BRIEF REPORT
Bladder Aspergillosis Detected by Urine Cytology n, M.D., Ph.D.,1* Santiago Martınez-Torre, B.S.,2 Rafael Martınez-Giro and Joaquın Mosquera-Martınez, M.D.3
Bladder aspergillosis is an unusual infection. We report the case of a 79-year-old man with clinical records of transitional cell carcinoma diagnosed 5 years ago. The presence of a fruiting body and septate hyphae in urine cytological smears were the key for a final diagnosis of fungal bladder infection caused by Aspergillus niger. Diagn. Cytopathol. 2014;00:000–000. VC 2014 Wiley Periodicals, Inc. Key Words: cytology
bladder aspergillosis; Aspergillus niger; urine
Isolated bladder aspergillosis is an unusual infection1–3 caused by Apergillus, a filamentous, cosmopolitan, and ubiquitous fungus found in nature and commonly isolated from soil, decaying matter, and indoor air environment. The genus Aspergillus includes about 184 species among which 40 are pathogenic for humans and animals. Among them, Aspergillus fumigatus is the most commonly isolated, followed by Aspergillus flavus and Aspergillus niger. Other species such as Aspergillus clavatus, Aspergillus nidulans, Aspergillus terreus, and Aspergillus versicolor are less commonly isolated as opportunistic pathogens.4 Among the predisposing factors for bladder aspergillosis, we can mention some such as indwelling urethral
1 CFGS Anatomic Pathology and Cytology, Instituto de Piedras Blancas 33450, Asturias, Spain 2 Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany 3 Medical Oncology Departament, Complejo Hospitalario Universitario de A Coru~na, As Xubias, 15006, A Coru~ na, Spain. *Correspondence to: Rafael Martınez-Gir on, M.D., Ph.D., Institute of Piedras Blancas, Avda. Principal 33, 33450-P. Blancas-Asturias, Spain. E-mail: [email protected] Received 29 April 2014; Revised 25 July 2014; Accepted 8 October 2014 DOI: 10.1002/dc.23231 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com).
C 2014 WILEY PERIODICALS, INC. V
catheters, obstructive uropathy, surgery, malignancy, immunosuppression, diabetes mellitus, and elderly.5 We report here the case of a 79-year-old man with clinical records of transitional cell carcinoma diagnosed 5 years ago. The presence of a fruiting body and septate hyphae in urine cytological smears were the key for a final diagnosis of fungal bladder infection caused by A. niger.
Case Report A 79-year-old man, insulin-dependent diabetic patient, with clinical records of transitional cell carcinoma diagnosed 5 years ago (T1a high grade and some foci of “in situ” carcinoma, treated with transurethral resection and BCG therapy) underwent cystoscopy resection due to a recurrence. After surgery, a Foley catheter was inserted for 10 days and he received a routine antibiotic prophylaxis with cyprofloxacine intravenously (0.4 g, twice a day) for the two first days, and orally (0.5 g, twice a day) for ten days. Approximately four months later, the patient was admitted to the emergency department because of urinary frequency, dysuria, terminal hematuria, and fever (38.2 C). Blood analysis, urinalysis, hemoculture, urine culture, and a simple abdominal X-ray were performed. Blood analysis revealed a mild leucocytosis (the rest of the hemogram and the biochemistry showed normal values), urinalyses revealed pyuria and hematuria, and both hemoculture and urine culture were negative for bacteria. The abdominal X-ray did not show significant alterations. Three consecutive samples from his urine were also sent to the laboratory of Cytology. The samples were processed by a cytospin (1500 rpm/10 min), fixed in 96% alcohol and stained by the Papanicolaou method. Under the microscope, in a granular background, it was observed the presence of a structure resembling a fungal fruiting body, with a 45 -branching hypha (7 lm in diameter) and a hyaline conidiophore ending in a round dark mass Diagnostic Cytopathology, Vol. 00, No 00
1
Diagnostic Cytopathology DOI 10.1002/dc
ET AL. MARTINEZ-GIRON
Fig. 3. Histological section from the excised bladder mass showing numerous 45 -branching hyphae (GMS stain, 2003). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary. com.]
