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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 51  |  Issue : 2  |  Page : 298-300
Catheter-related candidemia caused by Candida lipolytica in a child with tubercular meningitis


Department of Microbiology, IGMC, Shimla, Himachal Pradesh, India

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   Abstract 

Candida lipolytica is weakly pathogenic yeast, which is rarely isolated from the blood. We recovered this species from repeated blood samples and in the central venous catheter in a debilitated pediatric patient of tubercular meningitis. Identity was established on the basis of colony morphology and sugar assimilation tests (ID 32C assimilation profile). The fungemia and associated fever subsided after the removal of catheter and amphotericin B therapy. The data suggest that though of low virulence and usually a contaminant, C. lipolytica is emerging yeast pathogen in cases of catheter-related candidemia. Pathogenicity is indicated by isolation from repeated samples as in our case. Intensive therapy is recommended in cases not resolving spontaneously or responding to removal of catheter alone.

Keywords: Candida sp, fungal infections, septicemia, instrumentation, intensive care

How to cite this article:
Agarwal S, Thakur K, Kanga A, Singh G, Gupta P. Catheter-related candidemia caused by Candida lipolytica in a child with tubercular meningitis. Indian J Pathol Microbiol 2008;51:298-300

How to cite this URL:
Agarwal S, Thakur K, Kanga A, Singh G, Gupta P. Catheter-related candidemia caused by Candida lipolytica in a child with tubercular meningitis. Indian J Pathol Microbiol [serial online] 2008 [cited 2019 Oct 14];51:298-300. Available from: http://www.ijpmonline.org/text.asp?2008/51/2/298/41709



   Introduction Top


Invasive fungal infections are a frequent cause of morbidity and mortality in severely immunocompromised and debilitated patients. Candida sp. and Aspergillus sp. are the most frequent isolates from patients with fungemia. [1] Approximately 10-15% of the cases of fungemia seen in tertiary care hospitals are caused by Candida species. [2] Catheter-acquired candidemia is seen in surgical, medical, neonatal intensive care units, oncology and burn services. Hospital stay of 30 days and mortality rate of 38-40% is attributed to candidemia. [2],[3] For many years, Candida albicans was the principle pathogenic species isolated from specimens of blood. Among non- albicans Candida species isolated from cases of fungemia, Candida tropicalis accounts for one-third to one-fourth of isolates followed by Candida parapsilosis , Candida glabrata , Candida guilliermondii , Candida krusei , Candida lusitaniae and Candida lipolytica . Candida lipolytica has been an infrequent agent of opportunistic human infections. [2] Documented infections of candidemia due to C. lipolytica have been described in persons with hematological disorders such as leukemias, bone marrow transplant recipients, traumatic ocular infections, chronic sinusitis and vascular catheter-related infections. [1] We document a rare pediatric case of tubercular meningitis (TBM) with C. lipolytica candidemia predisposed by central venous catheter (CVC).


   Case History Top


A two-year-old male child presented with high-grade intermittent fever for 10 days, hemiplegia of the left half of the body and abnormal movements on the right side for 1 day. Prior to his visit to the Pediatric Department of IGMC, Shimla in December 2006, he was administered parenteral broad-spectrum antimicrobial agents for 5 days via a central venous line at a local health facility for suspected purulent meningitis. Referral was made to a specialized institutional care as the child's condition worsened. Family history was remarkable for contact with a case of pulmonary tuberculosis.

On examination, the child was drowsy, responding only to painful stimuli, pupillary response to light was normal and there was no apparent cranial nerve palsy. Neck rigidity and Kernig's sign were positive. Muscle tone on the left side of the body was increased; deep tendon reflexes were brisk with up going plantar reflex. Episodic decerebrations were present. Glasgow Coma Scale (GCS) [4] of E4V2M3 was recorded.

