INTRODUCTION: Pulmonary fungal infections and empyema thoracis are emerging clinical entities. According to the CDC national database, Candida species has become the 6th most common cause of nosocomial infections (7.2 %). Of all Candida infections, C.albicans and C.tropicalis account for the bulk of these infections (85%). Candida lusitaniae is an extremely rare but emerging nosocomial infection. We describe a 55-year-old female who was found to have bronchioloalveolar carcinoma and coexistent C. lusitaniae pleuropulmonary infection.
CASE PRESENTATION: A 55-year-old African-American actively smoking female presented with a three week history of cough, whitish sputum production and shortness of breath. Her past medical history was significant for Type 2 diabetes, recently treated COPD exacerbation with corticosteroids, untreated Hepatitis C and remote intravenous drug abuse (30 years ago). Her physical exam revealed a thin female (BMI 18) with crackles and decreased breath sounds over the right lower lobe. Radiographic studies identified a right middle and right lower lobe infiltrate with associated pleural effusion, which had worsened when compared to a chest X-ray done in 2007. High resolution computed tomography (HRCT) revealed right-sided pleural effusion with associated bilateral reticular opacities primarily in the right lung field associated with marked irregular septal thickening and small cystic air spaces. An ultrasound-guided thoracentesis revealed a serosanguinous exudative effusion with 85% lymphocytes. Despite adequate antibiotic coverage for health care associated pneumonia, her condition deteriorated requiring transfer to the Intensive Care Unit. She was intubated for worsening shortness of breath. A fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) and brushing was performed. Pleural fluid and BAL specimens sent four days apart grew C. lusitaniae. Blood cultures were sterile. Cytopathology revealed adenocarcinoma of bronchioloalveolar cell type in BAL, brushing and pleural fluid.
DISCUSSIONS: Review of the literature identified certain risk factors for pleural fungal infections, all of which were present in our patient. These include malignancy, diabetes, recent corticosteroid use, and active smoking. The diagnosis of saprophytic fungal bronchopulmonary infections is difficult to confirm, as sputum and to some extent BAL specimens are unreliable. Our patient grew Candida lusitaniae in both BAL and pleural fluid confirming the diagnosis. C. lusitaniae infection primarily presents as fungal sepsis or candidemia. It is extremely rare to isolate fungi in pleural fluid (11 % in one study of 140 patients with pulmonary fungal infections). An extensive literature review in multiple databases showed that this is probably the first reported case of C.lusitaniae pleuropulmonary infection, and possibly the first fungal pleuropulmonary infection coexisting with bronchioloalveolar carcinoma.
CONCLUSION: With increasing numbers of immunocompromised patients due to prolonged survival in HIV/AIDS patients, overall improvement in management strategies for cancer patients, and use of immunosuppressive medications, the recognition of this pathogen as a source for emerging nosocomial infections is very important. This organism is frequently resistant to amphotericin B (one of the only 3 candida species resistant to this drug); therefore appropriate initial antifungal therapy is potentially lifesaving. After six days of intravenous fluconazole our patient was successfully extubated and clinically stable.
DISCLOSURE: Ashish Tikotekar, No Financial Disclosure Information; No Product/Research Disclosure Information