Infecção do trato urinário por leveduras do gênero Candida ­ revisão de literatura / Urinary tract infection by yeast of the genus Candida - literature review / Infección del tracto urinario causada por levaduras del género Candida - revisión de la literatura

A ocorrência das infecções do trato urinário (ITU) causadas por leveduras do gênero Candida estão aumentando consideravelmente nas últimas décadas, sendo a Candida albicans a mais comumente diagnosticada como causadora deste tipo de infecções. Contudo, outras espécies, como exemplo da Candida tropicalis, estão emergindo como preocupantes causadores da doença. Neste sentido, o objetivo do presente trabalho é revisar os aspectos relacionados com as ITU causadas por leveduras do gênero Candida. Foi realizada uma pesquisa na base de dados PubMed, buscando artigos sobre a epidemiologia, patogenia e tratamento das ITU causadas por leveduras do gênero Candida. As espécies de Candida são os fungos patogênicos oportunistas mais relevantes causadores de infecções nosocomiais e podem causar infecção no trato urinário, tanto inferior (ureteres, bexiga e uretra) quanto superior (rins), principalmente em pacientes imunocomprometidos. Existem alguns fatores predisponentes, como gênero feminino, idade avançada, diabetes mellitus, hospitalização prolongada, imunossupressão, gravidez, hipertensão, neutropenia, cálculos renais, infecções nosocomiais, terapia antibiótica e procedimentos, como a cateterização, que atuam como facilitadores das ITU por Candida spp. A doença pode ocorrer de forma assintomática, porém, pode evoluir para casos mais graves com comprometimento sistêmico em situações de candidemia que pode causar a morte do paciente, principalmente se tratando de indivíduos imunocomprometidos. Sendo assim, devido ao risco existente, a doença não pode ser negligenciada e um diagnóstico preciso e um tratamento adequado devem ser estabelecidos.

The occurrence of urinary tract infections (UTI) caused by yeasts of the genus Candida has increased considerably in recent decades, with Candida albicans being the most commonly diagnosed as causing this type of infections. However, other species, such as Candida tropicalis, are emerging as worrisome causes of the disease. In this sense, the objective of the present paper is to review the aspects related to the UTI caused by yeasts of the genus Candida. A search was carried out in the PubMed database, searching for articles on the epidemiology, pathogenesis and treatment of UTI caused by yeasts of the genus Candida. Candida species are the most relevant opportunistic pathogenic fungi that cause nosocomial infections and can cause both lower (ureters, bladder and urethra) and upper (kidneys) urinary tract infections, especially in immunocompromised patients. There are some predisposing factors, such as female gender, advanced age, diabetes mellitus, prolonged hospitalization, immunosuppression, pregnancy, hypertension, neutropenia, kidney stones, nosocomial infections, antibiotic therapy and procedures, such as catheterization, that act as facilitators of UTI by Candida spp. The disease can occur asymptomatically, however, it can progress to more severe cases with systemic involvement in situations of candidemia that can cause the death of the patient, especially in immunocompromised individuals. Therefore, due to the existing risk, the disease cannot be neglected and an accurate diagnosis and adequate treatment must be established.

La aparición de infecciones del tracto urinario (ITU) causadas por levaduras del género Candida ha aumentado considerablemente en las últimas décadas. Candida albicans es la infección por levaduras más comúnmente diagnosticada. Sin embargo, otras especies, como la Candida tropicalis, están surgiendo como causa preocupante de la enfermedad. En este sentido, el objetivo del presente trabajo es revisar los aspectos relacionados con la ITU causada por levaduras del género Candida. Se realizó una búsqueda en la base de datos PubMed, buscando artículos sobre la epidemiología, la patogénesis y el tratamiento de la ITU causada por levaduras del género Candida. Las especies de Candida son los hongos patógenos oportunistas más relevantes que causan infecciones nosocomiales y pueden provocar infecciones del tracto urinario inferior (uréteres, vejiga y uretra) y superior (riñones), especialmente en pacientes inmunodeprimidos. Existen algunos factores predisponentes, como el sexo femenino, la edad avanzada, la diabetes mellitus, la hospitalización prolongada, la inmunosupresión, el embarazo, la hipertensión, la neutropenia, los cálculos renales, las infecciones nosocomiales, la terapia con antibióticos y los procedimientos como el cateterismo, que actúan como facilitadores de la ITU por Candida spp. La enfermedad puede presentarse de forma asintomática, pero puede evolucionar a casos más graves con afectación sistémica en situaciones de candidemia que pueden causar la muerte del paciente, especialmente en individuos inmunodeprimidos. Por lo tanto, debido al riesgo existente, no se puede descuidar la enfermedad y se debe establecer un diagnóstico preciso y un tratamiento adecuado.