Fig. 1. Urine cytology smears. A: Peculiar structure resembling an Aspergilus fruiting body (Papanicolaou stain, 4003). B: Long septate hypha (Papanicolaou stain, 6003, scale bar 5 50 mm). C: Urine culture. Aspergillus niger conidial heads and conidiophores (lactofenol cotton blue, 4003). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
(probably the conidial head) (Fig. 1A). However, a septate fragment of hypha was also observed (Fig. 1B). These observations were tentatively catalogued as Aspergillus sp. In spite of taking into account a possible contamination, a urine culture for fungus was required. In the Sabouraud dextrose agar medium, white colonies with numerous black color aerial mycelia were noticed. Microscopically, the presence of hyaline conidiophores ending in club-shaped biseriate vesicles (30–50 lm in diameter, surrounded by phialides covering the entire vesicle surface) was observed (Fig. 1C). The round conidia (3–5 lm in diameter) are over the phialides, forming radial chains toward the central axis. A bladder ultrasound showed an echogenic mass in the posterior wall (Fig. 2). The rest of the urinary tract did not show anomalies. A necrotic mass (similar to a fungus ball) adhered to the mucosal bladder was observed through a cystoscopy and removed by loop excision. The excised mass was processed for histological study. Grocott’s methenamine silver stain showed abundant branched filamentous hyphae (Fig. 3). These findings confirmed the diagnosis of isolated bladder aspergillosis. The patient was initially treated with intravenous Itraconazole (200 mg twice a day for two days) followed up by 200 mg oral, twice a day, for one week. After this, his clinical status improved considerably and nowadays he is completely healthy.
Discussion
Fig. 2. Ultrasound bladder. The white arrow indicates an echogenic mass in the posterior wall.
2
Diagnostic Cytopathology, Vol. 00, No 00
The number of infections as a result of Aspergillus species appears to be increasing, and in spite of the improvements in the surviving rates of patients with invasive fungal infection in recent years, continued research is
Diagnostic Cytopathology DOI 10.1002/dc
BLADDER ASPERGILLOSIS
required to meet the challenges associated with changes in epidemiology and resistance development.6 Aspergillus sp. may involve all the anatomical parts of the urinary tract (kidneys, renal pelvis, urether, and bladder), resulting in a spectrum of patterns and diseases such as asymptomatic funguria, fungal bezoars/mycetomas,7–9 obstructive uropathy and ureteral colic,10,11 renal failure and anuria,12,13 and emphysematous pyelonephritis.14 Thus, from local infectious foci in the lower urinary tract, the infection may carry on an ascending route,15 or in the course of a systemic infection provoked by an invasive aspergillosis. In the first case some conditions such as indwelling catheters, urinary tract instrumentation, and stones may be predisposing factors.16,17 In the second, an immunodepressed status caused by several conditions such as malignant hemopathies,18,19 transplants,20,21 (including kidneys from donors,22,23), AIDS,24,25 and longstanding steroid therapy26 has been also reported. In these settings, we think it is important to highlight the importance of culturing urine specifically for fungal organisms in the immunosuppressed host, as well as the detection of polysaccharide biomarkers, such as galactomannan-like antigens, in urine samples.27,28 Since A. niger prefers to grow in a moist and warm environment and is commonly found in soil and plants, it is important to highlight that it may be also found as contaminant in hospital environments,29 spreading to the patients through air, food, or other vehicles. This emphasizes the importance of searching for a source and ensuring high levels of hospital hygiene, and it is also applicable to microbiology laboratories where false positive cultures may have an important impact in the patient care.30 The presence of fruiting bodies of Aspergillus sp., in both cytological and histological samples, is an unusual finding. This may be due to an extrinsic contamination,31 or when the fungal ball is exposed to air with a high oxygen tension.32 On the other hand, some species of Aspergillus produce oxalic acid which reacts with tissue calcium or blood forming calcium oxalate crystals.33 The birefringence of these structures is demonstrated with polarized light examination. These crystals are most frequently seen in aspergillomas caused by A. niger.34,35 Nevertheless, in this case we do not observe the presence of such crystals in both cytological smears and histological sections. In summary, aspergillosis limited to the urinary tract is an uncommon infection. Immunosuppression, diabetes, indwelling bladder catheter, and prolonged courses of antibiotics have been identified as predisposing factors. Thus, in the presence of a symptomatic low urinary tract infection with negative cultures for bacteria, a fungal infection must be suspected. Urine cytology is still being
a simple, practical, and inexpensive method for detecting both malignant cells and inflammatory/infectious diseases of the urinary tract. In this case, the presence of a fruiting body and septate hyphae in cytological smears from voided urine were the initial key for a reach to a final diagnosis of fungal bladder infection caused by A. niger.
