Candida Tropicalis Cholangitis in a Patient With No Underlying Malignancy

Abstract

SESSION TITLE: Critical Care 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Acute cholangitis is characterized by fever, jaundice and abdominal pain occurring secondary to biliary infection due to sepsis. Candida tropicalis is a rare cause of acute cholangitis, predominantly seen in patients with underlying hematological malignancies. Here, we describe a case of acute cholangitis caused by mixed organisms (Candida tropicalis, Candida albicans and Enterococcus durans) without known risk factors. CASE PRESENTATION: 78 year old Chinese female was brought in to ED after an unwitnessed fall at home. Patient was found to be febrile to 102F, hypotensive with neutrophil predominant leukocytosis and had a cholestatic picture on liver function tests. Ultrasound showed evidence of common bile duct stone and intrahepatic and common bile duct dilatation. Percutaneous Transhepatic Cholangiographic (PTCA) drain was placed and bile was sent for culture. Broad spectrum antibiotics were initiated and sepsis protocol followed. Blood cultures grew E. coli. Antibiotic regimen was switched to target the sensitivities of this organism. Workup for malignancy and other immunocompromised states was pursued with no evidence on CT scan or blood work. Despite initial improvement, the patient decompensated and expired. Bile cultures later grew Candida tropicalis, Candida albicans and Enterococcus durans. DISCUSSION: Candida in bile cultures is usually considered to be a colonization and not treated unless known risk factors are present (underlying malignancy, Diabetes Mellitus, prolonged antibiotic use history, immunosuppression, and biliary stent). We describe a case of cholangitis who decompensated on optimal antibiotic therapy and later bile cultures grew Candida tropicalis, Candida albicans and Enterococcus durans. Cholangitis secondary to Candida tropicalis has mostly been defined in patients with underlying malignancy1. Our case had a negative malignancy workup, no history of previous ERCP/EST, no history of receiving long term antibiotics or Diabetes. Blood cultures were negative for Candida which is concordant with various studies which reported sensitivity of blood cultures to detect Candida to be 50-75% or lower2. CONCLUSIONS: 1) A case of Candida tropicalis cholangitis defined in patient with no underlying malignancy or other risk factors. 2) Biliary Candidiasis as a cause of cholangitis should be considered as a differential in immunocompetent patients especially in the ICU setting. 3) Candidemia is not frequently present in patients with biliary candidiasis. 4) Consider early empiric antifungal therapy in patients with cholangitis in the ICU setting. Reference #1: 1. Ballal M, Chakraborty R, Bhandary S, Kumar P. Candida tropicalis in a case of cholangiocarcinoma with cholangitis at a tertiary care hospital in Manipal. Med Mycol Case Rep. 2013;2:95-97. Reference #2: 2. Lenz P, Eckelskemper F, Erichsen T, et al. Prospective observational multicenter study to define a diagnostic algorithm for biliary candidiasis. World J Gastroenterol. 2014 Sep 14;20(34):12260-12268. DISCLOSURE: The following authors have nothing to disclose: Arjun Saradna, Shyam Shankar, ishan malhotra, Ankur Sinha, Yizhak Kupfer, Taek Yoon No Product/Research Disclosure Information