Year : 2008 | Volume
: 51 | Issue : 2 | Page : 286--288
Thoracic empyema due to Candida albicans
VP Baradkar, M Mathur, SD Kulkarni, S Kumar
Department of Microbiology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
V P Baradkar
Department of Microbiology, LTMMC and LTMGH, Sion, Mumbai - 400 022, Maharashtra
Few cases of empyema thoracis due to Candida species have been reported from the world and India. A 46-year-old male with esophageal carcinoma, who had taken radiotherapy, presented with fever and dyspnea. The chest X-ray showed findings suggestive of empyema. The diagnosis was confirmed by culturing Candida albicans from aspirated fluid and blood culture. The patient responded to antifungal treatment. High index of suspicion is required to diagnose such rare cases.
|How to cite this article:|
Baradkar V P, Mathur M, Kulkarni S D, Kumar S. Thoracic empyema due to Candida albicans.Indian J Pathol Microbiol 2008;51:286-288
|How to cite this URL:|
Baradkar V P, Mathur M, Kulkarni S D, Kumar S. Thoracic empyema due to Candida albicans. Indian J Pathol Microbiol [serial online] 2008 [cited 2021 Oct 18 ];51:286-288
Available from: https://www.ijpmonline.org/text.asp?2008/51/2/286/41699
The occurrence of fungal infection is rising worldwide. Data from the Center of Disease Control reveal that, between 1980 and 1990, Candida species emerged as the sixth most common nosocomial pathogen (7.2%).  The increase in the rate of fungal infections has been attributed mainly due to the use of broad-spectrum antibiotics, intravascular devices and hyperalimentation, as well as to the ever-increasing number of critically ill or immunocompromised patients in hospital populations. There are no major studies of thoracic empyema caused by fungal species; only few cases have been reported in literature. ,,,,, Here, we report a case of empyema thoracis due to Candida albicans in a 46-year-old male with previous history of esophageal carcinoma, for which he had received radiotherapy.
A 46-year-old male diagnosed with esophageal carcinoma grade III, who had previously undergone radiotherapy for treatment of esophageal carcinoma, was admitted with fever and dyspnea, after 1 week of radiotherapy. On examination, the patient was thin built; mild pallor was present with no icterus. There were white curdy lesions in the oral cavity, but there was no history of sudden onset of severe retrosternal pain suggestive of esophageal rupture. There was involvement of the axillary lymph nodes. On examination, there was dullness on percussion on the right side with diminished movement. On auscultation, respiratory sounds and vocal fremitus were diminished on the right side. Perabdominal examination did not reveal any abnormal finding. Due to the fever, the patient was already on oral cephalosporins for the last 7 days, prescribed by a private practitioner.
The patient's investigations revealed that the total leukocyte count was 16,000 cell/µl with 80% neutrophils, 18% lymphocytes and 2% eosinophils. His Hb was 10 g/dl. He was nondiabetic. After counseling, the HIV testing revealed that he was seronegative. Three sputum samples were examined for acid-fast bacilli, which were negative. Urine analysis was normal. Chest X-ray PA view showed findings suggestive of empyema [Figure 1]. Barium study and endoscopy showed only findings suggestive of esophageal carcinoma, but no signs suggestive of esophageal candidiasis or esophageal perforation. Diagnostic thoracocentesis revealed malodorous frank pus.
The Gram-stained smear it showed pus cells and budding yeast cells with pseudohyphae [Figure 2]. Acid-fast staining was also performed on the pleural fluid, but the smear was negative for acid-fast bacilli. The empyema fluid was cultured on blood agar, Lownstein-Jensen (LJ) medium and two tubes of Sabouraud's dextrose agar (SDA). One SDA was incubated at 37°C and the other at 20°C. The patient's blood culture was done using brain-heart infusion broth, which was subcultured on SDA. After 48 h of incubation, typical creamy pasty colonies appeared on the blood agar and on both tubes of SDA [Figure 3].
