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LETTER TO EDITOR Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 3  |  Page : 590-591
Candida glabrata : Etiologic agent of soft tissue abscess in a diabetic patient


Infectious Diseases and Clinical Microbiology Department, Trakya University, Edirne, Turkey

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Date of Web Publication22-Oct-2010
 

How to cite this article:
Celik AD, Yulugkural Z, Kuloglu F, Akata F. Candida glabrata : Etiologic agent of soft tissue abscess in a diabetic patient. Indian J Pathol Microbiol 2010;53:590-1

How to cite this URL:
Celik AD, Yulugkural Z, Kuloglu F, Akata F. Candida glabrata : Etiologic agent of soft tissue abscess in a diabetic patient. Indian J Pathol Microbiol [serial online] 2010 [cited 2020 Jun 2];53:590-1. Available from: http://www.ijpmonline.org/text.asp?2010/53/3/590/68266


Sir,

A 49-year-old woman presented (on 27.09.2008) with a one-week duration of redness and painful swelling on the plantar and dorsal surfaces of the left foot. She had a five-year history of diabetes mellitus with insulin treatment. She reported sunflower stick in her foot 10 days earlier. On physical examination, body temperature was 38C. There was swelling and erythema with tenderness on the plantar and dorsal surfaces of her left foot. A fluctuating mass, 3x2 cm in size, was palpated on this erythamatous region. Results of the laboratory tests were as follows: leukocyte count, 14600/mm 3 (77% polymorphonuclear leucocytes); hemoglobin, 9.7gr/dL; hematocrit, 29.6%; platelet, 300 000/mm 3 ; erythrocyte sedimentation rate, 143 mm/hour; glucose, 344 mg/dL; urea, 90 mg/dL; creatinine, 1.9 mg/dL; and C-reactive protein, 240 mg/L. Ultrasonographic examination revealed a 3 x 2 x 2-cm abscess located through the medial dorsal and plantar surfaces of the left foot. The abscess was drained and ampicillin-sulbactam (4 x 1.5 g/day) and ciprofloxacin given. Gram staining of the abscess fluid showed erythrocytes and leucocytes. Aerobic culture of the abscess specimen yielded yeast without germ tube formation. Fluconazole (400 mg/day) was added to the antibacterial therapy on the same day. Under this treatment, a white, milky secretion oozed continuously from the location of abscess drainage.

Another sample of this secretion was examined microbiologically. Further identification of the previous isolate by conventional methods revealed Candida glabrata. The second material also grew C. glabrata. Treatment was changed to caspofungin (50 mg/day) and antibacterial antibiotics were stopped. Findings of the left foot from leukocyte-labeled bone scintigrapy and magnetic resonance imaging (MRI) also showed soft tissue infection. No sign of osteomyelitis was detected through either of these techniques. Purulent, milky discharge from the lesion ended on the tenth day of caspofungin therapy. The redness and swelling of the foot regressed within a month of caspofungin therapy. Her laboratory results were completely normal after five weeks of antifungal therapy.

Candida is the most frequent etiologic agent in fungal infections. It causes opportunistic infections ranging from simple mucocutanaeus to invasive infections in patients with immunocompromising diseases. Candida species are not frequently seen among the etiologic agents of soft tissue infections. Diseases such as diabetes mellitus, renal failure, organ transplantation, and neutropenia are the main predisposing factors for Candida infections. Hematogenous dissemination due to candidemia or direct inoculation following any trauma can cause development of soft tissue infections due to Candida spp. Our patient has a history of dipping of sunflower stick on her foot ten days prior to the appearance of the symptoms. Hematogenous dissemination and candidemia were not detected.

Necrotizing soft tissue infection that is rarely seen is another clinical scheme described among soft tissue infections due to Candida. There are limited numbers of cases of necrotizing soft tissue infection reported in the literature. Candida albicans in a necrotizing soft tissue infection that developed around an operation incision scar was described in a renal transplant patient with diabetes mellitus. [1] Fournier gangrene due to Candida spp. was also reported in two patients. [2],[3] A case of untreated diabetes mellitus and an ulcer on the perineum resulting in necrotizing soft tissue infection with candidemia by C. glabrata was reported by Shindo et al. [4] Another case of isolated C. albicans skin abscess in a critically ill patient with a history of intrabdominal surgery and candidemia was reported by Tuon et al. [5]

Diabetes mellitus is an important risk factor in the development of systemic and superficial Candida infections. These infections usually occur as diabetic foot ulcers or superficial skin and nail infections. All of these infections were in the form of an ulcer; soft tissue abscess was not described. In our case, C. glabrata was isolated from a soft tissue abscess. C. glabrata is an important species among non-albicans Candida because it carries intrinsic resistance against the azole group of antifungal drugs. Treatment of infections caused by this species should be with antifungal agents such as amphotericin, voriconazole, or caspofungin. Clinical response was poor with fluconazole, which was used until the species was determined. Caspofungin, which was preferred to amphotericin B due to renal toxicity, gave a good clinical result in our patient.

The management of soft tissue infections in the diabetic foot involves early and prompt diagnosis and treatment. The treatment strategy is directed according to microbiological results in addition to surgery. Candida species should be considered etiologic agents in these cases.

 
   References Top

1.Wai PH, Ewing CA, Johnson LB, Lu AD, Attinger C, Kuo PC. The microbiology of necrotizing soft tissue infections. Am J Surg 2000;179:361-6.  Back to cited text no. 1      
2.Johnin K, Nakatoh M, Kadowaki T, Kushima M, Koizumi S, Okada Y. Fournier's gangrene caused by Candida species as the primary organism. Urology 2000;56:153.  Back to cited text no. 2      
3.Loulergue P, Mahe V, Bougnoux ME, Poiree S, Hot A, Lortholary O. Fournier's gangrene due to Candida glabrata. Med Mycol 2008;46:171-3.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Shindo M, Yoshida Y, Adachi K, Nakashima K, Watanabe T, Yamamoto O. Necrotizing soft-tissue infection caused by both Candida glabrata and Streptococcus agalactiae. Arch Dermato 2009;145:96-7.   Back to cited text no. 4      
5.Tuon FF, Nicodemo AC. Candida albicans skin abscess. Rev Inst Med Trop Sao Paulo 2006;48:301-2.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Aygul Dogan Celik
Trakya University Medical Faculty, Infectious Diseases Department, 22030 Edirne
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.68266

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