oral infections of geotrichum candidum are clinically similar to candidiasis and commonly associated with diabetes mellitus and hiv infection , . cases of dissemination and fungemia are reported in patients with chronic and acute myeloid leukemia , , , , , , .
old women post - partum with isolated renal calculi and renal fungal bezoar attributed to geotrichum candidum and to illustrate the diagnostic dilemmas .
old women presented with history of left flank pain and intermittent fever since 15 days .
she was evaluated elsewhere with contrast enhanced computerized tomography ( ct ) scan which revealed contracted left kidney with 2 calculi in the lower and middle calyx of 89  mm each with intrapelvic mass and multiple air pockets in the renal pelvis ( fig .
2 ) . she had undergone cytoscopy and left dj stenting elsewhere but continued to have fever and flank pain when she was presented to us . after routine investigation ,
patient was started on 3rd generation cephalosporin and she underwent left percutaneous nephrolithotripsy ( pcnl ) which revealed brownish gray material with 2 calculi .
gross specimen consists of multiple irregular gray brown tissue bits , largest measuring 0.5  cm0.5  cm and cut portion showed gray brown areas .
section showed fungal ball containing aggregates of macerated , distorted fungal hyphae with some showing acute angle branching surrounded by cell debris and neutrophils .
both urine and biopsy material sent to mycology laboratory for culture investigation were inoculated on sabourauds dextrose agar ( hi - media laboratories ltd . , mumbai ) and incubated at 37  c and 28  c which grew a rapidly growing fungus with flat , white to creamy having a smooth texture later becoming hairy consistent with geotrichum candidum ( fig .
geotrichum candidum was morphologically identified by the presence of true hyphae , hyaline smooth , one - celled , subglobose to cylindrical , slimy arthroconidia and the lack of blastoconidia .
the arthroconidia vary in size and germinate at one end giving a  hockey stick appearance ( fig .
4 ) . biochemical identification was carried out in the mycology laboratory , kasturba medical college , manipal using both conventional and api 20c yeast identification system ( biomerieux inc . ) .
it was further differentiated from trichosporon by the absence of urea utilization and inability to assimilate carbohydrate ; maltose , sucrose , lactose , cellobiose , inositol raffinose and trehalose .
antifungal susceptibility testing for the isolate was performed according to the clinical and laboratory standards institute ( clsi ) document m38-a2 .
the mic90 ( minimum inhibitory concentration ) for amphotericin , fluconazole , itraconazole and voriconazole were found to be 0.125  g / ml , 16  g / ml , 4  g / ml and 0.25  g / ml respectively .
patient continued to have fever in the post - operative period and responded only after starting intravenous itraconazole 200  mg bd for 2 days followed by oral itraconazole 200  mg bd and continued for 6 weeks . during the follow up , a repeat ct done showed complete clearance of the fungal material from the left kidney .
the saprophytic colonization of a preformed cavity by conglomerate of fungal mycelia without invasion of adjacent tissue is termed as fungal ball or fungal bezoar .
renal colic can be caused by passage of fungal ball that obstruct the collecting system .
genitourinary tract is rarely a site of primary fungal infection with exception of candida species , however it may be involved as a result or part of systemic infection .
candidal infection can cause pyelonephritis , abscess , papillary necrosis and obstruction with fever and flank pain , .
genitourinary fungal infections are usually encountered as a part of disseminated disease in immunocompromised host ( aids , corticosteroids , malignancy , neutropenia ) , , , , , , .
fungal balls also called and fungal bezoars or accretions are known to cause ureteral and uretro - pelvic junction obstruction .
diagnosis is established by identification the of fungi in urine and imaging studies using ( computerized tomography , ultra sonography , intravenous urography ) that document obstructive uropathy and soft tissue density with in renal collecting system .
have successfully managed the removal of bilateral renal pelvis mycotic bezoars using a mechanical thrombectomy device followed by antifungal renal pelvis irrigation .
percutaneous nephrostomy , tract dilation and fluoroscopically guided extraction of renal fungal ball under epidural anesthesia is described by doemeny et al . .
the outcome of geotrichum infections depend on the degree of tissue invasion by the organism and the immune status of the host .
sheehy et al . suggested that geotrichum lack virulence and ability to colonize renal tubules based on the rarity of disseminated disease , lack of tissue invasion and their rapid clearance in most of the case reported .
its incidence may be under reported since it can be misdiagnosed histopathologically as candida , aspergillus or trichosporon .
this possibility of misinterpretation highlights the importance of obtaining repeated fungal cultures in addition to histopathological examination .
we hereby reiterate the pathogenic potential of geotrichum candidum and report its role in causing renal fungal ball .
 geotrichum candidum is yeast like fungi that cause infections in immunocompromised patients . 
 we report a case of renal fungal ball with geotrichum candidum in a 27  yr . 
 old women post - partum . 
 this case to our knowledge is the first case of renal fungal bezoar due to geotrichum candidum reported in india . 
Introduction
Case
Discussion
Conflict of interest