PMC6243339_01
Ultrasonogram (a) and colour Doppler (b) images of the right kidney showing an isoechoic lesion (white arrows) in the renal pelvis with a peripheral rim of calcification and absence of vascularity.
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The patient was referred for ultrasonogram (USG) of the abdomen, which showed a predominantly hypoechoic lesion in the dilated right renal pelvis with specks of echogenic foci in the periphery (Figure 1a). It did not show any colour flow (Figure 1b) on Doppler study.
Plain CT scan axial (a) and sagittal (b) reconstruction showing an isodense mass lesion with a peripheral rim of calcification in the dilated renal pelvis.
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Plain CT imaging of the abdomen (Figure 2a,b) confirmed the presence of right renal pelvic dilatation with an isodense intraluminal lesion in the renal pelvis with tiny peripheral calcifications.
Contrast-enhanced CT images. (a) Nephrogram phase shows no enhancement of the lesion; subtle wall enhancement of the ureter is seen. (b) Delayed coronal reconstructed image shows contrast-filled urine all around the lesion.
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On contrast-enhanced CT scan (Figure 3a), a thin rim of ureteric wall enhancement was seen. Coronal contrast-enhanced CT image (Figure 3b) showed contrast outlining of the lesion, with no attachment of the lesion to the renal pelvic wall.
MR urogram (a) shows signal void within the dilated renal pelvis and axial T2 sequence (b) shows a hypointense lesion in the renal pelvis surrounded by hyperintense urine. Coronal T2 sequence (c) showing the contracted right kidney with the lesion in the renal pelvis mimicking a staghorn calculus.
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MRI urogram (Figure 4a) showed a ballooned out renal pelvis with filling defect mimicking a calculus or mass and normal calibre ureter below. In axial short tau inversion-recovery sequence (Figure 4b), the lesion in the renal pelvis appears isointense with a peripheral rim of hypointensity that was surrounded by a rim of urine (hyperintense line all around the lesion). T2 sequence (Figure 4c) confirms that the renal pelvic wall is seen separate from the lesion.
Post-endourological procedure specimen (a) showing bits of extracted tissues; microscopic picture (b) showing large pseudomycelia of coelomyecetes.
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Endourologically extracted bits of tissue (Figure 5a) sent for culture and microscopy (Figure 5b) showed hyphae of coelomyecetes.
PMC6243339_02
(a-c) Plain CT axial section showing multiple well-defined isodense oval lesions within the renal pelvis interspersed with air pockets and significantly thinned out renal parenchyma. (d) One of the lesions projects from the anterior wall (arrow).
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Plain CT scan of the abdomen (Figure 6a-d) showed significant air collection in the renal collecting system. One of those lesions was seen projecting from the anterior non-dependent wall (arrow in Figure 6d).
Nephrectomy specimen cut open showing thinned out renal cortex and renal pelvis completely studded with fungal ball.
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The cut-open nephrectomy specimen showed multiple fungal balls (Figure 7).