30 May 2022: Articles
An Atypical Source of Persistent Fungemia in the Intensive Care Unit
Unknown etiology, Challenging differential diagnosis, Unusual or unexpected effect of treatment, Rare disease
Alexandra Wiggins1BEF*, Raju Reddy 2BCDEFDOI: 10.12659/AJCR.936223
Am J Case Rep 2022; 23:e936223
Abstract
BACKGROUND: Candidemia is a common complication of critically ill and immunocompromised patients, with more than 50% associated mortality. Typical etiologies include valvular vegetations, intra-abdominal fluid collections, and central venous catheters. Treatment often entails surgical excision, but anticoagulation may be sufficient.
CASE REPORT: Our case was a 63-year-old woman with diabetes mellitus, left hip osteoarthritis status after hemiarthroplasty, and alcohol use disorder, admitted to the Intensive Care Unit with diabetic ketoacidosis (DKA) and hemorrhagic shock from an upper gastrointestinal bleed. Complicating her course was the development of Candida species fungemia. An extensive workup including transthoracic echocardiography, computed tomography of the chest, abdomen, and pelvis, ocular examination, and hip aspiration was unrevealing in determining the etiology. Despite early line removal and appropriate antifungal therapy, the fungemia persisted. A broader evaluation revealed a venous thromboembolism, which ultimately was thought to be the source. Subsequent initiation of anticoagulation and continued antifungal therapy led to clearance of blood cultures with overall clinical improvement.
CONCLUSIONS: In critically ill patients at higher risk for development of venous thromboembolism, septic thrombi should be considered in the differential diagnosis when evaluating for source control in a patient with fungemia.
Keywords: candidemia, Shock, Septic, Thrombophlebitis, Anticoagulants, Antifungal Agents, Candidiasis, Critical Illness, Diabetic Ketoacidosis, Female, Humans, Intensive Care Units, Middle Aged, venous thromboembolism
Background
Case Report
Our patient was a 63-year-old woman with alcohol use disorder, type 2 diabetes mellitus, hypertension, and chronic pancreatitis complicated by a pseudocyst, who was admitted to the ICU for mixed hemorrhagic/distributive shock in the setting of acute gastrointestinal bleed and diabetic ketoacidosis. On presentation to an outside hospital, she was reportedly lethargic with declining responsiveness, hypothermic to 32.4°C, and hypotensive with a blood pressure of 52/33 millimeters of mercury (mmHg). Initial laboratory test results revealed hemoglobin of 13 grams/deciliter (g/dL), glucose greater than 1500 milligrams/deciliter (mg/dL) with a beta-hydroxybutyrate greater than 22.50 millimoles per liter (mmol/L), creatinine of 3.55 mg/dL (with a baseline of 0.7–0.8 mg/dL), blood urea nitrogen (BUN) of 101 mg/dL, bicarbonate of 5 mmol/L, and pH of 7.01 on arterial blood gas. Her outside hospital course was complicated by large-volume hematemesis requiring 2 units of packed red blood cells, intubation for airway protection, and subsequent placement of a right internal jugular vein central line. She was then started on insulin and pantoprazole drips, given 1 dose of 2 g of intravenous (i.v.) ceftriaxone, and transferred to our hospital for further management.
On arrival at our hospital, she was afebrile, tachycardic to 120 beats per minute (bpm), maintaining a mean arterial pressure of 90/60 mmHg with a norepinephrine infusion at 0.3 microgram/kilogram/minute, and vasopressin infusion at 0.03 units/minute. Initial laboratory test results on arrival revealed a pH of 7.21 with a bicarbonate of 22 mmol/L based on arterial blood gas. Her glucose was 902 mg/dL, anion gap of 28 mmol/L with a potassium of 3.7 mmol/L, a BUN of 84 mg/dL, and a creatinine of 2.47 mg/dL. Other pertinent laboratory test results included a lipase of 69 units per liter (U/L), C-reactive protein of 262 milligrams per liter (mg/L), sedimentation rate of greater than 120 millimeters per hour (mm/h), undetectable ethanol, hemoglobin of 15 g/dL with platelets of 165 000 per cubic millimeter (cu mm), and white blood cell count of 3300 per cu mm. Given her degree of critical illness, an infectious diseases workup was initiated after obtaining blood, sputum, and urine cultures. A chest X-ray showed increased bilateral lower lung predominant patchy opacities. She remained on norepinephrine, vasopressin, and insulin drips and was started on broad-spectrum antimicrobial coverage with piperacillin/tazobactam.
On hospital day 1, her blood cultures returned positive for
Discussion
Invasive candidiasis is often fatal unless caught early and treated appropriately. Complicating a prompt diagnosis is the variety of clinical presentations, low yield of blood cultures, and the time it takes for fungal speciation. The presentation can vary from fever and leukocytosis to overt septic shock and can be missed unless accessible to involved tissue, or positive blood cultures. Our case highlights the importance of broad work-up when it comes to diagnosis and the difficulties encountered when the location challenges the ability to obtain proper source control.
A study done in Europe found the incidence of ICU-acquired invasive candidiasis to be 7.07 episodes per 1000 ICU admissions [1]. However, there is limited literature on infected thrombi as a source of persistent fungemia, noting as of 2012 that there had only been 24 reports of well-documented cases in the 30 years prior [6]. In a case series of 46 patients with suspected CVC-related septic thrombophlebitis, a mere 5 (11%) cases were due to
Over the years, recommendations for the treatment of
Several years later, Sung-ching Pan and colleagues published a case report in 2005 describing a patient with
Finally, the impact of this condition raises the question of whether prophylaxis is warranted. The EMPIRICUS trial looked at this exact question, assessing critically ill adults who were mechanically ventilated with known
Conclusions
Our case highlights a rare etiology of fungemia. The presence of appropriate risk factors and persistent fungemia despite the removal of lines, ruling out other sources of infection such as intra-abdominal fluid collection, and use of appropriate anti-fungals should prompt the clinician to assess rare sources of infection such as infected thrombi.
References:
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10.. Pan SC, Hsieh SM, Chang SC: Med Mycol, 2005; 43(8); 731-34
11.. Pappas PG, Kauffman CA, Andes DR, Clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of America: Clin Infect Dis, 2016; 62(4); e1-e50
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