Vital parameters were recorded as: temperature - 104°F, pulse rate - 108/min, respiratory rate - 42/min, shallow. Hematological profile revealed routine blood sugar - 110 mg%; total leucocyte count - 11,800/mm 3 ; differential leucocyte count - polymorphs 42%, lymphocytes 53%, monocytes 2% and eosinophils 3%; erythrocyte sedimentation rate - 52 mm in the first hour. Serum proteins, urea, creatinine, aspartate aminotransferase and alanine aminotransferase were in normal range. Sputum, gastric lavage and urine samples were negative for acid-fast bacilli. Urine routine and microscopic examination showed normal findings. Urine culture was sterile for bacteriological, mycobacteriological and fungal elements. X-ray chest revealed no abnormal finding. Mantoux test was positive (12 mm × 12 mm). Blood culture sample collected at the time of admission was kept in brain-heart infusion broth and sent to a microbiology laboratory. The subcultures on blood agar revealed growth of a yeast after 72 h, which was identified as C. lipolytica by standard methods and considered as contaminant. [2]

A computed tomographic (CT) scan of the head revealed communicating hydrocephalous with periventricular ooze and basal exudates. Prior to the emergency surgical intervention, a CVC was positioned for instituting conservative therapy. Decongestive and symptomatic treatment was given in the form of intravenous mannitol, glycerol, corticosteroids, phenytoin, paracetamol, tepid sponging and oxygen inhalation followed by ventriculoperitoneal (VP) shunt operation. Cerebrospinal fluid (CSF) cytology revealed 132 leucocytes/ml with 50% lymphocytes and 50% polymorphonuclear cells; CSF proteins - 210 mg%, sugar - 25 mg% with concomitant blood sugar - 112 mg%; adenosine deaminase (ADA) of CSF - 13.10 units (normal range <10 units). Entertaining the diagnosis of TBM guided by clinical profile, family history of contact, Mantoux test, CT scan and CSF analysis, child was started on anti-tubercular drugs, i.e., INH, rifampicin, pyrazinamide and streptomycin.

Post-operatively over a week, favorable response was observed with unremarkable vital signs, normal pupillary reflexes and absence of fever and meningeal signs. GCS improved from E4V2M3 to E4V4M4. After 1 week, temperature was charted as 104.2°F despite the absence of meningeal signs and features of raised intracranial pressure. Suspecting catheter-associated superadded infection, a new central venous line was inserted. The tip of removed catheter and blood sample were sent for culture in brain-heart infusion broth and subcultures on blood agar and MacConkey agar were made. Growth of yeast was obtained on blood agar after 72 h of incubation at 37°C. Isolate was subcultured on Sabouraud's dextrose agar (SDA) with antibiotics and was identified as Candida sp. on the basis of colony morphology on SDA and CHROM agar, urease test that was positive and Germ tube test that was negative in our isolate. For further species identification, isolate was sent to Vallabhai Patel Chest Institute, Delhi. Based on ID 32C assimilation profile, isolate revealed to be C. lipolytica (id profile no. 3300111201 with %id = 99.9). Fever did not subside even after 2 days of removing the catheter. The child was started on Amphotericin B (AMB) infusion in 5% dextrose in a dose of 0.5 mg/kg body weight. After 3 days, he became afebrile. Subsequent blood cultures after 7 days of starting AMB was reported sterile.

The patient developed partial VP shunt blockade after 15 days of admission, which resulted in decerebrations, appearance of features of raised intracranial pressure, bilateral dilated pupils and GCS - E4V2M2 (Coma Grade II). As parents took the child from the hospital against medical advice, so could not be followed up.


   Discussion Top


Invasive fungal infections are rarely diagnosed at an early stage as presenting symptoms may be atypical, vague and non-specific. Fungi with high inherent virulence remained the common agents of systemic mycoses. Opportunistic fungi due to their limited inherent virulence cause vascular infections in hospitalized patients and immunocompromised patients. Factors proposed for the sudden emergence of yeast species as agents of hospital-acquired candidemia include vascular and urinary catheters, administration of broad-spectrum antimicrobial agents, anti-neoplastic agents and corticosteroids, surgical procedures, neutropenia, depressed cellular immunity, severe burns, debilitating diseases and parenteral nutrition. Candida sp. is one of the common species ascribed to this group. Candida albicans , once the leading species isolated, has decreased proportionately due to widespread prophylactic use of fluconazole. [2],[5] Non- albicans Candida species are being reported more commonly as these are resistant to fluconazole. [6]

Wingard reviewed 1591 cases of infections due to Candida sp. and reported non- albicans Candida species as the causative agents in 46% of systemic infections, i.e., C. tropicalis (25%), C. glabrata (8%), C. parapsilosis (7%) and C. krusei (4%). [5] Another report reviewed cases of candidemia and documented non- albicans Candida accounting for 63.4%. [1] Amongst other species isolated from opportunistic infections, C. lipolytica has been rarer still.

