 5 weeks prior to admission, he was admitted to another hospital and treated with several antibiotics including vancomycin, but fever did not subside and renal dysfunction showed rapid progression. On admission, laboratory findings revealed pyuria, inflammatory changes, acute renal failure, and disseminated intravascular coagulation (DIC). Computed tomography showed left ureteral stone and hydronephrosis. Gallium scintigraphy showed avid uptake in the left kidney. Serum concentration of vancomycin was 57.4 μg/ml. Candida glabrata was isolated from blood, sputum and urine. Under the diagnosis of fungemia and left pyelonephritis, he was treated with micafungin (150 mg/day), gabexate mesilate and insertion of a double-ended pigtail catheter. The above treatment produced regression of systemic inflammation, DIC and acute renal failure. At the last follow-up 3 weeks after discharge, ureteroscopy showed that the ureter stone had already passed but a soft white-yellowish bezoar was detected in the ureter. In this case, neurogenic bladder, poorly controlled diabetes, and long-term antibiotic treatment probably enhanced the development of C. glabrata infection. Antifungal treatment with micafungin is useful in patients with non-albicans Candida infection crease in the frequency of infections caused by this fungus [Schulz and Bernhardt 1997]. In contrast to other sites of infection, approximately 50% of urinary isolates of Candida are non-albicans Candida species, including C. glabrata [Sobel et al. 2000]. C. glabrata infections are often resistant to azole antifungals [Hitchcock et al. 1993]. Consequently, C. glabrata fungemia is associated with a high mortality rate in compromised, at-risk hospitalized patients [Gumbo et al. 1999, Krcmery et al. 1999, Malani et al. 2005]. We report here a case of severe acute pyelonephritis and fungemia due to C. glabrata infection, successfully treated with micafungin and pigtail ureteral stent insertion.