References 1. Sakamoto S, Ogata J, Sakazaki Y, Ikegami K. Fungus ball formation of aspergilus in the bladder. An unusual case report. Eur Urol 1978;4:388–389. 2. Dervisoglu E, Dikmen E, Filinte D, Yilmaz A. Isolated bladder aspergillosis as the primary presentation of non-oluguric acute renal failure. Scand J Urol Neprhol 2008;42:189–191. 3. Siddappa S, Mythri KM, Kowsalya R, Shivalingaiah M. An unusual case of non-disseminated bladder aspergillosis in a setting of transitional cell carcinoma. Indian J Med Microbiol 2012;30:106–108. 4. Arunmozhi Balajee S, Brandt M. Aspergillus and Penicillium. In: Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D, editors. Manual of clinical microbiology. 10th ed. Washington, DC: ASM Press; 2011. p 1836–1852. 5. Schiefer HG. Mycoses of the urogenital tract. Mycoses 1997;40:33–36. 6. Erjavec Z, Kluin-Nelemans H, Verweij PE. Trends in invasive fungal infections, with emphasis on invasive aspergillosis. Clin Microbiol Infect 2009;15:625–633. 7. Smaldone MC, Cannon GM, Benoit RM. Case report: Bilateral obstruction secondary to Aspergilus bezoar. J Endourol 2006;20: 318–320. 8. Irby PB, Stoller ML, McAninch JW. Fungal bezoars of the urinary tract. J Urol 1990;143:447–451. 9. Lang EK. Myceliatomas (Aspergilus niger) in the renal collecting system and ureters. J Urol 2005;174: 2014. 10. Melchior J, Mebust WK, Valk WL. Ureteral colic from a fungal ball: Unusual presentation of systemic aspergilosis. J Urol 1972; 108:698–699. 11. Bibler MR, Gianis JT. Acute ureteral colic from an obstructing renal aspergiloma. Rev Infect Dis 1987;9:790–794. 12. Krishnamurthy R, Aparajitha C, Abraham G, Shroff S, Sekar U, Kuruvilla S. Renal aspergillosis giving rise to obstructive uropathy and recurrent anuric renal failure. Geriatr Nephrol Urol 1998;8:137–139. 13. Kueter JC, MacDiarmid SA, Redman JF. Anuria due to bilateral ureteral obstruction by Aspergillus flavus in an adult male. Urology 2002;59:601. 14. Ahmad M, Dakshinamurty KV. Emphysematous renal tract disease due to Aspergillus fumigatus. J Assoc Physicians India 2004;52: 495–497. 15. Flechner SM, McAninch JW. Aspergilosis of the urinary tract: Ascending route of infection and evolving patterns of disease. J Urol 1981;125:598–601. 16. Haq JA, Khan MA, Afroze N, Haq T. Localized primary renal aspergilosis in a diabetic patient following lithotripsy—A case report. BMC Infect Dis 2007;7:58. 17. Khan ZU, Gopalakrishnan G, al-Awadi K, et al.Renal aspergilloma due to Aspergillus flavus. Clin Infect Dis 1995;21:210–212. 18. Torrington KG, Old CW, Urban ES, Carpenter JL. Transurethral passage of Aspergillus fungus balls in acute myelocytic leukemia. South Med J 1979;72:361–363. 19. Hartman BJ, Coleman M, Brause BD, Saletan S. Localized renal aspergillosis with hairy cell leukemia: A review of urinary tract aspergillosis in malignant and nonmalignant conditions. Cancer Invest 1984;2:199–202. 20. de Medeiros CR, Dantas da Cunha A, Jr, Pasquini R, Arns da Cunha C. Primary renal aspergillosis: Extremely uncommon Diagnostic Cytopathology, Vol. 00, No 00