Gram's staining and lactophenol cotton blue preparation were done from the SDA tubes, which showed budding yeast cells with pseudohyphae. The isolate was identified as Candida albicans by the germ tube test, growth on Cornmeal agar [Figure 4] and sugar assimilation tests. From blood culture also Candida albicans was isolated. The patient was started on intravenous Amphotericin B for 7 days followed by oral Fluconazole for 3 weeks. As no other organism was isolated from blood agar and MacConkey agar, antibacterial agents were stopped. The LJ culture was followed up for growth, which revealed no growth.
The patient responded to antifungal treatment and percutaneous catheter drainage.
Candida species frequently colonize the oral cavity, the gastrointestinal tract and vagina in human beings. ,, They are also opportunistic pathogens that cause significant morbidity and mortality among patients with breached epithelial barriers and impaired cell-mediated immunity. ,,,,,, Oral carriage or infection due to Candida species may occur in patients with malignancy and receiving radiotherapy. Even long-term administration of antibiotics may cause colonization or infection in the oral cavity in an individual who is already immunosuppressed due to malignancy. From the oral cavity, Candida may spill over into the blood, leading to hematogenous spread and may cause bronchopulmonary infection, as happened in this case. There was no candidal involvement of the esophagus and there was no perforation of the esophagus, so infection from the esophagus was ruled out. The diagnosis of bronchopulmonary infection caused by fungi is difficult to confirm, because fungi isolated from sputum may present as either pathogen or a saprophyte. Invasive procedures are usually required. 
The diagnosis of fungal empyema thoracis requires that the following criteria be met: (1) isolation of fungal species from thoracocentesis fluid belonging to exudates category, (2) significant signs of infection as fever or leukocytosis and (3) isolation of the same fungus from pleural fluid and other specimens, such as blood, sputum or surgical wounds, that showed evidence of tissue invasion.  In this case, the patient was febrile with leukocytosis, Candida albicans was isolated from thoracocentesis fluid as well as blood culture, thus satisfying all the three criteria mentioned above.
Candida species are the most important pathogens in fungal empyema thoracis; empyema thoracis caused by filamentous fungi are rare and only sporadic cases have been reported. ,
Candida empyema thoracis has been reported as a complication of operation, gastropleural fistula, spontaneous esophageal rupture, HIV infection, diabetes, malignancy and cirrhosis of liver. ,,,,,,, In the present case, the patient had undergone radiotherapy for the esophageal carcinoma and had received antibiotics for 8 days, which might have acted as the predisposing factor for the development of oral candidiasis and cause hematogenous spread, leading to empyema thoracis, but there was no other systemic involvement due to Candida .
Data from the Center of Disease Control and Prevention's National Nosocomial Surveillance, which showed Candida and Torulopsis species to account for 80% of fungal isolates with nosocomial infections.  The commonest Candida species reported from empyema thoracis is Candida albicans followed by Candida tropicalis. ,
A large study from Taiwan,  67 patients with fungal empyema thoracis were studied. A total of 73 fungal isolates were recovered from pleural fluid, the most common was Candida species (47 isolates 64%), Torulopsis glabrata (13 isolates, 18%); Aspergillus species (9 isolates, 12%). Candida albicans (28 isolates) was the commonest followed by Candida tropicalis (13 isolates). Candida tropicalis is also reported in a case report from India.  In the major study from Taiwan,  53 patients (79%) had compromised immunity caused by (in the order of decreasing frequency) malignancy, diabetes mellitus, long-term steroid use, cirrhosis of liver, organ transplantation, uremia, alcoholism or AIDS. Among 33 patients (49%) with malignancies, abdominal and hematological malignancies were most common and four patients were transplant recipients. In the present case also, there was underlying malignancy of esophagus as predisposing factors, which was also reported earlier. 
Most common manifestations observed in that large study among 67 patients were fever (76%), leukocytosis (67%) and dyspnea (60%). Twenty-one percent had shock as initial presentation. WBC count was 720,000/µl in 28 patients.  In the present case, a similar clinical presentation was present, i.e., fever, dyspnea, but no leukocytosis was observed. ,,,,,, All patients with antifungal therapy with Fluconazole or Amphotericin B alone or in combination, survived in that study.
We decided to report this case to highlight the need for greater interaction between clinicians and microbiologists in clinical decision-making process for early diagnosis to reduce morbidity and mortality.
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