Lupus cystitis presenting with hidronephrosis and gastrointestinal involvement / Cistite lúpica apresentando hidronefrose e envolvimento gastrointestinal

Abstract Introduction: Lupus cystitis is a rare manifestation of systemic lupus erythematosus, characterized by thickening of the bladder wall, associated with ureterohydronephrosis. In several cases gastrointestinal symptoms are the main manifestation. The optimal immunosuppressive regimen is still unknown. Methods: 16-year-old girl with systemic lupus erythematosus was admitted with dysuria, renal impairment, diarrhea, abdominal pain, nausea and vomiting. An abdominal CT scan demonstrated moderate bilateral dilation from the pelvis to the ureterovesical junction, and the bladder exhibited reduced capacity and diffusely thickened walls. A diagnosis of chronic interstitial cystitis was performed and treatment with high dose methylprednisolone resulted in a significant relief of gastrointestinal and urinary symptoms and a reduction of the bladder thickness with improvement of their capacity. Conclusion: Lupus cystitis is a rare and underdiagnosed urinary manifestation of LES and the presence of mild urinary symptoms and abdominal pain may alert about this possibility.

Resumo Introdução: A Cistite Lúpica é uma manifestação rara do Lúpus Eritematoso Sistémico, caracterizada pelo espessamento da parede da bexiga, podendo estar associada com ureterohidronefrose. Em vários casos, os sintomas gastrointestinais são a principal manifestação e ainda não se sabe qual o regime imunossupressor mais adequado nesta situação. Método: Uma jovem de 16 anos de idade com lúpus eritematoso sistémico foi admitida com disúria, insuficiência renal, diarreia, dor abdominal, náuseas e vómitos. A tomografia computadorizada de abdome demonstrou dilatação moderada de ureter e pelve renal bilateralmente e bexiga exibindo capacidade reduzida e paredes difusamente espessadas. Foi feito o diagnóstico de cistite intersticial crónica e o tratamento com dose elevada de metilprednisolona resultou em um alívio significativo dos sintomas urinários e gastrointestinais e uma redução da espessura da bexiga, com melhora da sua capacidade. Conclusão: A Cistite Lúpica é uma manifestação urinária rara e subdiagnosticada do LES e a presença de sintomas urinários leves e dor abdominal devem alertar para essa possibilidade diganóstica.

Safety and efficacy of intravesical alum for intractable hemorrhagic cystitis: a contemporary evaluation

ABSTRACT Introduction: Hemorrhagic cystitis (HC) represents a challenging clinical entity. While various intravesical agents have been utilized in this setting, limited data exist regarding safety or efficacy. Herein, then, we evaluated the effectiveness and complications associated with intravesical alum instillation for HC in a contemporary cohort. Materials and Methods: We identified 40 patients treated with intravesical alum for HC between 1997-2014. All patients had failed previous continuous bladder irrigation with normal saline and clot evacuation. Treatment success was defined as requiring no additional therapy beyond normal saline irrigation after alum instillation. Results: Median patient age was 76.5 years (IQR 69, 83). Pelvic radiation was the most common etiology for HC (n=38, 95%). Alum use decreased patient's transfusion requirement, with 82% (32/39) receiving a transfusion within 30 days before alum instillation (median 4 units) versus 59% (23/39) within 30 days after completing alum (median 3 units) (p=0.05). In total, 24 patients (60%) required no additional therapy prior to hospital discharge. Moreover, at a median follow-up of 17 months (IQR 5, 38.5), 13 patients (32.5%) remained without additional treatment for HC. Adverse effects were reported in 15 patients (38%), with bladder spasms representing the most common event (14/40; 35%). No clinical evidence of clinically significant systemic absorption was detected. Conclusion: Intravesical alum therapy is well-tolerated, with resolution of HC in approximately 60% of patients, and a durable response in approximately one-third. Given its favorable safety/efficacy profile, intravesical alum may be considered as a first-line treatment option for patients with HC.

