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Graeter A, Lee D, Handley G, Baluch A, Klinkova O. Chronic disseminated candidiasis in a patient with acute leukemia - an illustrative case and brief review for clinicians. BMC Infect Dis 2024; 24:296. [PMID: 38448809 PMCID: PMC10916012 DOI: 10.1186/s12879-024-09172-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 02/24/2024] [Indexed: 03/08/2024] Open
Abstract
Chronic disseminated candidiasis (CDC) is a severe but rarely seen fungal infection presenting in patients with hematologic malignancies after a prolonged duration of neutropenia. A high index of suspicion is required to diagnose CDC as standard culture workup is often negative. While tissue biopsy is the gold standard of diagnosis, it is frequently avoided in patients with profound cytopenias and increased bleeding risks. A presumptive diagnosis can be made in patients with recent neutropenia, persistent fevers unresponsive to antibiotics, imaging findings of hypoechoic, non-rim enhancing target-like lesions in the spleen and liver, and mycologic evidence. Here, we describe the case of an 18-year-old woman with relapsed B-cell acute lymphoblastic leukemia treated with re-induction chemotherapy who subsequently developed CDC with multi-organ involvement. The diagnosis was made based on clinical and radiologic features with positive tissue culture from a skin nodule and hepatic lesion. The patient was treated for a total course of 11 months with anti-fungal therapy, most notably amphotericin B and micafungin, and splenectomy. After initial diagnosis, the patient was monitored with monthly CT abdomen imaging that showed disease control after 5 months of anti-fungal therapy and splenectomy. The diagnosis, treatment, and common challenges of CDC are outlined here to assist with better understanding, diagnosis, and treatment of this rare condition.
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Affiliation(s)
- Allison Graeter
- Department of Internal Medicine, University of South Florida, 17 Davis Blvd., Suite 308, 33606, Tampa, FL, USA
| | - Dasom Lee
- Division of Hematology, Stanford University, 94305, Stanford, CA, USA
| | - Guy Handley
- Department of Infectious Disease and International Medicine, 1 Tampa General Circle, 33606, Tampa, FL, USA
| | - Aliyah Baluch
- Infectious Disease Division, Moffitt Cancer Center, 12902 USF Magnolia Drive, 33612, Tampa, FL, USA
| | - Olga Klinkova
- Infectious Disease Division, Moffitt Cancer Center, 12902 USF Magnolia Drive, 33612, Tampa, FL, USA.
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Cohen N, Orenbuch-Harroch E, Olshtain-Pops K, Lachish T, Korem M. Epidemiology, Clinical Characteristics and Risk Factors for Severity of Chronic Disseminated Candidiasis in Jerusalem, Israel. Mycopathologia 2023; 188:873-883. [PMID: 37326819 DOI: 10.1007/s11046-023-00755-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/25/2023] [Indexed: 06/17/2023]
Abstract
Chronic disseminated candidiasis (CDC) occurs mostly in patients with acute hematologic malignancy and its clinical manifestations derive from immune reconstitution following neutrophil recovery. The aim of this study was to describe epidemiological and clinical characteristics of CDC and define risk factors for disease severity. Demographic and clinical data were collected from medical files of patients with CDC hospitalized in two tertiary medical centers in Jerusalem between 2005 and 2020. Associations between different variables and disease severity were evaluated, as well as characterization of Candida species. The study included 35 patients. CDC incidence slightly increased during study years and the average number of involved organs and disease duration was 3 ± 1.26 and 178 ± 123 days, respectively. Candida grew in blood in less than third of cases and the most common isolated pathogen was Candida tropicalis (50%). Histopathological or microbiological workup in patients who underwent an organ biopsy demonstrated Candida in about half of the patients. Nine months after starting antifungals, 43% of the patients still didn't have resolution of organ lesions in imaging modalities. Factors associated with protracted and extensive disease were prolonged fever prior to CDC and absence of candidemia. A C- Reactive Protein (CRP) cutoff level of 7.18 mg/dL was found to predict extensive disease. In conclusion, CDC incidence is increasing and the number of involved organs is higher than previously described. Clinical factors such as fever duration prior to CDC and absence of candidemia can predict severe course of disease and assist in treatment decisions and follow-up planning.