3
Diagnostic Cytopathology DOI 10.1002/dc
ET AL. MARTINEZ-GIRON presentation in patients treated with bone marrow transplantation. Bone Marrow Transplant 1999;24:113–114. 21. Gonzalez-Vicent M, Lassaletta A, L opez-Pino MA, Romero-Tejada JC, de la Fuente-Trabado M, Dıaz MA. Aspergillus “fungus ball” of the bladder after hematopoietic transplantation in a pediatric patient: Successful treatment with intravesical voriconazole and surgery. Pediatr Transplant 2008;12:242–245.
28. Dufresne SF, Datta K, Li X, et al. Detection of urinary excreted fungal galactomannan-like antigens for diagnosis of invasive aspergillosis. PLoS One 2012;7:e42736. 29. Loudon KW, Coke AP, Burnie JP, Shaw AJ, Oppenheim BA, Morris CQ. Kitchens as a source of Aspergillus niger infection. J Hosp Infect 1996;32:191–198.
22. Hadaya K, Akposso K, Costa de Beauregard MA, Haymann JP, Rondeau E, Sraer JD. Isolated urinary aspergillosis in a renal transplant recipient. Nephrol Dial Transplant 1998;13:2382–2384.
30. Laurel VL, Meier PA, Astorga A, Dolan D, Brockett R, Rinaldi MG. Pseudoepidemic of Aspergillus niger infections traced to specimen contamination in the microbiology laboratory. J Clin Microbiol 1999;37:1612–1616.
23. Mueller NJ, Weisser M, Fehr T, et al. Donor derived aspergilosis from use of a solid organ recipient as a multiorgan donor. Transpl Infect Dis 2010;12:54–59.
31. Chandra S, Gaur D, Harsh M, Chaturvedi J, Kishore S. An unusual presentation of Aspergillus species in a routine cervicovaginal pap smear: A case report. Acta Cytol 2009;53:229–231.
24. Martinez-Jabaloyas J, Osca JM, Ruiz JL, Beamud A, Blanes M, JimenezCruz JF. Renal aspergillosis and AIDS. Eur Urol 1995;27:167–169. 25. Oosten AW, Sprenger HG, van Leeuwen JT, Meessen NE, van Assen S. Bilateral renal aspergillosis in a patient with AIDS: A case report and review of reported cases. AIDS Patient Care STDS 2008;22:1–6.
32. Khurana U, Raghubanshi G, Handa U, Chander J. “Fruiting bodies” of Aspergillus flavus: A rare finding in histopathology. Int J Surg Pathol 2012;20:60–61. 33. Pabuc¸c¸uo glu U. Aspects of oxalosis associated with aspergillosis in pathology specimens. Pathol Res Pract 2005;201:363–368.
26. Vodovnik A. Isolated diffuse invasive renal aspergillosis in an immunocompromized patient due to longstanding steroid treatment: A case report. Cases J 2009;2:6825.
