What is the best course of treatment for a patient with gross hematuria and chronic fungal infections?

Management of Gross Hematuria with Chronic Fungal Infections

Immediate Priorities

This clinical scenario requires simultaneous urgent urologic evaluation for the gross hematuria (given 30-40% malignancy risk) and targeted antifungal therapy for the fungal infection. 1

The presence of gross hematuria mandates a complete urologic workup regardless of other findings, as malignancy risk is substantially elevated compared to microscopic hematuria (30-40% versus 2.6-4%). 1 The chronic fungal infection requires parallel management but should not delay hematuria evaluation.

Hematuria Evaluation Algorithm

Risk Stratification

• Gross hematuria automatically places patients in high-risk category requiring full urologic workup including cystoscopy and upper tract imaging. 1
• Additional high-risk features include: male gender, age >35 years, smoking history, occupational chemical exposure, chronic urinary tract infection, and history of pelvic irradiation. 1

Diagnostic Workup

• CT urography (CTU) is the preferred imaging modality, utilizing unenhanced images followed by IV contrast-enhanced nephrographic and excretory phases. 1
• Cystoscopy is mandatory for all patients with gross hematuria to evaluate the bladder and urethra. 1
• Urinalysis with microscopy, urine culture (including fungal culture), and serologic testing should be obtained. 1

Fungal Infection Management

For Symptomatic Candida Cystitis

Fluconazole 200 mg (3 mg/kg) orally daily for 14 days is the first-line treatment for symptomatic lower urinary tract candidiasis. 1, 2, 3

For Candida Pyelonephritis or Upper Tract Involvement

Fluconazole 200-400 mg (3-6 mg/kg) orally daily for 14 days is recommended for fluconazole-susceptible organisms. 1, 3

For Fluconazole-Resistant Organisms (e.g., C. glabrata, C. krusei)

• Amphotericin B deoxycholate 0.3-0.6 mg/kg IV daily for 1-7 days (for cystitis) or 0.5-0.7 mg/kg daily for 2 weeks (for pyelonephritis). 1, 3
• Flucytosine 25 mg/kg orally four times daily for 7-10 days as an alternative monotherapy or in combination with amphotericin B. 1, 3

For Renal Fungal Balls

Combined medical and surgical approach is required: 1

• Systemic antifungal therapy with fluconazole 200-400 mg (3-6 mg/kg) daily or amphotericin B 0.5-0.7 mg/kg daily. 1
• Nephrostomy placement for drainage and potential amphotericin B irrigation (50 mg/L sterile water) if access to the renal collecting system is available. 1, 4
• Continue treatment until symptoms resolve and urine cultures clear. 1, 2

For Aspergillus Renal Infection (if applicable)

Nephrostomy with amphotericin B lavage plus systemic antifungal therapy is recommended, as antifungals are not primarily excreted into urine. 1

Critical Management Pitfalls to Avoid

• Never use echinocandins (caspofungin, micafungin, anidulafungin) for urinary tract infections as they achieve minimal urinary concentrations and are ineffective. 1, 2, 3, 5
• Avoid lipid formulations of amphotericin B for UTI as they do not achieve adequate urine concentrations. 2, 3
• Do not delay hematuria workup even if fungal infection is identified, as malignancy must be excluded. 1
• Amphotericin B bladder irrigation alone is inadequate for upper tract disease and should only be considered as adjunctive therapy for refractory lower tract infections. 1

Catheter and Obstruction Management

• Remove or replace indwelling urinary catheters if present, as catheter removal alone clears candiduria in approximately 40% of cases. 1, 3
• Eliminate urinary tract obstruction as a critical component of treatment. 2
• For patients with nephrostomy tubes or stents, consider removal or replacement if feasible. 2

Treatment Duration and Monitoring

• Continue antifungal therapy until symptoms resolve AND urine cultures no longer yield Candida species, with minimum 14 days for cystitis. 1, 2, 3
• Obtain follow-up urine cultures to confirm clearance of fungal infection. 1, 2, 3
• Follow-up blood cultures daily or every other day if candidemia is present until clearance is documented. 1
• Ophthalmologic examination is recommended for all patients with candidemia to rule out endophthalmitis. 1

When to Escalate Care

• Immediate urologic referral for all patients with gross hematuria for cystoscopy and definitive evaluation. 1, 6
• Consider imaging (ultrasound or CT) if persistent fungal infection despite appropriate therapy, concern for obstruction, or suspected fungus ball formation. 2, 3
• Nephrology consultation if evidence of renal parenchymal disease or glomerulonephritis. 1
• Infectious disease consultation for refractory fungal infections, fluconazole-resistant organisms, or suspected disseminated candidiasis. 1