The patient is a 68-year-old man with type 2 diabetes for 10 years. His current diabetes therapy consists of insulin glargine injection 25 units in the evening and metformin 1000 mg twice daily. The patient had been on canagliflozin and dulaglutide in the recent past. Insulin glargine injection was started 1 week prior to hospital admission per his home endocrinologist to improve glycemic control. Canagliflozin and dulaglutide were initiated in the last year but were discontinued at the time of insulin initiation. The patient reported a 20-pound weight loss in the last year since starting on canagliflozin and dulaglutide, and he was experiencing persistent fungal infections. His A1c on hospital admission is noted to be elevated at 11.5%.

Prior to hospital admission, the patient saw a local urologist to evaluate funguria. CT scan showed right hydroureteronephrosis. The urologist attempted right retrograde stent placement but was unable to cannulate the right ureteral orifice. Eventually, a ureteroscope was inserted, and there was a blind-ending ureteral orifice per the operative report from the outside urologist. A nephrostomy tube was never placed. The patient was discharged on another 2-week course of fluconazole, again with no improvement. An ultrasound 2 weeks later revealed persistent right hydroureteronephrosis and mobile debris.

The patient is now seeking care at this institution to further evaluate this persistent funguria, increased right flank pain, and new-onset intermittent fevers. On hospital admission, a percutaneous nephrolithotomy was performed. A stone was extracted and later determined to be a fungal ball.

Blood Glucose Monitoring

Since starting insulin therapy, the patient has begun metering glucose values once daily in the morning. According to a review of the record book, his glucose values average 193 to 310 mg/dL since changes were made to his diabetes medication regimen.

Diet/Exercise

The patient reports that he has been making an effort to stay consistent with carbohydrate intake with meals, eating 3 meals per day. He has not been obtaining regular exercise in the last 3 months.