Correspondence

A Potential Hazard of Prolonged Insertion of an Intrauterine Device

N Engl J Med 1994; 330:1395May 12, 1994

Article

To the Editor:

We report the occurrence of Candida albicans fungemia in a 70-year-old woman that was associated with an intrauterine contraceptive device that had been in place for 28 years.

The woman had a six-month history of non-insulin-dependent diabetes, controlled by diet. She presented with confusion, fever, hyperglycemia, and anuria. Initial examination suggested no focus of infection apart from a copious vaginal discharge containing blood. An intrauterine device was seen on x-ray examination. The white-cell count was 16,700 per cubic millimeter; glucose, 47.5 mmol per liter; sodium, 118 mmol per liter; and creatinine, 7.06 mg per deciliter (624 μmol per liter). Hemoglobin, platelets, potassium, and bicarbonate were all normal.

Septicemia with secondary acute renal failure and uncontrolled diabetes was diagnosed. Treatment included intravascular volume replacement, broad-spectrum antibiotics, and insulin. In addition, fluconazole was started1.

C. albicans was isolated from blood, urine, and vaginal-swab cultures. Anuria persisted. Ultrasound examination showed right hydronephrosis and hydroureter and a normal-sized, unobstructed left kidney. Hemodialysis was started. Cystourethroscopy and retrograde pyelography confirmed the hydronephrosis and hydroureter, which were possibly congenital. Soft, whitish particles were seen in the lower right ureter. Bilateral double-J stents were placed, and an incomplete intrauterine device was removed. The patient recovered. Dialysis was no longer necessary, and the diabetes was again controlled by diet. The ureteric stents were removed.

A Lippes loop had been inserted some 28 years earlier, 5 years before the patient's menopause. At the time of the insertion, she was healthy. The patient assumed that the intrauterine device had come out, because she had seen a fragment during menstrual bleeding. The Lippes loop is a plastic device no longer used in the United Kingdom or the United States. Currently available intrauterine devices containing copper should be changed after five years and removed at menopause2. (The Paragard T380A intrauterine copper contraceptive is marketed in the United States. According to the manufacturer, GynoPharma of Somerville, New Jersey, it must be replaced by the end of the eighth year of use).

In this case, we believe the intrauterine device, the patient's mild diabetes,3 and the asymptomatic hydroureter combined to produce major illness4,5.

Sarah Wyatt, M.R.C.P.
Ian W. Gallen, M.D.
Anthony Nicholls, F.R.C.P.
Royal Devon and Exeter Hospital, Exeter EX2 4RE, United Kingdom

5 References

1. 1

   Graninger W, Presteril E, Schneeweiss B, Teleky B, Georgopoulos A. Treatment of Candida albicans fungaemia with fluconazole. J Infect 1993;26:133-146
   CrossRef | Web of Science | Medline

2. 2

   Newton J, Tacchi D. Long-term use of copper intrauterine devices. Lancet 1990;335:1322-1323
   CrossRef | Web of Science | Medline

3. 3

   Hostetter MK. Handicaps to host defense: effects of hyperglycemia on C3 and Candida albicans. Diabetes 1990;39:271-275
   CrossRef | Web of Science | Medline

4. 4

   Michigan S. Genitourinary fungal infections. J Urol 1976;116:390-397
   Web of Science | Medline

5. 5

   Fisher JF, Chew WH, Shadomy S, Duma RJ, Mayhall CG, House WC. Urinary tract infections due to Candida albicans. Rev Infect Dis 1982;4:1107-1118
   CrossRef | Medline