34. Oda M, Saraya T, Wakayama M, et al. Calcium oxalate crystal deposition in a patient with aspergilloma due to Aspergillus niger. J Thorac Dis 2013;5:E174–E178.
27. Klont RR, Mennink-Kersten MA, Verweij PE. Utility of Aspergillus antigen detection in specimens other than serum specimens. Clin Infect Dis 2004;39:1467–1474.
35. Shinohara MM, Miller CJ, Seykora JT. Pigmented fruiting bodies and birefringent crystals in a surgical wound: A clue to Aspergillus niger infection. J Cutan Pathol 2011;38:603–606.
4
Diagnostic Cytopathology, Vol. 00, No 00
Bladder Aspergillosis Detected by Urine Cytology n, M.D., Ph.D.,1* Santiago Martınez-Torre, B.S.,2 Rafael Martınez-Giro and Joaquın Mosquera-Martınez, M.D.3
Bladder aspergillosis is an unusual infection. We report the case of a 79-year-old man with clinical records of transitional cell carcinoma diagnosed 5 years ago. The presence of a fruiting body and septate hyphae in urine cytological smears were the key for a final diagnosis of fungal bladder infection caused by Aspergillus niger. Diagn. Cytopathol. 2014;00:000–000. VC 2014 Wiley Periodicals, Inc. Key Words: cytology
bladder aspergillosis; Aspergillus niger; urine
Isolated bladder aspergillosis is an unusual infection1–3 caused by Apergillus, a filamentous, cosmopolitan, and ubiquitous fungus found in nature and commonly isolated from soil, decaying matter, and indoor air environment. The genus Aspergillus includes about 184 species among which 40 are pathogenic for humans and animals. Among them, Aspergillus fumigatus is the most commonly isolated, followed by Aspergillus flavus and Aspergillus niger. Other species such as Aspergillus clavatus, Aspergillus nidulans, Aspergillus terreus, and Aspergillus versicolor are less commonly isolated as opportunistic pathogens.4 Among the predisposing factors for bladder aspergillosis, we can mention some such as indwelling urethral
1 CFGS Anatomic Pathology and Cytology, Instituto de Piedras Blancas 33450, Asturias, Spain 2 Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany 3 Medical Oncology Departament, Complejo Hospitalario Universitario de A Coru~na, As Xubias, 15006, A Coru~ na, Spain. *Correspondence to: Rafael Martınez-Gir on, M.D., Ph.D., Institute of Piedras Blancas, Avda. Principal 33, 33450-P. Blancas-Asturias, Spain. E-mail: [email protected] Received 29 April 2014; Revised 25 July 2014; Accepted 8 October 2014 DOI: 10.1002/dc.23231 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com).
C 2014 WILEY PERIODICALS, INC. V
catheters, obstructive uropathy, surgery, malignancy, immunosuppression, diabetes mellitus, and elderly.5 We report here the case of a 79-year-old man with clinical records of transitional cell carcinoma diagnosed 5 years ago. The presence of a fruiting body and septate hyphae in urine cytological smears were the key for a final diagnosis of fungal bladder infection caused by A. niger.
Case Report A 79-year-old man, insulin-dependent diabetic patient, with clinical records of transitional cell carcinoma diagnosed 5 years ago (T1a high grade and some foci of “in situ” carcinoma, treated with transurethral resection and BCG therapy) underwent cystoscopy resection due to a recurrence. After surgery, a Foley catheter was inserted for 10 days and he received a routine antibiotic prophylaxis with cyprofloxacine intravenously (0.4 g, twice a day) for the two first days, and orally (0.5 g, twice a day) for ten days. Approximately four months later, the patient was admitted to the emergency department because of urinary frequency, dysuria, terminal hematuria, and fever (38.2 C). Blood analysis, urinalysis, hemoculture, urine culture, and a simple abdominal X-ray were performed. Blood analysis revealed a mild leucocytosis (the rest of the hemogram and the biochemistry showed normal values), urinalyses revealed pyuria and hematuria, and both hemoculture and urine culture were negative for bacteria. The abdominal X-ray did not show significant alterations. Three consecutive samples from his urine were also sent to the laboratory of Cytology. The samples were processed by a cytospin (1500 rpm/10 min), fixed in 96% alcohol and stained by the Papanicolaou method. Under the microscope, in a granular background, it was observed the presence of a structure resembling a fungal fruiting body, with a 45 -branching hypha (7 lm in diameter) and a hyaline conidiophore ending in a round dark mass Diagnostic Cytopathology, Vol. 00, No 00
1
Diagnostic Cytopathology DOI 10.1002/dc
ET AL. MARTINEZ-GIRON
Fig. 3. Histological section from the excised bladder mass showing numerous 45 -branching hyphae (GMS stain, 2003). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary. com.]