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Affiliation(s)
- Nerel Cohen
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Medical Corps, Israel Defense Forces, Ramat-Gan, Israel
| | - Efrat Orenbuch-Harroch
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Medical Intensive Care Unit, Hadassah Medical Center, Jerusalem, Israel
| | - Karen Olshtain-Pops
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Center, P.O. Box 12000, 9112102, Jerusalem, Israel
| | - Tamar Lachish
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Infectious Diseases Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Maya Korem
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
- The Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Center, P.O. Box 12000, 9112102, Jerusalem, Israel.
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Chen CY, Cheng A, Tien FM, Lee PC, Tien HF, Sheng WH, Chen YC. Chronic disseminated candidiasis manifesting as hepatosplenic abscesses among patients with hematological malignancies. BMC Infect Dis 2019; 19:635. [PMID: 31315582 PMCID: PMC6637637 DOI: 10.1186/s12879-019-4260-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 07/04/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The outcomes of deep-seated abscesses attributed to chronic disseminated candidiasis (CDC) in patients with hematological malignancies have rarely been reported in recent years. METHODS We retrospectively reviewed and analyzed the data of patients with hematological malignancies who received a diagnosis of CDC at a medical center in Taiwan between 2008 and 2013. RESULTS Sixty-one patients (32 men and 29 women) were diagnosed with CDC. The median age was 51 years (range: 18-83). The overall incidence of CDC was 1.53 per 100 patient-years in patients with hematological malignancies between 2008 and 2013. The highest incidence of CDC was 4.3 per 100 patient-years for acute lymphoblastic leukemia, followed by 3.6 for acute myeloid leukemia. We detected 3 (4.9%) proven, 13 (21.3%) probable, and 45 (73.8%) possible cases of CDC. A total of 13 patients had positive blood cultures for Candida species: C. tropicalis (8), C. albicans (2), C. glabrata (2), and C. famata (1). The median duration of antifungal treatment was 96 days (range: 7-796 days). Serial imaging studies revealed that the resolution rate of CDC was 30.0% at 3 months and 54.3% at 6 months. Five patients (8.2%) had residual lesions that persisted beyond one year. A multivariate analysis of the 90-day outcome revealed that shock was the only independent prognostic factor of 90-day survival in patients with CDC. CONCLUSION The incidence of CDC did not decrease between 2008 and 2013. Patients with acute leukemia had a higher risk of CDC than those with other hematological malignancies. Imaging studies conducted at 6 months after diagnosis revealed that only half of the patients showed complete resolution. CDC requires prolonged treatment, and serial imaging at 6 months interval is suggested. Shock is the only independent prognostic factor of 90-day survival in patients with CDC.
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Affiliation(s)
- Chien-Yuan Chen
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan.
| | - Aristine Cheng
- Division of Infectious Disease, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Feng-Ming Tien
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan.,Tai-Cheng Stem Cell Center, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, Taiwan
| | - Po-Chu Lee
- Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.,Department of Trauma, National Taiwan University Hospital, Taipei, Taiwan
| | - Hwei-Fang Tien
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan.,Department of Medicine, National Taiwan University, College of Medicine, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Wang-Huei Sheng
- Division of Infectious Disease, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan. .,Department of Medicine, National Taiwan University, College of Medicine, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan.
