SGLT2抑制劑併用輸尿管支架患者之難治性腎真菌球處置：從單一病例經驗到文獻回顧

陳偉安¹、曾浩翔^1,2

¹中國醫藥大學附設醫院 泌尿部;² 中國醫藥大學北港附設醫院 泌尿部

A case of fungal bezoar and the interplay between SGLT2 inhibitors and indwelling ureteral stents: a multimodal management approach

Wei-An Chen¹, Hao Xiang Chen^1,2

¹ Department of Urology, China Medical University Hospital, China Medical University, Taichung 404, Taiwan

² Division of Urology, Department of Surgery, China Medical University Beigang Hospital, Beigang, Yunlin, 651012, Taiwan.

Case Presentation

An 88-year-old male with type 2 diabetes managed with dapagliflozin presented with Candida albicans pyonephrosis. Initial management involved percutaneous nephrostomy and intravenous fluconazole. Blood cultures remained negative for bacterial growth, and drug sensitivity test of the urine culture confirmed fluconazole-sensitive Candida albicans. Following a refractory clinical course, ureteroscopy on Day 66 identified an extensive renal fungal bezoar occupying the entire ureter and renal pelvis. Management was adjusted by discontinuing the Sodium-glucose cotransporter-2 (SGLT2) inhibitor and initiating targeted antifungal therapy with fluconazole and flucytosine. Definitive mechanical clearance was achieved on Day 92 using aspiration and forceps, resulting in complete clinical and symptomatic resolution by Day 130.

Discussion

To evaluate clinical characteristics and management outcomes, a systematic literature review was performed, and 33 cases of renal fungal bezoars were collected for pooled analysis. Immunocompromise was nearly universal in this cohort (90.9%), with diabetes mellitus (69.7%) being the most prevalent comorbidity. Drug-induced glycosuria from SGLT2 inhibitors like dapagliflozin creates a nutrient-rich medium that facilitates refractory fungal proliferation. While 51.5% of cases were managed conservatively, 48.5% required invasive interventions such as ureteroscopy or percutaneous removal. Although invasive management did not significantly reduce the duration of systemic medication compared to non-invasive strategies (26.2 vs. 31.8 days; p = 0.57), mechanical removal remains essential for reducing the infectious burden in cases where conservative therapy fails. Additionally, local antifungal instillation was utilized in 30.3% of cases as a site-specific escalation strategy.

Conclusion

The management of refractory renal fungal bezoars requires a multimodal approach centered on the discontinuation of predisposing medications and the establishment of adequate urinary drainage. Our findings highlight that when conservative antifungal therapy and simple drainage are insufficient, invasive mechanical removal is vital to ensure definitive clearance and prevent life-threatening urosepsis. This structured strategy is particularly critical for high-risk patients with persistent glycosuria or indwelling ureteral stents.