- Email: [email protected]
Candidal cystitis in pregnancy treated with amphotericin B
International Journal of Gynecology & Obstetrics 47 (1994) 57-58
Letter to the editor
Candidal cystitis in pregnancy treated with amphotericin B P. Maheshwari*, R. Jose, L. Seshadri Departmentof Obstetricsand Gynecology,ChristianMedical College and Hospital, Vellore632 004. Tamil Nadu, India Received 7 March 1994; revision received 7 May 1994; accepted 14 May 1994
Keywordr: Candidiasis;
Amphotericin
B
Fungal infections of the genitourinary tract are almost exclusively limited to candidiasis. These fungi which exist as saprophytes or as commensals become pathogenic in conditions of compromised immune status. Vulvovaginal candidiasis is common in pregnancy but candidal urinary tract infection is rarely seen. There is also a tendency for dormant infections to be reactivated during pregnancy due to depression of the maternal immune response [ 11. A 23-year-old primigravida presented with acute urinary retention at 14 weeks’ gestation. She gave a history of recurrent bouts of urine retention relieved by repeated intermittent catheterization. At admission the bladder was distended up to the umbilicus. On catheterization 1400 ml of clear urine drained. Her investigations showed Hb 8.5 g/100 ml, serum creatinine 0.4 mg/lOO ml, nonreactive VDRL and a normal oral glucose tolerance test. She was negative for HIV antibodies. Ultrasonography of the pelvis demonstrated a normal in* Corresponding author, Tel.: (91) 416-22102, Ext. 2093; Fax: (91) 416-25035.
trauterine pregnancy of 14 weeks. Urine culture revealed growth of 11 000 CFU/ml of gram-positive budding yeast-like organisms. However the patient was not treated for this. The catheter was removed after 72 h. She voided several times but went into urinary retention after 24 h. She was catheterized again and nitrofurantoin was started as a precautionary measure. Forty-eight hours later, the catheter was removed but she developed urinary retention again within 12 h. Examination of the external genitalia showed cotton wool-like plugs obstructing the external urethral meatus. She voided following removal of the plugs and urethral dilatation. A repeat urine culture also showed growth of yeast-like organisms. Cystoscopy showed the presence of whitish patches all over the bladder mucosa in a mosaic pattern. Serum antibodies to Candida were negative. On the basis of urine culture reports and cystoscopic findings a diagnosis of fungal candidal cystitis was made. The patient was treated with local irrigation of bladder with amphotericin B solution which was administered in a daily dose of 25 mg diluted in 500 ml normal saline, over 4 h. This treatment
0020-7292194LW7.00 0 1994 International Federation of Gynecology and Obstetrics SSDI 0020-7292(94)02154-Q
58
Letters to the editor / Int. J. Gynecol. Obstet. 47 (1994) 57-58
was given for 4 consecutive days. Repeat urine culture showed no growth. The patient had no further problems and delivered a healthy baby girl at term by emergency lower segment cesarean section due to fetal distress in early labor. The postoperative period was uneventful. Candidal urinary tract infection can cause a variety of clinical symptoms and signs such as frequency, dysuria, strangury pyuria and hematuria. Small bezoars passing spontaneously may be the only symptom of bezoar formation in the urinary bladder [2]. Microscopic examination of the urine may reveal Candida with budding forms or pseudohyphae, and urine culture confirms the diagnosis. The important point in evaluating candiduria is its relationship to the total clinical picture. A fungiuric patient needs treatment if symptomatic or if there is evidence of systemic infection or significant candiduria (15 000 CFU/ml). Localized candidal cystitis needs bladder irrigation with an antifungal agent such as amphotericin B or miconazole. Multifocal or disseminated infection demands systemic therapy. Numerous reports have described the use of am-
photericin B for fungal infections during various stages of pregnancy including first trimester. Amphotericin B when given intravenously crosses the placenta in a ratio of 1:0.38 between maternal serum and cord blood. Local irrigation with amphoteritin B is associated with minimal absorption with serum levels not exceeding 0.4 &ml [3,4]. The side effects of amphotericin B such as nephrotoxicity and hypocalcemia are no worse in pregnant women than in non-pregnant women. Thus treatment for fungal infection in pregnant women is not an indication for termination of pregnancy. References RI
Loke YW: Female reproductive immunology. In: Scientific Foundations of Obstetrics and Gynecology (eds E.E. Philipp, J. Barnes, M. Newton), 3rd edn., p. 66. Heinemann, London, 1987. 121 Wise GJ: Fungal infections of urinary tract. In: Campbell’s Urology (eds P.C. Walsh, A.B. Retik, J.A. Stamey, E.O. Vaughan Jr.), 6th edn., p. 928, W.B. Saunders, Philadelphia, PA, 1992. 131 Ismail MA, Lerner SA: Disseminated blastomycosis in a pregnant woman. Am Rev Respir Dis 126: 350, 1982. MJ, Ellenberg JF, Killam AP: Coc141 McCoy cidioidomycosis complicating pregnancy. Am J Obstet Gynecol 137: 739, 1980.