Fig. 1. Urine cytology smears. A: Peculiar structure resembling an Aspergilus fruiting body (Papanicolaou stain, 4003). B: Long septate hypha (Papanicolaou stain, 6003, scale bar 5 50 mm). C: Urine culture. Aspergillus niger conidial heads and conidiophores (lactofenol cotton blue, 4003). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
(probably the conidial head) (Fig. 1A). However, a septate fragment of hypha was also observed (Fig. 1B). These observations were tentatively catalogued as Aspergillus sp. In spite of taking into account a possible contamination, a urine culture for fungus was required. In the Sabouraud dextrose agar medium, white colonies with numerous black color aerial mycelia were noticed. Microscopically, the presence of hyaline conidiophores ending in club-shaped biseriate vesicles (30–50 lm in diameter, surrounded by phialides covering the entire vesicle surface) was observed (Fig. 1C). The round conidia (3–5 lm in diameter) are over the phialides, forming radial chains toward the central axis. A bladder ultrasound showed an echogenic mass in the posterior wall (Fig. 2). The rest of the urinary tract did not show anomalies. A necrotic mass (similar to a fungus ball) adhered to the mucosal bladder was observed through a cystoscopy and removed by loop excision. The excised mass was processed for histological study. Grocott’s methenamine silver stain showed abundant branched filamentous hyphae (Fig. 3). These findings confirmed the diagnosis of isolated bladder aspergillosis. The patient was initially treated with intravenous Itraconazole (200 mg twice a day for two days) followed up by 200 mg oral, twice a day, for one week. After this, his clinical status improved considerably and nowadays he is completely healthy.
Discussion
Fig. 2. Ultrasound bladder. The white arrow indicates an echogenic mass in the posterior wall.
2
Diagnostic Cytopathology, Vol. 00, No 00
The number of infections as a result of Aspergillus species appears to be increasing, and in spite of the improvements in the surviving rates of patients with invasive fungal infection in recent years, continued research is
Diagnostic Cytopathology DOI 10.1002/dc
BLADDER ASPERGILLOSIS
required to meet the challenges associated with changes in epidemiology and resistance development.6 Aspergillus sp. may involve all the anatomical parts of the urinary tract (kidneys, renal pelvis, urether, and bladder), resulting in a spectrum of patterns and diseases such as asymptomatic funguria, fungal bezoars/mycetomas,7–9 obstructive uropathy and ureteral colic,10,11 renal failure and anuria,12,13 and emphysematous pyelonephritis.14 Thus, from local infectious foci in the lower urinary tract, the infection may carry on an ascending route,15 or in the course of a systemic infection provoked by an invasive aspergillosis. In the first case some conditions such as indwelling catheters, urinary tract instrumentation, and stones may be predisposing factors.16,17 In the second, an immunodepressed status caused by several conditions such as malignant hemopathies,18,19 transplants,20,21 (including kidneys from donors,22,23), AIDS,24,25 and longstanding steroid therapy26 has been also reported. In these settings, we think it is important to highlight the importance of culturing urine specifically for fungal organisms in the immunosuppressed host, as well as the detection of polysaccharide biomarkers, such as galactomannan-like antigens, in urine