Candida famata-induced fulminating cholecystitis

Abstract

Lithiasic cholecystitis is classically associated with the presence of enterobacteria, such as Escherichia coli, Enterococcus, Klebsiella, and Enterobacter, in the gallbladder. Cholecystitis associated with fungal infections is a rare event related to underlying conditions such as diabetes mellitus, steroid use, and broad-spectrum antibiotic use for prolonged periods, as well as pancreatitis and surgery of the digestive tract. Here, we present the first reported case of a gallbladder infection caused by Candida famata.

Cholecystitis; Candida ; Gallbladder

INTRODUCTION

Lithiasic cholecystitis, which predominantly occurs in the elderly, is classically associated with the presence of enterobacteria, such as Escherichia coli, Enterococcus, Klebsiella, and Enterobacter, in the gallbladder. Cholecystitis associated with fungal infections is a rare event related to underlying conditions such as diabetes mellitus, steroid use, and broad-spectrum antibiotic use for prolonged periods, as well as pancreatitis and surgery of the digestive tract¹. Candida famata is mostly nonpathogenic in humans². It has been isolated in patients with large burn areas³, stem cell transplant recipients⁴, individuals undergoing peritoneal dialysis⁵, patients with retinopathy⁶, and patients with acute infections of the central nervous system⁷.

CASE REPORT

Herein, we describe the case of a 79-year-old woman, born in Recife, State of Pernambuco, Brazil, who visited our hospital because of abdominal discomfort, nausea, and vomiting for 3 days. She did not experience any changes in her bowel habits. She had had diabetes for 2 years, for which she was irregularly taking metformin. She had no other comorbidities or fever, but she was dehydrated and dyspneic. Cardiopulmonary auscultation indicated normal sounds, and the abdominal examination indicated distension with bowel sounds. Lab oratory tests revealed hyperglycemia (glycemia = 400mg/dL), neutrophil leukocytosis, impaired renal function (urea = 83.0mg/dL and creatinine = 2.1mg/dL), and a mild elevation in pancreatic enzyme levels. Urinalysis showed only mild proteinuria and glycosuria. Abdominal ultrasonography (USG) revealed thickening of the gallbladder wall and the presence of a calculus. No dilatation of the bile ducts was present, the pancreas had a normal texture, and no free liquid was present in the abdominal cavity. Blood and urine were collected for microbiological examination. Her clinical condition worsened with the aggravation of dyspnea and a decreased level of consciousness. She was admitted to the intensive care unit (ICU) for respiratory failure and hemodynamic instability, where she was provided with ventilatory support. Her hemodynamic condition deteriorated, and she was unresponsive to vigorous blood volume replacement.

The patient was administered a combination of meropenem and teicoplanin. She later presented with circulatory collapse, for which she received high doses of vasopressors. Her echocardiogram was normal. On her fifth day in the ICU, a new USG was performed to guide a percutaneous cholecystostomy, during which some pus-containing bile was drained. The drained material was cultured in 3 vials of blood using a medium for aerobic and anaerobic bacteria and fungi (Bact-Alert Bottles). The procedure was performed following the principles of safe surgery. However, after hemodialysis, her hemodynamic condition deteriorated again, and refractory metabolic acidosis occurred. The patient then died on the sixth day of hospitalization. Both blood and urine cultures were negative for pyogenic bacteria and fungi. Candida famata was identified in all 3 samples using the Vitek 2® automated system (degree of precision > 99%), which is a rapid and accurate method for the identification of yeast species in clinical mycology laboratories, some of which are relatively uncommon⁸.

DISCUSSION

Candidiasis often occurs in diabetic patients with inadequate glycemic control; however, this case is the first report of a gallbladder infection caused by Candida famata. We could not determine whether this infection was a primary or secondary infection of the gallbladder. The decompensation of her diabetes during hospitalization could have potentially favored a systemic infection by Candida famata, leading to a secondary infection of the gallbladder. Clinicians need to be aware of the possibility of this type of infection and judiciously administer antifungal agents in addition to surgical treatments in cases of biliary tract infection in diabetic patients, especially in those presenting with systemic clinical conditions.

REFERENCES

• ¹
  Morris AB, Sands ML, Shiraki M, Brown RB, Ryczak M. Gallbladder and biliary tract candidiasis: nine cases and review. Rev Infect Dis 1990; 12:483-489.
• ²
  Desnos-Ollivier M, Ragon M, Robert V, Raoux D, Gantier JC, Dromer F. Debaryomyces hansenii (Candida famata), a rare human fungal pathogen often misidentified as Pichia guilliermondii (Candida guilliermondii). J Clin Microbiol 2008; 46:3237-3242.
• ³
  Luo GX, Penq YZ, Nie ZH, Zhanq XB, Zhuanq Y, Yuan ZQ, et al. A clinical study of fungal infection in burn patients. Chinese J Burns 2009; 25:91-93.
• ⁴
  Wagner D, Sander A, Bertz H, Finke J, Kern WV. Breakthrough invasive infection due to Debaryomyces hansenii (teleomorph Candida famata) and Scopulariopsis brevicaulis in a stem cell transplant patient receiving liposomal amphotericin B and caspofungin for suspected aspergillosis. Infection 2005; 33:397-400.
• ⁵
  Gupta A, Mi H, Wroe C, Jaques B, Talbot D. Fatal Candida famata peritonitis complicating sclerosing peritonitis in a peritoneal dialysis patient. Nephrol Dial Transplant 2006; 21:2036-2037.
• ⁶
  Carrasco L, Ramos M, Galisteo R, Pisa D, Fresno M, Gonzalez ME. Isolation of Candida famata from a patient with acute zonal occult outer retinopathy. J Clin Microbiol 2005; 43:635-640.
• ⁷
  Prinsloo B, Weldhagen GF, Blaine RW. Candida famata central nervous system infection. S Afr Med J 2003; 93:601-602.
• ⁸
  Sanguinetti M, Porta R, Sali M, La Sorda M, Pecorini G, Fadda G, et al. Evaluation of VITEK 2 and RapID yeast plus systems for yeast species identification: experience at a large clinical microbiology laboratory. J Clin Microbiol 2007; 45:1343-1346.

Publication Dates

• Publication in this collection
  Nov-Dec 2013

History

• Received
  20 Aug 2013
• Accepted
  25 Nov 2013