Fever Related to Fungemia Facilitated by Intralipid® Infusion

Abstract

Purpose: A 62-year-old man with a history of small bowel pseudo-obstruction requiring long term total parenteral nutrition (TPN) with Intralipid® which he received via a tunneled central venous catheter presented to the clinic. He was well until approximately 6 weeks prior to admission when he developed fever and generalized malaise. He was hospitalized elsewhere on two prior occasions, treated empirically with antibiotics, and his blood cultures were negative. On his third admission, he had a catheter related bloodstream infection with Staphylococcus epidermidis requiring catheter exchange and intravenous antibiotics. Unfortunately, he presented again with his usual symptoms of fever, chills, and generalized malaise for a fourth time. Blood cultures were negative and he remained afebrile during hospitalization and was discharged home. During the admission, he was not given Intralipid® due to a nationwide shortage. At home, he developed fevers, but only on days he received Intralipid infusion. He was admitted a fifth time and blood cultures eventually grew Malassezia. His tunneled catheter was removed and he was treated with fluconazole. Malassezia species are lipophilic fungi that colonize the skin and can be associated with catheter related bloodstream infections, typically in the setting of TPN with Intralipid®. Specialized culture techniques utilizing sterilized lipid solutions are required to make the diagnosis, so a high index of suspicion must be maintained for patients receiving TPN and experiencing intermittent fevers.