Letter to the editor
Candidal cystitis in pregnancy treated with amphotericin B P. Maheshwari*, R. Jose, L. Seshadri Departmentof Obstetricsand Gynecology,ChristianMedical College and Hospital, Vellore632 004. Tamil Nadu, India Received 7 March 1994; revision received 7 May 1994; accepted 14 May 1994
Keywordr: Candidiasis;
Amphotericin
B
Fungal infections of the genitourinary tract are almost exclusively limited to candidiasis. These fungi which exist as saprophytes or as commensals become pathogenic in conditions of compromised immune status. Vulvovaginal candidiasis is common in pregnancy but candidal urinary tract infection is rarely seen. There is also a tendency for dormant infections to be reactivated during pregnancy due to depression of the maternal immune response [ 11. A 23-year-old primigravida presented with acute urinary retention at 14 weeks’ gestation. She gave a history of recurrent bouts of urine retention relieved by repeated intermittent catheterization. At admission the bladder was distended up to the umbilicus. On catheterization 1400 ml of clear urine drained. Her investigations showed Hb 8.5 g/100 ml, serum creatinine 0.4 mg/lOO ml, nonreactive VDRL and a normal oral glucose tolerance test. She was negative for HIV antibodies. Ultrasonography of the pelvis demonstrated a normal in* Corresponding author, Tel.: (91) 416-22102, Ext. 2093; Fax: (91) 416-25035.
trauterine pregnancy of 14 weeks. Urine culture revealed growth of 11 000 CFU/ml of gram-positive budding yeast-like organisms. However the patient was not treated for this. The catheter was removed after 72 h. She voided several times but went into urinary retention after 24 h. She was catheterized again and nitrofurantoin was started as a precautionary measure. Forty-eight hours later, the catheter was removed but she developed urinary retention again within 12 h. Examination of the external genitalia showed cotton wool-like plugs obstructing the external urethral meatus. She voided following removal of the plugs and urethral dilatation. A repeat urine culture also showed growth of yeast-like organisms. Cystoscopy showed the presence of whitish patches all over the bladder mucosa in a mosaic pattern. Serum antibodies to Candida were negative. On the basis of urine culture reports and cystoscopic findings a diagnosis of fungal candidal cystitis was made. The patient was treated with local irrigation of bladder with amphotericin B solution which was administered in a daily dose of 25 mg diluted in 500 ml normal saline, over 4 h. This treatment
0020-7292194LW7.00 0 1994 International Federation of Gynecology and Obstetrics SSDI 0020-7292(94)02154-Q
58
Letters to the editor / Int. J. Gynecol. Obstet. 47 (1994) 57-58
was given for 4 consecutive days. Repeat urine culture showed no growth. The patient had no further problems and delivered a healthy baby girl at term by emergency lower segment cesarean section due to fetal distress in early labor. The postoperative period was uneventful. Candidal urinary tract infection can cause a variety of clinical symptoms and signs such as frequency, dysuria, strangury pyuria and hematuria. Small bezoars passing spontaneously may be the only symptom of bezoar formation in the urinary bladder [2]. Microscopic examination of the urine may reveal Candida with budding forms or pseudohyphae, and urine culture confirms the diagnosis. The important point in evaluating candiduria is its relationship to the total clinical picture. A fungiuric patient needs treatment if symptomatic or if there is evidence of systemic infection or significant candiduria (15 000 CFU/ml). Localized candidal cystitis needs bladder irrigation with an antifungal agent such as amphotericin B or miconazole. Multifocal or disseminated infection demands systemic therapy. Numerous reports have described the use of am-
photericin B for fungal infections during various stages of pregnancy including first trimester. Amphotericin B when given intravenously crosses the placenta in a ratio of 1:0.38 between maternal serum and cord blood. Local irrigation with amphoteritin B is associated with minimal absorption with serum levels not exceeding 0.4 &ml [3,4]. The side effects of amphotericin B such as nephrotoxicity and hypocalcemia are no worse in pregnant women than in non-pregnant women. Thus treatment for fungal infection in pregnant women is not an indication for termination of pregnancy. References RI
Loke YW: Female reproductive immunology. In: Scientific Foundations of Obstetrics and Gynecology (eds E.E. Philipp, J. Barnes, M. Newton), 3rd edn., p. 66. Heinemann, London, 1987. 121 Wise GJ: Fungal infections of urinary tract. In: Campbell’s Urology (eds P.C. Walsh, A.B. Retik, J.A. Stamey, E.O. Vaughan Jr.), 6th edn., p. 928, W.B. Saunders, Philadelphia, PA, 1992. 131 Ismail MA, Lerner SA: Disseminated blastomycosis in a pregnant woman. Am Rev Respir Dis 126: 350, 1982. MJ, Ellenberg JF, Killam AP: Coc141 McCoy cidioidomycosis complicating pregnancy. Am J Obstet Gynecol 137: 739, 1980.