Case Presentation: A 69 year old male with a medical history of oxygen dependent COPD, diabetes and hypertension presented with one week history of worsening shortness of breath and non-productive cough. Review of systems was positive for subjective fevers and negative for weight changes and hemoptysis. He had no recent travel history. The patient was in a homosexual relationship with a single partner for 25 years and non-smoker who denied intravenous illicit drug abuse. On presentation, he was afebrile and saturated 95% on 15 liters oxymizer with respiratory rate 18, remaining vitals were stable. Labs showed elevated WBC count 14.2 with 84.9% neutrophils. Lung examination showed diffuse bilateral crackles. Chest x-ray revealed mild to moderate interstitial infiltrate and/or edema bilaterally. Chest CT scan showed several bilateral infiltrates concerning for opportunistic infection like pneumocystis jirovecii and possible obstruction of right bronchus causing right lower lobe atelectasis. A decision was made to start dapsone and primaquine for pneumocystis. On hospital day 4, he was intubated for hypoxemic respiratory failure. Subsequently, underwent bronchoscopy that showed bilateral bronchitis, severe retained secretions and bloody plug obstructing right bronchial tree which was removed. Status post the procedure patient’s oxygenation mildly improved. Bronchial washings came back positive for candida glabrata. Serology for opportunistic infections including HIV, coccidioidomycosis and legionella were negative. Micafungin was initiated and dapsone and primaquine were discontinued. Patient symptoms improved and was extubated on hospital day 13, however 24 hours later his condition decompensated requiring reintubation for altered awareness. He expired on hospital day 14 as his family made the decision to withdraw medical care for poor prognosis in the setting of multi-organ failure.
Discussion: Candida is a normal commensal of skin, respiratory flora, gastrointestinal tract and vagina. It is harmless in the immunocompetent population, but evident in the immunosuppressed and neutropenic, especially in those with HIV. Specific risk factors include prolonged hospitalization, prior antibiotic use, use of fluconazole and other immunosuppressive agents. [1] Candidiasis can manifests as an oropharyngeal lesion, vaginitis, or invasive candidiasis invades the bloodstream, heart, eyes, brain or bones. Hospitalizations due to pneumonia are especially common in the elderly, herein we present a case of primary Candida bronchopneumonia.
Conclusions: As illustrated, this patient’s scenario was anomalous, his presentation resembled candida bronchopneumonia. Per literature review, conflicting data has been documented on the initiation of medical therapy between the Infectious disease and Critical Care intensivists [2]. On a significant note, non-albicans candida including the glabrata species, has developed resistance to the commonly used azole group of antifungals by upregulating ATP-binding cassette transporters, such as CDR1 and SNQ2, that effectively pump the drugs out of the yeast cell, recommended drug of choice is an echinocandin (such as caspofungin, micafungin, or anidulafungin), or the combination regimen of fluconazole and amphotericin B. [3,4] Fungal bronchopneumonia in non-neutropenic ICU patients is extremely rare, thus further studies are warranted to determine the predisposing factors in immunocompetent individuals such as our patient.