| | - Yee-Chun Chen
- Division of Infectious Disease, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Medicine, National Taiwan University, College of Medicine, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan
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van Prehn J, Menke-van der Houven van Oordt CW, de Rooij ML, Meijer E, Bomers MK, van Dijk K. Hepatosplenic Candidiasis Without Prior Documented Candidemia: An Underrecognized Diagnosis? Oncologist 2017; 22:989-994. [PMID: 28469041 PMCID: PMC5553951 DOI: 10.1634/theoncologist.2017-0019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 02/16/2017] [Indexed: 11/27/2022] Open
Abstract
Hepatosplenic candidiasis (HSC) often occurs without prior documented candidemia. Underrecognized HSC can be mistaken for metastases and can have serious consequences for patients, especially when additional, inappropriate treatment, such as surgery and chemo‐ or immunotherapy, is initiated. To emphasize the importance of diagnosing HSC without prior documented candidemia, three illustrative cases and a review of the literature on HSC and candidemia are presented. Introduction. Patients with a history of chemotherapy or stem cell transplantation (SCT) and prolonged neutropenia are at risk for hepatic and/or splenic seeding of Candida. In our experience, hepatosplenic candidiasis (HSC) without documented candidemia often remains unrecognized. Case presentations. We describe three cases of HSC without documented candidemia and the challenges in establishing the diagnosis and adequately treating this condition. The first patient had a history of SCT for treatment of breast cancer and was scheduled for hemihepatectomy for suspected liver metastasis. A second opinion at our institute resulted in the diagnosis of hepatic candidiasis without prior documented candidemia, for which she was treated successfully with fluconazole. The second case demonstrates the limitations of (blood and tissue) cultures and the value of molecular methods to confirm the diagnosis. Case 3 illustrates treatment challenges, with ongoing dissemination and insufficient source control despite months of antifungal therapy, eventually resulting in a splenectomy. Literature review. A structured literature search was performed for articles describing any patient with HSC and documented blood culture results. Thirty articles were available for extraction of data on candidemia and HSC. Seventy percent (131/187) of patients with HSC did not have documented candidemia. The majority of HSC events were described in hematologic patients, although some cases were described in patients with solid tumors treated with SCT (n = 1) or chemotherapy and a history of leukopenia (n = 2). Current guidelines and practices for diagnosis and treatment are described. Conclusion. Clinicians should be aware that HSC most often occurs without documented candidemia. In case of persistent or unexplained fever or lesions in the liver and/or spleen, a history of neutropenia should place disseminated candidiasis in the differential diagnosis. HSC is not limited to hematological patients and may occur in patients with solid tumors treated with bone marrow‐suppressing chemotherapy or SCT. In the latter group, HSC as alternative diagnosis for hepatic metastasis should be considered when lesions are not typical for metastasis. This might prevent unnecessary surgery or inappropriate treatment. Implications for Practice. Timely diagnosis of hepatosplenic candidiasis (HSC) is challenging, but can prevent further complications and dissemination, and may even prevent unnecessary invasive procedures. Clinicians should realize that HSC often occurs without documented candidemia and that sensitivity of blood cultures for candidemia is limited. HSC is not strictly limited to hematologic patients and might also occur in patients with solid tumors treated with intensive chemotherapy or stem cell transplantation. Increased awareness for HSC in patients with any history of neutropenia is of importance to increase detection and prevent serious sequelae.
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Affiliation(s)
- Joffrey van Prehn
- Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Madelon L de Rooij
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Ellen Meijer
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Marije K Bomers
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Karin van Dijk
- Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, The Netherlands
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Abstract
Hepatosplenic candidiasis is a fungal infection, which mostly affects patients with hematologic malignancies such as leukemia. The pathogenesis of this infection is not clear yet, and the liver is the most commonly affected organ. Diagnosis of hepatosplenic candidiasis can be only established via biopsy, since computed tomography (CT) scan, ultrasonography, and magnetic resonance imaging (MRI) yield non-specific results. The role of fluorine-18 fluorodeoxyglucose positron emission tomography /computed tomography (18F-FDG PET/CT) in diagnosis of hepatosplenic candidiasis remains undetermined, considering a few evidences in the literature. In this case report, we present the case of a 47-year-old patient, affected by acute myeloid leukemia, which was treated with three cycles of chemotherapy, resulting in the development of neutropenia and fever following the last cycle. The 18F-FDG PET/CT scan showed some foci of intense FDG uptake in the liver and spleen. The subsequent diagnostic investigations (i.e., abdominal CT scan and biopsy) were suggestive of hepatosplenic candidiasis. The patient was started on antifungal treatment with fluconazole. After one month, the clinical conditions were resolved, and the subsequent abdominal CT scan was negative.
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Affiliation(s)
| | - Giovanni Bosio
- Nuclear Medicine, Spedali Civili di Brescia, Brescia, Italy
| | - Mattia Bertoli
- Nuclear Medicine, Spedali Civili di Brescia, Brescia, Italy
| | - Giulia Petrilli
- Department of Molecular and Translational Medicine, Anatomic Pathology Section, Spedali Civili di Brescia, Brescia, Italy
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