samples.27,28 Since A. niger prefers to grow in a moist and warm environment and is commonly found in soil and plants, it is important to highlight that it may be also found as contaminant in hospital environments,29 spreading to the patients through air, food, or other vehicles. This emphasizes the importance of searching for a source and ensuring high levels of hospital hygiene, and it is also applicable to microbiology laboratories where false positive cultures may have an important impact in the patient care.30 The presence of fruiting bodies of Aspergillus sp., in both cytological and histological samples, is an unusual finding. This may be due to an extrinsic contamination,31 or when the fungal ball is exposed to air with a high oxygen tension.32 On the other hand, some species of Aspergillus produce oxalic acid which reacts with tissue calcium or blood forming calcium oxalate crystals.33 The birefringence of these structures is demonstrated with polarized light examination. These crystals are most frequently seen in aspergillomas caused by A. niger.34,35 Nevertheless, in this case we do not observe the presence of such crystals in both cytological smears and histological sections. In summary, aspergillosis limited to the urinary tract is an uncommon infection. Immunosuppression, diabetes, indwelling bladder catheter, and prolonged courses of antibiotics have been identified as predisposing factors. Thus, in the presence of a symptomatic low urinary tract infection with negative cultures for bacteria, a fungal infection must be suspected. Urine cytology is still being
a simple, practical, and inexpensive method for detecting both malignant cells and inflammatory/infectious diseases of the urinary tract. In this case, the presence of a fruiting body and septate hyphae in cytological smears from voided urine were the initial key for a reach to a final diagnosis of fungal bladder infection caused by A. niger.
References 1. Sakamoto S, Ogata J, Sakazaki Y, Ikegami K. Fungus ball formation of aspergilus in the bladder. An unusual case report. Eur Urol 1978;4:388–389. 2. Dervisoglu E, Dikmen E, Filinte D, Yilmaz A. Isolated bladder aspergillosis as the primary presentation of non-oluguric acute renal failure. Scand J Urol Neprhol 2008;42:189–191. 3. Siddappa S, Mythri KM, Kowsalya R, Shivalingaiah M. An unusual case of non-disseminated bladder aspergillosis in a setting of transitional cell carcinoma. Indian J Med Microbiol 2012;30:106–108. 4. Arunmozhi Balajee S, Brandt M. Aspergillus and Penicillium. In: Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D, editors. Manual of clinical microbiology. 10th ed. Washington, DC: ASM Press; 2011. p 1836–1852. 5. Schiefer HG. Mycoses of the urogenital tract. Mycoses 1997;40:33–36. 6. Erjavec Z, Kluin-Nelemans H, Verweij PE. Trends in invasive fungal infections, with emphasis on invasive aspergillosis. Clin Microbiol Infect 2009;15:625–633. 7. Smaldone MC, Cannon GM, Benoit RM. Case report: Bilateral obstruction secondary to Aspergilus bezoar. J Endourol 2006;20: 318–320. 8. Irby PB, Stoller ML, McAninch JW. Fungal bezoars of the urinary tract. J Urol 1990;143:447–451. 9. Lang EK. Myceliatomas (Aspergilus niger) in the renal collecting system and ureters. J Urol 2005;174: 2014. 10. Melchior J, Mebust WK, Valk WL. Ureteral colic from a fungal ball: Unusual presentation of systemic aspergilosis. J Urol 1972; 108:698–699. 