Candida albicans lung abscess sensitive to fluconazole and responding only to amphotericin B in a non-immunocompromised critically ill patient

Abstract

To the Editor: We would like to present an uncommon case of candida lung abscess in a non-immunocompromised patient who developed disseminated candidiasis and candida albicans lung abscess responding only to amphotericin B despite sensitivity to fluconazole. A 53-yr-old male was transferred to our intensive care unit (ICU) from the floor after developing high fever, respiratory failure requiring mechanical ventilation, bilateral basal infiltrates on his chest x-ray and blood cultures growing Candida Albicans sensitive to fluconazole. The patient had undergone a meningioma excision 53 days previously. Postoperative course was complicated by ventilator-associated pneumonia and herpetic meningoencephalitis which were treated with cefuroxime, ceftazidime, vancomycin and acyclovir. No steroids were administered and the patient received total parenteral nutrition for 11 days. On the floor and subsequently in the ICU the patient was placed on iv high-dose fluconazole (800 mg daily) and on empiric broad spectrum antibiotic coverage due to known colonization with methicillin-resistant staphylococcus aureus and acinetobacter baumanii. In the following nine days the blood cultures continued growing C. albicans and the patient remained febrile despite therapy with fluconazole. No candida was grown from intravascular catheters. A thoraco-abdominal computerized tomography revealed multiple cavitary lung lesions consistent with lung abscesses (Figure). Fundoscopy revealed findings consistent with C. albicans endophthalmitis and C. albicans was isolated from the bronchoalveolar lavage fluid. Both staining for acid-fast bacteria and cultures were negative for M. tuberculosis. The patient was switched to amphotericin B on the ninth day of his ICU stay (60 mg daily) and became afebrile two days later. Blood cultures became negative the next day after amphotericin B was administered and remained negative until the patient was discharged in good condition with significant improvement of the lung legions. This course contrasts recent studies in which high-dose fluconazole appeared equivalent to standard dose amphotericin B.1 The persistence of our patient's lesions during therapy with broad-spectrum antibiotic therapy and their resolution after appropriate antifungal therapy points towards the diagnosis of candida lung abscess, a very rare clinical entity.2,3 The negative cultures of the intravascular catheters argue against septic candida lung emboli. Additionally, poor tissue penetration of a candida lung abscess and the predominantly fungistatic activity of fluconazole against C. albicans in vitro may explain the poor response to fluconazole.4 Clinicians taking care of critically ill patients with documented C. albicans infection sensitive to fluconazole should consider switching to amphotericin B if high-dose fluconazole therapy is not effective and especially if there is a suspicion of a developing lung abscess.