Embolização vesical superseletiva para tratamento de hematúria maciça por cistite actínica / Selective vesical artery embolization for treatment of gross hematuria due to actinic cystitis

Os autores relatam o caso de uma paciente de 46 anos de idade, que, após ter sido submetida a tratamento radioterápico por neoplasia de colo uterino, desenvolveu cistite actínica com episódios frequentes de hematúria franca. A paciente necessitou ser submetida a repetidos cateterismos vesicais por retenção urinária, hemotransfusões e internacões hospitalares. As medidas conservadoras e as tentativas de hemostasia por cistoscopia não foram bem-sucedidas no controle do sangramento. A paciente foi então submetida a tratamento endovascular com embolização superseletiva das artérias vesicais e outros pedículos vasculares, que se demonstraram associados ao sangramento. O procedimento foi bem-sucedido e a paciente vem sendo acompanhada há nove meses sem a necessidade de novas hemotransfusões nem de novas internações hospitalares. De acordo com a revisão da literatura, o uso dessa técnica ainda não havia sido descrito em trabalhos brasileiros.

This article describes the case of a 46-year-old female patient who had been treated with radiotherapy for cervical cancer. She developed actinic cystitis with frequent episodes of severe hematuria. She required repeated catheterization to manage urinary retention, blood transfusions and hospital admissions. Conservative measures and attempts to achieve hemostasis by cystoscopy were unsuccessful at controlling bleeding. The patient therefore underwent endovascular treatment with superselective embolization of the vesical arteries and other vascular pedicles found to be linked with the bleeding. The procedure was successful and the patient has been in follow-up for 9 months with no need for further blood transfusions or admission to hospital. According to a review of the literature, use of this technique has not previously been described in Brazil.

Cistitis enfisematosa: una inusual forma de presentación de la infección del tracto urinario bajo / Emphysematous cystitis: Report of one case

Emphysematous cystitis is found in diabetic patients and in individuals with urinary stasis and immunosuppression. We report a 58-year-old male with hypertension, type 2 Diabetes on insulin treatment and central nervous system vasculitis on immunosuppressive therapy. He was admitted with weight loss and gait instability. A PET-CT showed a circumscribed image of air in the bladder contour without involving the upper urinary tract, suggesting emphysematous cystitis. Re-interrogated, the patient referred pneumaturia, dysuria and febrile sensation one week before admission. Urine culture showed Enterobacter aerogenes. He was treated with a urinary catheter, metabolic control and parenteral antimicrobials. The patient was discharged without symptoms 21 days after admission, with the bladder catheter.

Pneumorraquis, espondilitis y meningitis secundarios a cistitis enfisematosa / Pneumorrhachis, spondylitis and meningitis secondary to emphysematous cystitis. Report of one case

We report a 57-year-old woman who presented with low back pain, fever and impairment of consciousness. The patient was admitted to the intensive care unit in Glasgow 8, with neck stiffness, peritoneal irritation, leukocytosis, hyperglycemia requiring insulin and a urine test suspecting an infection. Brain CT was unremarkable, while CT of the abdomen and pelvis evidenced emphysematous cystitis, retropneumoperitoneum and pneumorrhachis. Blood, urine and cerebrospinal fluid cultures were positive to Escherichia coli. She was treated with ceftriaxone, ciprofloxacin and amikacin during one month followed by ciprofloxacin until completing 100 days. The air in the spinal canal and bladder decreased. However she suffered several infectious complications such as multiple paravertebral, epidural and psoas abscesses, L5-S1 spondylitis and a L3 fracture. As an inflammatory complication she developed a bulbar infarction and tetraparesis. She had a good clinical response with medical treatment, partial improvement of the paresis and reduction of epidural abscesses.

Pielonefritis, colecistitis y cistitis enfisematosas en paciente con diabetes mellitus descompensada / Pyelonephritis, cholecystitis, and emphysematous cystitis in a diabetic patient

Background. Emphysematous pyelonephritis is a necrotizing infection characterized by gas production that usually is located in the kidney tissue, urinary tract and retroperitoneal tissue. Gas can escape following the renal veins and accumulate in the hepatic veins and other places. E coli is the most common causative organism. Clinical case: We report a 62 years old diabetic female, admitted to the hospital with a diabetic ketoacidosis. An abdominal CT scan disclosed a left emphysematous pyelonephritis, cholecystitis and cystitis. The patient was operated, performing a left nephrectomy, cholecystectomy and placement of sub hepatic and retroperitoneal drainages. The pathological study of the surgical piece showed an acute pyelonephritis with abscess formation and chronic cholecystitis. The patient died due to a multi systemic failure.

