SESSION TITLE: Infectious Disease Global Case Reports
SESSION TYPE: Global Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: However it has been reported that pulmonary candidiasis is rare, when present in immunocompromised or critically ill patients, it is associated with considerable mortality. The most common computed tomography (CT) findings of pulmonary candidiasis have been reported as multiple bilateral nodules often associated with air-space consolidation . We present a rare case of pulmonary candidiasis presenting multiple cavitary lesions on chest CT.
CASE PRESENTATION: An 80-year-old man admitted to our hospital for the treatment of small bowel obstruction. Initial management involved nasogastric tube insertion and fluid resuscitation with central venous (CV) catheters. His small bowel obstruction did not resolve, and on the 8th day, he presented fever and hypoxemia. He had a history of stage 4 chronic kidney disease secondary to hypertensive nephrosclerosis for 15 years, and distal gastrectomy for gastric cancer 20 years ago. He did not have smoking history and risk factors for HIV infection, and drank alcoholic beverages occasionally. Physical examination revealed poor oral hygiene only. The chest x-ray revealed multiple nodules in the right upper lung field and mixed ground-glass and airspace opacities in the entire right lung. The chest CT scan showed multiple small cavitary lesions and nodules with surrounding ground-glass opacity, and also bilateral pleural effusion. Examination of sputum showed no predominant pathogen and no acid-fast organisms on staining. Laboratory test revealed elevated serum β-D-glucan (483pg/ml, normal, < 20pg/ml), positive serum Candida antigen latex agglutination test, and negative serum Aspergillus galactomannan antigen test. Two sets of blood culture specimens were drawn on the 8th day which yielded Candida albicans. Transbronchial biopsy and bronchial washings of the cavitary lesion in the right upper lobe were performed, however, non-specific inflammation of the lung tissue without any bacteria was revealed. The patient was diagnosed as pulmonary candidiasis. Therefore, potentially contaminated CV catheter was removed and antifungal therapy with intravenous fluconazole was started. The patient became afebrile after the 3rd day of the initiation of antifungal therapy, and blood culture of the same day did not yield any organisms. The treatment was continued for three weeks, and on the 15th day of antifungal therapy, the chest CT findings showed remarkable improvement.
DISCUSSION: The few available studies indicate that pulmonary candidiasis is seen in no greater than 0.2 to 8.0 % of at-risk ICU patients and cancer patients . The most common CT findings were reported as multiple bilateral nodules often associated with air-space consolidation. These findings are nonspecific and the differentiation of other fungal infections (especially, aspergillosis) is difficult. However, it was reported that cavitary lesions were less common in pulmonary candidiasis than in aspergillosis . Multiple cavitary lesions seen in our patient were rare, and precluded differential diagnosis of pulmonary candidiasis from other fungal infections.
CONCLUSIONS: Multiple cavitary lesions are rare CT manifestation of pulmonary candidiasis. When there is a risk of invasive candidiasis, such as central venous catheter and parenteral nutrition, we should consider invasive candidiasis from those findings. We believe that our case will add to our understanding and recognition of the spectrum of this rare condition.
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Reference #3: Althoff Souza C, Müller NL, Marchiori E, Escuissato DL, Franquet T. Pulmonary invasive aspergillosis and candidiasis in immunocompromised patients: a comparative study of the high-resolution CT findings: J Thorac Imaging. 2006; 21: 184-189.
DISCLOSURE: The following authors have nothing to disclose: Yuichiro Yasuda, Kazunori Tobino, Kosuke Tsuruno, Mina Asaji, Keisuke Anan, Yoshikazu Yamaji, Noriyuki Ebi
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