11. Bibler MR, Gianis JT. Acute ureteral colic from an obstructing renal aspergiloma. Rev Infect Dis 1987;9:790–794. 12. Krishnamurthy R, Aparajitha C, Abraham G, Shroff S, Sekar U, Kuruvilla S. Renal aspergillosis giving rise to obstructive uropathy and recurrent anuric renal failure. Geriatr Nephrol Urol 1998;8:137–139. 13. Kueter JC, MacDiarmid SA, Redman JF. Anuria due to bilateral ureteral obstruction by Aspergillus flavus in an adult male. Urology 2002;59:601. 14. Ahmad M, Dakshinamurty KV. Emphysematous renal tract disease due to Aspergillus fumigatus. J Assoc Physicians India 2004;52: 495–497. 15. Flechner SM, McAninch JW. Aspergilosis of the urinary tract: Ascending route of infection and evolving patterns of disease. J Urol 1981;125:598–601. 16. Haq JA, Khan MA, Afroze N, Haq T. Localized primary renal aspergilosis in a diabetic patient following lithotripsy—A case report. BMC Infect Dis 2007;7:58. 17. Khan ZU, Gopalakrishnan G, al-Awadi K, et al.Renal aspergilloma due to Aspergillus flavus. Clin Infect Dis 1995;21:210–212. 18. Torrington KG, Old CW, Urban ES, Carpenter JL. Transurethral passage of Aspergillus fungus balls in acute myelocytic leukemia. South Med J 1979;72:361–363. 19. Hartman BJ, Coleman M, Brause BD, Saletan S. Localized renal aspergillosis with hairy cell leukemia: A review of urinary tract aspergillosis in malignant and nonmalignant conditions. Cancer Invest 1984;2:199–202. 20. de Medeiros CR, Dantas da Cunha A, Jr, Pasquini R, Arns da Cunha C. Primary renal aspergillosis: Extremely uncommon Diagnostic Cytopathology, Vol. 00, No 00
3
Diagnostic Cytopathology DOI 10.1002/dc
ET AL. MARTINEZ-GIRON presentation in patients treated with bone marrow transplantation. Bone Marrow Transplant 1999;24:113–114. 21. Gonzalez-Vicent M, Lassaletta A, L opez-Pino MA, Romero-Tejada JC, de la Fuente-Trabado M, Dıaz MA. Aspergillus “fungus ball” of the bladder after hematopoietic transplantation in a pediatric patient: Successful treatment with intravesical voriconazole and surgery. Pediatr Transplant 2008;12:242–245.
28. Dufresne SF, Datta K, Li X, et al. Detection of urinary excreted fungal galactomannan-like antigens for diagnosis of invasive aspergillosis. PLoS One 2012;7:e42736. 29. Loudon KW, Coke AP, Burnie JP, Shaw AJ, Oppenheim BA, Morris CQ. Kitchens as a source of Aspergillus niger infection. J Hosp Infect 1996;32:191–198.
22. Hadaya K, Akposso K, Costa de Beauregard MA, Haymann JP, Rondeau E, Sraer JD. Isolated urinary aspergillosis in a renal transplant recipient. Nephrol Dial Transplant 1998;13:2382–2384.
30. Laurel VL, Meier PA, Astorga A, Dolan D, Brockett R, Rinaldi MG. Pseudoepidemic of Aspergillus niger infections traced to specimen contamination in the microbiology laboratory. J Clin Microbiol 1999;37:1612–1616.
23. Mueller NJ, Weisser M, Fehr T, et al. Donor derived aspergilosis from use of a solid organ recipient as a multiorgan donor. Transpl Infect Dis 2010;12:54–59.
31. Chandra S, Gaur D, Harsh M, Chaturvedi J, Kishore S. An unusual presentation of Aspergillus species in a routine cervicovaginal pap smear: A case report. Acta Cytol 2009;53:229–231.
24. Martinez-Jabaloyas J, Osca JM, Ruiz JL, Beamud A, Blanes M, JimenezCruz JF. Renal aspergillosis and AIDS. Eur Urol 1995;27:167–169. 25. Oosten AW, Sprenger HG, van Leeuwen JT, Meessen NE, van Assen S. Bilateral renal aspergillosis in a patient with AIDS: A case report and review of reported cases. AIDS Patient Care STDS 2008;22:1–6.
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