Fungal Infection of Prostate Mimicking

Prostate Cancer

Jinxing Yu, MD

Professor of Radiology & SurgeryDirector of Prostate Imaging & Intervention

Virginia Commonwealth UniversityRichmond

History

Ø 56 years old with Diabetes

Ø Had chronic urinary retention requiring Foley

catheter

Ø PSA level of 4.5 ng/mL

Ø Never have prior TRUS-guided prostate biopsy

Ø Presented to VCU for mpMRI at 3T without

endorectal coil (Fig. 1)

ADC Coronal T2 Axial T2 DCE

B

Fig. 1 – A) ADC demonstrates a large mass (arrows) involving the left side of prostate extending to the right, mimicking prostate cancer. B) and C) Axial and coronal T2 show a large slightly high T2 signal intensity mass (arrows) surrounding the urethra (arrowhead). Bladder (B) is noted. D) DCE shows only peripheral enhancement of the mass (arrows), making the tumor unlikely. The patient underwent US/MRI fusion guided biopsy of the mass and histology confirmed 95% necrosis with fungal forms (Candida). No prostate cancer was found.

Fig. 1 – E) Axial T2 shows significant decrease in size of the mass (arrows). F) DCE shows marked decrease in size of the peripheral enhanced mass (arrows). The patient was discharged home.

After treatment with Fluconazole, 2 weeks later

Axial T2 DCE

Teaching Points

Ø Infections of the prostate caused by fungi are unusual in urologic practice

Ø It likely occurs in patients whose immune status is compromised by disease or medication

Ø The physicians must be cognizant of fungal infections that involve the prostate gland for many reasons. Fungal prostatitis

Ø Can cause lower urinary tract symptoms, mimic prostate cancer

Ø Can co-exist with prostate cancer

Ø Can be a harbinger of systemic infection

Ø Candida urinary infections can be associated with a variety of clinical conditions that include pyelonephritis, renal function accretions associated with obstructive uropathy, and cystitis

Teaching Points at Mp-MRIØ Fungal infection of prostate may demonstrate a soft tissue mass with diffusion

restriction in the prostate as seen in our case, mimicking prostate cancer

Ø The key imaging feature that helps to make a distinction is the enhancement of the mass - only peripheral enhanced

Ø Therefore, fungal infection of prostate has a similar imaging feature as TB granulomatous prostatitis (Fig. 2) – at DCE the lesion (arrow) only had minimal enhancement (arrowhead)

Fig.2 - Sagittal T2 ADC DCE

ReferencesØ Yu S, Provet J: Prostatic abscess due to Candida tropicalis in a nonacquired

immunodeficiency syndrome patient. J Urol 1992, 148:1536–1538.

Ø Lentino JR, Zielinski A, Stachowski M, et al.: Prostatic abscess due to Candida albicans. J Infect Dis 1984, 149:282

Ø Elert A, von Knobloch R, Nusser R, et al.: Isolated candidal prostatitis. J Urol2000, 163:244

Ø Williamson MR, Smith AY, Black WC, Rosenberg RD: Diagnosis of candidalinfection of the prostate by transrectal ultrasonography and biopsy. J Clin Ultrasound 1992, 20:618–620

Ø Yu J, Ann S. Fulcher, Mary Ann Turner, Charles Cockrell, Eric P. Cote, Timothy J. Wallace. Prostate Cancer and Its Mimics at Multiparametric Prostate MRI. British Journal of Radiology (BJR), May, 2014

Ø Nirjhor M. Bhowmik, MD; Yu J, MD; Ann S. Fulcher, MD; Mary A. Turner, MD. Benign Causes of Diffusion Restriction Foci in the Peripheral Zone of the Prostate: Diagnosis and Differential Diagnosis. Abdominal Imaging, April, 2016