Introducción: La Pielonefritis enfisematosa es una infección necrotizante caracterizada por la producción de gas, que habitualmente se ubica en el parénquima renal, las vías urinarias y los tejidos retroperi-toneales. Cuando el gas es abundante puede escapar siguiendo las venas renales y acumularse en las venas hepáticas, y el resto del sistema. La E. coli es el patógeno más frecuente. Caso clínico: Presentamos el caso de paciente femenina de 62 años, diabética que ingresa con sintomatología de vías urinarias diagnosticada como pielonefritis enfisematosa izquierda por tomografía y encontrando como hallazgos adicionales.

Emphysematous cystitis: a case report

Emphysematous Cystitis is a primary infection of the bladder with production of gas by bacteria. The infection is uncommon, still has obvious clinical importance due to its morbidity and mortality potential, as the following case enlightens. We report a clinical case of a patient admitted with acute myocardial infarction who developed an acute emphysematous cystitis, a further complication in his long and complex period of hospitalization.

Two case reports of emphysematous cystitis in two diabetic patients with related literature review

Emphysematous cystitis is a rare form of acute infection of the bladder is which most cases are seen in diabetic patients. Most infections are due to E.coli and Klebsiella species. Predisposing factors are diabetes mellitus, recurrent urinary tract infections, bladder outlet obstruction and neurogenic bladder. CT-scan is the most sensitive method of diagnosis that detects air whithin intramular of bladder that is pathogonomonic of the disease. In this case report we reported two cases of emphysematous cystitis. The first case was a 73 years old diabetic woman who was admitted due to acute renal failure after cholecystectomy. During hospitalization, after remission of renal function, she developed fever, abdominal pain, hematuria and progressive abdominal distention. In physical examination she had generalized abdominal tenderness with dominance in the lower abdomen without rebound tenderness which with observation of air in intramural bladder by CT-scan, diagnosis of emphysematous cystitis was confirmed and the patient was treated and improved. The second case was a 37 years old diabetic woman. She was refered to the hospital because of nausea, recurrent vomiting and abdominal pain. In physical examination she had severe hypotention, generalized abdominal tenderness that was dominant in the lower abdomen and abdominal mass in suprapubic area. Suspicious to emphysematous cystitis, pelvic CT-scan was ordered. By observation of air in intramural bladder, emphysematous cystitis was confirmed. Patient was treated with antibiotic, insertion of fouly catheter and was improved. Undiagnosing or delaying in initiating appropriate treatment can lead to peritonitis secondary to intraperitoneal perforation of the bladder, septisemia and ultimately death of the patient. Timely diagnosis and aggressive therapy are important for the survival of these patients

Cistitis hemorrágica relacionada al trasplante de médula ósea: primer reporte de casos en el país / Hemorrhagic cystitis in bone marrow trasplant recipients: first report of cases in our country

Objetivo: Determinar la incidencia, características clínicas y complicaciones de la cistitis hemorrágica (CH). Material y Métodos: Estudio descriptivo sobre pacientes transplantados de médula ósea en la Unidad de Trasplante de Médula Ósea del Hospital Nacional Edgardo Rebagliati Martins, desde noviembre 1994 hasta octubre 2003, y que desarrollaron cistitis hemorrágica. Resultados: En 9 años fueron transplantados 170 pacientes, desarrollando cistitis hemorrágica 8 de ellos (incidencia acumulada 4,7 por ciento). El cuadro clínico se caracterizó por disuria más hematuria macroscópica o microscópica. La presentación tardía fue la más frecuente. En 4 pacientes, la cistitis hemorrágica fue severa. Dos de los tres pacientes que desarrollaron el cuadro de cistitis hemorrágica en dos oportunidades, fallecieron. Conclusiones: La mitad de los pocos pacientes que desarrollan CH en la Unidad, lo hacen bajo la forma severa y, si presentan la CH por segunda vez, su pronóstico se complica.

Objective: To determine the incidence, clinical features and complications of bone marrow transplant-related hemorrhagic cystitis (HC). Material and Methods: Retrospective study of bone marrow transplant patients attended at the Edgardo Rebagliati Martins National Hospital Bone Marrow Transplant Unit from November 1994 to October 2003 and who developed HC. Results: A total of 170 patients underwent hematopoietic cell transplantation. Eight patients developed HC with a cumulative incidence of 4,7 per cent, characterized by mainly late onset hematuria and dysuria. In 4 patients, the HC was severe. Two of the three patients who developed HC twice died. Conclusions: Half of the few patients with HC attended at the Unit developed serious disease and when they had HC for a second time the prognosis was fatal.