Candida lipolytica inhabits the mouth, pulmonary tree and intestines of healthy individuals. It is also a ubiquitous soil saprophyte having been isolated from refrigerated meat products, petroleum products and agricultural processing units. [1] This yeast has not been included in Hazen's list of emerging yeast pathogens. [7] In the present case, repeated isolation of C. lipolytica in three consecutive blood samples and from the tip of vascular catheter, improvement in patient's condition after changing CVC line, institution of AMB therapy, sterile subsequent subculture and no other source of infection suggest possibility of CVC-associated candidemia. These observations are in accordance with other reports, which have also derived a correlation of this isolate with central venous line infection. [1],[3],[5],[6]

Review of the literature incriminates C. lipolytica as being of weak virulence. [3] Shin et al , have reported the ability of this fungus to cause epidemic transmission but deep visceral infections and mortality have not been documented. [3],[6] In the present case, despite long persistence of candidemia, there was no evidence of deep visceral infection. The deteriorating condition of the child could be directly corroborated with TBM.

The ability of C. lipolytica to adhere to and colonize the CVC line is due to microevolution and slime production, consequent to genetic variation. Appropriate patient management is still controversial. Some suggest a stand back or a wait-and-watch approach without catheter removal or antifungal therapy. [1] Others suggest that although the yeast may colonize in the catheter and be seeded into the bloodstream, removal of catheter alone resolves fungemia. [3] Some workers favor intensive treatment regimens by removal of potentially infected CVC line and by empirical therapy with antifungal agents such as AMB. [6] Belet et al , have documented treatment failure with catheter removal and AMB. In their study, patients of fungemia due to C. lipolytica were treated successfully with caspofungin and AMB suggesting role of intensive treatment in unresponsive cases. [8]


   Conclusion Top


Though C. lipolytica is an environmental contaminant, but in the present case, it has been implicated as an agent of candidemia. This yeast should be included in the list of emerging pathogenic yeasts. The recognition of unusual yeasts as agents of life-threatening infection and their unpredictable antifungal susceptibilities impresses upon the need to pursue complete species identification. Further clinical data need to be evaluated for formulating management strategies of seriously ill patients infected with uncommon fungal agents.

 
   References Top

1.D'Antonio D, Romano F, Pontieri E, Fioritoni G, Caracciolo C, Bianchini S, et al. Catheter-related candidemia caused by Candida lipolytica in a patient receiving allogeneic bone marrow transplantation. J Clin Microbiol 2002;40:1381-6.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Candidiasis. In : Kwon-Chung KJ, Bennett JE, editors. Medical mycology . 2 nd ed. Pennsylvania: Lea and Febiger; 1992. p. 280-336.  Back to cited text no. 2    
3.Chang CL, Park TH, Lee EY, Lim YT, Son HC. Recurrent self-limited fungemia caused by Yarrowia lipolytica in a patient with acute myelogenous leukemia. J Clin Microbiol 2001;39:1200-1.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Kopper AH. Traumatic injuries of the head and spine. In : Braunwald E, Hauser SL, Fauci AS, Longo DL, Kasper DL, Jameson JL, editors. Harrison's Principles of Internal medicine . 15 th ed. United States: McGraw Hill; 2003. p. 2434-42.  Back to cited text no. 4    
5.Mycology. In : Koneman EW, Allen SD, Janda WM, Schreckenberger PC, Winn WC, editors. Color atlas and textbook of diagnostic microbiology. 5 th ed. Philadelphia, USA: Lippincott Williams and Wilkins; 1997. p. 983-1069.  Back to cited text no. 5    
6.Shin JH, Kook DH, Shin DH, Hwang TJ, Kim M, Suh SP, et al. Nosocomial cluster of Candida lipolytica fungemia in pediatric patients. Eur J Clin Microbiol Infect Dis 2000;19:344-9.  Back to cited text no. 6    
7.Hazen KC. New and emerging yeast pathogens. Clin Microbiol Rev 1995;8:462-78.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Belet N, Çiftηi E, Ince E, Dalgiη N, Oncel S, Güriz H, et al. Caspofungin treatment in two infants with persistent fungemia due to Candida lipolytica. Scand J Infect Dis 2006;38:559-62.  Back to cited text no. 8    

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Correspondence Address:
Santwana Agarwal
C/o Dr. C.P. Agarwal, 3 Oak Wood Place, Jakhoo, Shimla - 171 001, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.41709

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    Abstract
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    Case History
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