Fungal ball kidney ultrasound

Fungal ball kidney ultrasound DEFAULT

Renal fungal ball—two case reports and review of literature


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Fungal ballsof the urinary tract, also known as fungal bezoars or mycetomas of the urinary tract, are a rare manifestation of funguria, usually candiduria.

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While candiduria may be seen in approximately 20% of hospitalized patients 1, development of fungal balls is considered very uncommon, although the exact incidence is unknown. They are more commonly seen in the neonatal and elderly demographics 2-7.

Risk factors

Fungal balls are generally seen in the presence of at least one of the following 2-5:

  • diabetes mellitus
  • immunocompromised state (e.g. post-transplant patients, HIV with poor virological suppression)
  • indwelling catheterization
  • anatomical urinary tract anomalies
  • urinary retention (e.g. bladder obstruction, neurogenic bladder)
  • prolonged antibiotic therapy
  • concurrent malignancy

Fungal balls of the urinary tract are usually diagnosed in the context of a symptomatic urinary tract infection or urosepsis, and are not symptomatic themselves unless they cause obstruction 2-7. If obstructive, they may contribute to renal colic-type pain, development of or worsening of pyelonephritis, and a post-renal acute kidney injury 2-7.


The etiology of fungal balls is not clearly understood, however they are thought to be an agglutination of 2,4:

The most commonly implicated pathogen is Candida albicans, however many other fungal isolates have been described in the literature, including other Candida spp., Aspergillus spp., Rhizopus oryzae, and Geotrichum candidum2,5,7.


Fungal balls can exist anywhere along the urinary tract, however are most commonly described as existing within the renal pelvis 2-7.

Fungal balls are often seen in the setting of cystitis, pyelonephritis, papillary necrosis, and/or evidence of urinary tract obstruction (e.g. hydronephrosis, hydroureter) 2-7.

Plain radiograph

Plain radiography is often unremarkable, however unusual locules of gas or calcification may be seen within the urinary system possibly indicative of underlying fungal ball 6.


Cystography and pyelography may reveal contrast filling defects where the fungal balls lie 2,6.


Generally, fungal balls are appreciated as mobile, rounded, heterogeneously hypoechoic masses, although hyperechoic masses have also less frequently been described 2-5. No evidence of vascularity is seen within the mass on a Doppler study 5.


Fungal balls have a heterogeneous soft-tissue density on CT without contrast-enhancement, but may also have regions of gas or calcification 5. They are rounded and not attached to the walls of the urinary tract, with a thin rim of urine often appreciable around the mass 5. CT urography (e.g. CT intravenous pyelogram) reveals filling defects, similar to fluoroscopy 5,7.


Morphological findings are identical to those seen on CT 5,9. Signal characteristics of fungal balls have been rarely described, but include 3,5,8,9:

  • T1: isointense to renal parenchyma
  • T2: hyperintense to renal parenchyma

Similar to other modalities, MR urography reveals filling defects 5.

Treatment and prognosis

Treatment is typically with local and/or systemic antifungal therapy, such as fluconazole or amphotericin B 2-7. If refractory to pharmacotherapy, fungal balls may be surgically removed 2-7.

Depending on the modality, the following may be considered:

Quiz questions



  • 1. Kobayashi CC, de Fernandes OF, Miranda KC, de Sousa ED, Silva Mdo R. Candiduria in hospital patients: a study prospective. (2004) Mycopathologia. 158 (1): 49-52. Pubmed
  • 2. Praz V, Burruni R, Meid F, Wisard M, Jichlinski P, Tawadros T. Fungal ball in urinary tract, a rare entity, which needs a specific approach. (2014) Canadian Urological Association Journal. 8 (1-2): e118. doi:10.5489/cuaj.1254 - Pubmed
  • 3. Erden A, Fitoz S, Karagülle T, Tükel S, Akyar S. Radiological findings in the diagnosis of genitourinary candidiasis. (2000) Pediatric Radiology. 30 (12): 875. doi:10.1007/s002470000351 - Pubmed
  • 4. Kale H, Narlawar RS, Rathod K. Renal fungal ball: an unusual sonographic finding. (2002) Journal of clinical ultrasound : JCU. 30 (3): 178-80. Pubmed
  • 5. Jegannathan D, Ramanathan K. Renal fungal ball-two case reports and review of literature. (2016) BJR case reports. 2 (3): 20150247. doi:10.1259/bjrcr.20150247 - Pubmed
  • 6. McDonald DF, Fagan CJ. Fungus balls in the urinary bladder: case report. (1972) American Journal of Roentgenology. 114(4):753-7. doi:10.2214/ajr.114.4.753
  • 7. Palacio-Bedoya F, Cadena JA, Thompson GR, Sutton DA, Owens AD, Patterson TF. A noninvasive renal fungus ball caused by Rhizopus--a previously unreported manifestation of zygomycosis. (2010) Medical mycology. 48 (6): 866-9. doi:10.3109/13693781003694796 - Pubmed
  • 8. Orlowski HLP, McWilliams S, Mellnick VM, Bhalla S, Lubner MG, Pickhardt PJ, Menias CO. Imaging Spectrum of Invasive Fungal and Fungal-like Infections. (2017) Radiographics : a review publication of the Radiological Society of North America, Inc. 37 (4): 1119-1134. doi:10.1148/rg.2017160110 - Pubmed
  • 9. Takemura K, Takazawa R, Kohno Y, Yoshida S, Kato H, Tsujii T. Vesical fungus balls (fungal bezoars) by mimicking urothelial carcinoma in a patient with diabetic neurogenic bladder. (2018) Urology case reports. 18: 50-51. doi:10.1016/j.eucr.2018.03.005 - Pubmed

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Renal fungal ball: an unusual sonographic finding

Fungal infections of the urinary tract tend to occur in the drainage structures instead of the renal parenchyma. In patients with systemic candidiasis, the kidney is vulnerable to the formation of cortical abscesses or obstructive intrarenal masses ("fungal balls"), usually at the ureteropelvic junction. We describe the case of a boy who presented with dysuria, fever, and chills. Sonographic examination showed mild enlargement of both kidneys and moderate dilatation of the pelvicaliceal system bilaterally. A well-defined, echogenic, oval, mobile mass measuring 2.5 x 2.0 cm, without posterior acoustic shadowing, was visualized in the pelvis of the left kidney. The upper and middle ureters were dilated bilaterally. A urine culture revealed hyphae of Candida albicans. The child received systemic antifungal therapy with fluconazole for 3 weeks. Follow-up sonography showed complete resolution of the mass (a fungal ball) with residual hydronephrosis.

Ultrasound Tutorial: Kidney \u0026 Bladder / Urinary Tract - Radiology Nation

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Ultrasound fungal ball kidney

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