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Renal lesions are rarely demonstrated on 18F- fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) in candidiasis.
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Renal lesions are often overlooked due to physiological urinary tracer excretion.
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Careful review is needed in oncology cases due to the risk of opportunistic infection.
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FDG PET/CT is a valuable problem-solving tool in cases of fever of unknown origin.
A 7-year-old boy with newly diagnosed B-cell acute lymphoblastic leukaemia on chemotherapy presented with fever of unknown origin (FUO). 18F- fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) showed abnormal FDG uptake with decreased enhancement in the cortex of the left kidney upper pole (Figure 1a) , which was distinct from the normal tracer activity in the medulla and collecting system. Urine cultures were positive for Candida tropicalis and Candida glabrata and consistent with fungal pyelonephritis. There was also increased FDG uptake in the lower oesophagus and lower lobes (Figure 1b). Cultures from oesophagoscopy and bronchoalveolar lavage were positive for C. tropicalis and C. glabrata, and antifungal treatment with intravenous caspofungin was commenced. Follow-up ultrasound over 1 month showed resolution of the hyper-echoic lesion in the left kidney upper pole (Figure 1c).
Figure 1a FDG PET/CT showing an FDG-avid lesion in the cortex of the left kidney upper pole (solid arrows), which is distinct from the normal tracer activity in the medulla and collecting system (dashed arrows). (b) FDG PET/CT also showing increased FDG uptake in the lower oesophagus and bilateral lower lobes (arrows). (c) Follow-up renal ultrasound over 1 month demonstrating resolution of the focal cortical swelling and increased echogenicity in the left kidney upper pole (arrow).
This case highlights the need to pay careful attention to the configuration of tracer excretion and correlate it with CT, so that lesions are not missed. This is especially pertinent in oncology patients in whom opportunistic infections often involve the kidneys. In invasive candidiasis, blood cultures are often negative despite the presence of deep-seated tissue infections, such as in the present patient.
In cases of FUO, FDG PET/CT is valuable in highlighting potential tissue sampling sites with the highest yield for cultures, allowing both diagnosis and susceptibility testing.
While the finding of increased FDG uptake in the kidneys is not specific, there may occasionally be morphological features on CT that point towards a fungal aetiology, such as the soft tissue filling defect of a fungus ball in the collecting system.
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