[Recurrent Candida sepsis with prolonged respiratory failure and severe liver dysfunction]

Systemic mycoses, especially pulmonary diseases and septicemia are observed increasingly at intensive care units. Essential risk factors for development of candidosis are the expanded use of antibiotics and immunocompromised patients, caused either as a result of a severe underlying disease or iatrogenically induced after organ transplantation. Candida albicans is the most frequent pathogen in microbiological findings. Blood cultures are only positive in massive fungemia. We report a 50-year-old patient with recurrent Candida-septicemia: rupture of the distal esophagus after dilatation because of cardiac achalasia with mediastinal emphysema and mediastinitis. Severe acute respiratory distress syndrome after aspiration with septic shock and acute renal failure at the beginning. Long-term mechanical ventilation, continuous renal replacement therapy and multifarious antibiotic therapy. Early microbiological samples of several positive blood cultures and bronchoalveolar lavages revealed the presence of Candida albicans. In the further clinical course, detection of Pseudomonas species in bronchoalveolar lavages and Staphylococci as well as Enterococci in a number of positive blood cultures. Later on development of a severe liver dysfunction with test results that showed an intrahepatic cholestasis. Because of coagulation failure commencement of artificial liver support with the MARS-system (molecule adsorbent recirculating system). Decrease of high bilirubin levels was accompanied by improvement of clinical condition of the patient. In the following course, repeated severe systemic infections with phases of septicemia or rather septic shock and detection of Candida in several positive blood cultures and bronchoalveolar lavages. In each case increasing bilirubin levels with signs of intrahepatic cholestasis and each time improvement with antimycotic therapy (voriconazol, caspofungin and fluconazol). The patient showed more and more signs of immunodeficiency in the sequel. The clinical appearance of candidosis is manifold. Systemic Candida infections are frequent in patients with immunodeficiency. A recurrent Candida septicemia with prolonged respiratory failure and severe liver dysfunction in form of cholestatic hepatosis, that improved several times with antimycotic therapy in combination with evidence based intensive care measures and artificial organ support is a comparatively rare event.

[Pulmonary zygomycosis--a rare angioinvasive fungal infection]

Zygomycosis caused by Rhizopus species is an aggressive and rapidly progressive opportunistic fungal infection in immunocompromised patients. It comprises mucocutaneous, rhinocerebral, pulmonary, urological and disseminated infections. Predisposing factors are immunosuppression owing to severe diseases, immunological defects or metabolic disturbances like diabetic ketoacidosis. Rhizopus infections are characterized by angioinvasive growth, necroses of infected tissue and perineural invasion. The histopathologic demonstrable invasion of blood vessels is remarkable for a fungal infection. The mortality of zygomycosis is very high, especially for disseminated disease and when immunosuppression cannot be corrected. We report about two cases of pulmonary zygomycosis, caused by Rhizopus spp.: patient 1, female 73 years old: Delayed clinical course according to hip arthroplasty infection and infection of a femoropopliteal bypass of the right leg, eventually exarticulation of the right hip joint, Pseudomonas pneumonia, severe sepsis caused by staphylococci, acute respiratory distress syndrome (ARDs), acute renal failure and multiple use of antibiotics. Subsequently detection of Rhizopus spp. in the bronchoalveolar lavage and treatment with amphotericin B for this reason. Patient 2, male 68 years old: transplantation of kidney in past medical history, presenting with acute renal failure and with quite a few infections before. In the sequel development of abscessing pneumonia on the right side with a pleural empyema. Rhizopus spp. were detected by microbiological testing in the empyema fluid. These findings required surgical intervention, resection of the lower lobe of the right lung and within the same operation of the renal graft because of rejection. The patient was treated with caspofungin. The further course was delayed by several septic phases. Both patients died later on in spite of all efforts. The very rarely seen pulmonary zygomycosis caused by infection with Rhizopus spp. developed in both patients owing to immunosuppression, in one patient iatrogenically induced by immunosuppressive drugs after organ transplantation, in the other as a result of prolonged severe sepsis. In comparison with other mycoses treatment of Rhizopus infections remains difficult. The affinity to blood vessels, where the fungi multiply, and their feature of vascular invasion with thrombosis and infarction complicate therapeutic efforts.