Disseminated Candida Tropicalis Infection in an 11‐Year‐Old Patient with Medulloblastoma

Case Presentation:

An 11‐year‐old female patient with a history of medulloblastoma presented with fever and vomiting. Shortly after admission, she developed tachycardia and had low blood pressures consistent with septic shock. CBC revealed neutropenia and she was started on empiric antibiotic therapy with vancomycin and cefepime. Her initial blood culture grew Enterobacter cloacae but the following blood culture on day 4 of hospitalization grew non‐albicans Candida species. She was started on voriconazole which caused hallucinations, thus it was later changed to liposomal amphotericin B. Once identification ofCandida tropicalis was available, amphotericin B was discontinued and she was started on micafungin. Subsequent multiple blood cultures were negative.

Despite the antimicrobial therapy, she developed generalized erythematous papular skin lesions involving scalp, hands, trunk, and lower legs. On day 11 of hospitalization, a pustular lesion was observed on her left leg, and the pustule fluid was sent for culture. On day 14 of hospitalization, she developed chest pain, prompting a chest CT that revealed multiple pulmonary nodules. She underwent a lung nodule biopsy. The histologic findings showed a necrotizing granuloma with abundant central polymorphonuclear leukocytes and occasional foreign body giant cells. GMS stain showed fungal elements with morphology consistent with Candida sp. Subsequently, cultures from both the lung tissue and pustular fluid from the leg lesion grew C. tropicalis.

Discussion:

Neutropenic patients are at a high risk for invasive infections caused by a wide variety of pathogens including, but not limited to, bacteria and fungi. Among fungi, non‐albicans Candida spp. are being increasingly reported as pathogens causing invasive infections. C. tropicalis is emerging as one of the leading causes of bloodstream infection and has the ability to rapidly disseminate in the immunocompromised host. In our patient, despite an absence of delayed clearance of positive blood cultures, she had pulmonary and cutaneous manifestations of disseminated candidiasis. Although prolonged duration of candidemia is known as one of the risk factors for disseminated infection in children with candidemia, our case demonstrates disseminated candida infection in a neutropenic patient who had only one positive blood culture for C. tropicalis. Further studies are necessary to understand the virulence of C. tropicalis, and to determine the extent of evaluation needed for detection of dissemination in neutropenic patients with candidemia caused by C. tropicalis.

Conclusions:

Our findings suggest that disseminated candidal infection can occur in neutropenic patients in the absence of prolonged duration of candidemia.