Analysis on pathogenesis of 50 cases of bladder proliferative lesions / 华中科技大学学报（医学）（英德文版）

In order to study the pathogenesis, clinical and pathological characteristics of proliferative lesions of the bladder, 50 cases of proliferative lesions of the bladder from 150 patients with complaints of frequency, urgency, hematuria and dysuria were subjected to cystoscopic biopsy of the suspicious foci in the bladder. In combination with the symptoms, urine and urodynamics, the relationship of proliferative lesions of the bladder to the inflammation and obstruction of the lower urinary tract was analyzed. Of the 50 cases of proliferative bladder lesions, 44 cases (88%) had lower urinary tract infection and 29 (58%) lower urinary tract obstruction. The patients with lower urinary tract obstruction were all complicated with infection. Three cases were associated with transitional cell carcinoma. Malignant cells were detected in 1 case by urinary cytologic examination. Proliferative lesions of the bladder, especially those without other obvious mucosa changes under cystoscopy, are common histological variants of urothelium in the patients with chronic inflammation and obstruction of the lower urinary tract. Chronic inflammation and obstruction of the lower urinary tract might be the causes for proliferative lesions of the bladder. It is suggested that different treatments should be applied according to the scope and histological type of the proliferative lesions.

Haematuria as the presenting symptom: experience from a tertiary referral centre in Sri Lanka.

OBJECTIVES: To examine the causes of macroscopic (gross) haematuria in patients where it is the main presenting symptom and to evaluate the role of cystoscopy in their investigation. DESIGN: Prospective audit. SETTING: One urology unit at the National Hospital of Sri Lanka, Colombo. PATIENTS: 174 consecutive new patients with macroscopic haematuria, where haematuria was the presenting symptom. OUTCOME MEASURES: Causes of macroscopic haematuria in the under 40 years and over 40 age groups; role of cystoscopy. RESULTS: Of the 156 (130 male and 26 female) patients evaluated for macroscopic haematuria 67 were under the age of 40 years and 89 over 40. The causes of macroscopic haematuria in the under 40s in descending order of frequency are urinary stone disease, idiopathic and inflamed urothelium. In the over 40 group bladder cancer was the commonest cause, affecting 31.5% of patients, followed by stone disease. CONCLUSIONS: Macroscopic haematuria in a patient over the age of 40 years could be due to bladder cancer and merits cystourethroscopy. In younger patients, urolithiasis is the predominant cause.

Tratamiento de la Cistitis Radiogéna Hemorrágica con Formalina. Reporte de 5 casos / Treatment of hemorrhagic radiogenic cystitis with formaldehyde. Report of 5 cases

Se informan los resultados del tratamiento con formalina al 5 por ciento utilizada intravesical en 5 pacientes portadores de hematuria vesical masiva por cistitis radiógena hemorrágica. Se obtuvo remisión completa en el 100 por ciento de los casos, dada por el cese inmediato del sangramiento. Como complicación se presentó espasmo vesical moderado en todos los pacientes. Se recomienda este proceder terapéutico para el sangramiento incontrolable producido por cistitis radiógena hemorrágica con riesgo para la vida

Control of persistent vesical bleeding due to radiation cystitis by intravesical application of 15 (S) 15-methyl prostaglandin F2-alpha.

A 45 year old female who received radiotherapy for stage II-B uterine cervical cancer four and half years ago, presented with persistent hematuria due to radiation cystitis. 15 (S)-15-methyl prostaglandin F2-alpha (1 mg in 100 ml of normal saline) was instilled into the bladder daily for two days. The severity of bleeding decreased considerably. However, significant hematuria recurred 19 days later which continued despite bladder irrigation with normal saline. 1 mg of 15 (S) 15-Me PGF2 alpha mixed with hydroxyethyl cellulose gel to a volume of 10 ml was then instilled into the urinary bladder daily for three days and macroscopic hematuria ceased. Urinary frequency and urgency were the side effects which lasted for ten days. There has been no recurrence of macroscopic hematuria during the five months follow-up. In conclusion, 15 (S) 15-Me PGF2-alpha may be administered intravesically to control moderate hematuria due to radiation cystitis.