Giant Fungal Ball, Emphysematous Cystitis and Spontaneous Vesico-Vaginal Fistula in a Lady with Diabetes Mellitus

A 52-year-old diabetic lady on hypoglycemic drugs attended emergency services with history of lower abdominal pain, fever and urinary incontinence along with passing of whitish material in urine for one week. She was a thinly built lady with aenemia (Hb, 8.4mg%) and hyperglycemia (random blood sugar, 564 mg%). Urinary bladder was palpable. She had renal failure (serum creatinine, 2.7mg%). She was started on injection Piperacillin /Tazobactum and regular Insulin. She was transfused two units of red blood cells. Urine analysis showed haematuria and pyuria and urine culture grew non-candida albicans. She was started on injection Fluconazole. CT scan (non-contrast) detected moderate bilateral hydronephrosis, intraluminal gas in urinary bladder with thickened walls suggestive of emphysematous cystitis. At cystoscopy, a whitish mass filling up the whole of urinary bladder was found and the mass extruded in toto into the vagina through a vesico-vaginal fistula. The histopathological report demonstrated predominantly necrotic material, fungal organism in the form of spores and hyphae. PAS and GMS stain were positive for fungal organism. Ultrasonography repeated after 14 days of Fluconazole showed resolution of hydronephrosis. Patient was scheduled for repair of the vesico-vaginal fistula after six weeks but she did not return for the operation.