MULTIORGAN SYSTEM DYSFUNCTION IN THE PREVIOUSLY HEALTHY HOST: A CASE OF COMMUNITY-ACQUIRED CANDIDA PARAPSILOSIS

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Candida parapsilosis has been described as an opportunistic invasive pathogen implicated in septic shock and multiorgan system dysfunction in the immunocompromised host. Given the stereotypical presentation, invasive candida species may not be high on the differential diagnosis in an otherwise young and healthy host presenting from the community. In such cases, a high clinical suspicion in conjunction with supportive care and risk mitigation may be the most effectual intervention. CASE PRESENTATION: We present a twenty-five-year-old healthy man admitted for fever, rash, and severe acute liver injury without any occupational, medication, or environmental exposure. His clinical status rapidly deteriorated. He developed septic shock, acute respiratory distress syndrome requiring intubation, rhabdomyolysis, acute kidney injury, and volume overload with ascites and bilateral pleural effusions. He was treated with ceftaraline, doxycycline, posaconazole, micafungin, intravenous crystalloid, vasopressors, and underwent bone marrow, liver, and skin biopsies, thoracenteses, and bronchoscopy. Extensive investigation for infectious, autoimmune, immunodeficiency, and inflammatory etiologies was initially unrevealing. These included: COVID-19, HTLV-I/II, CMV, HSV, HIV, Dengue, Ova and Parasites, Coccidiodes, Histoplasma, Schistosoma, Toxoplasma, Leptospirosis, Tuberculosis, Pneumocystis, Familial Mediterranean Fever, Viral Hepatitis, ceruloplasmin, alpha-1-antitrypsin, HFE, rheumatoid factor, c/p-ANCA, cryoglobulins, porphyrins, immunoglobulins, VZV, MMR, and liver/kidney auto-antibodies. Serology for parvovirus and coxsackie virus conferred positivity of unclear timeline. Liver biopsy would ultimately produce growth of candida parapsilosis. With time, antimicrobials and supportive care, progressive improvement was noted followed by extubation and eventual discharge. The patient has since returned to baseline functionality. DISCUSSION: The initial presentation was concerning for a viral etiology with suspected superimposed infection. Given the significant fungal growth on biopsy, it was determined to be an atypical case of invasive candida parapsilosis in the setting of likely viral predisposition. While a paucity of literature has described this pathogen as invasive in the immunocompetent host or notable from the community setting, nevertheless, cases such as these may be of significant prevalence in the modern medical intensive care unit. Early recognition of sepsis, aggressive resuscitation, and willingness to investigate etiology allowed for clinical stabilization. Meaningful recovery is arguably achieved through a thoughtful, concerted effort to provide supportive care and avoid iatrogenesis. CONCLUSIONS: Atypical presentations of disease are common. We posit that in the face of uncertainty, the greatest tool at a clinician's disposal is patience, timely responsiveness, and deliberate intervention. REFERENCE #1: Trofa D, Gácser A, Nosanchuk JD. Candida parapsilosis, an emerging fungal pathogen. Clin Microbiol Rev. 2008;21(4):606-625. doi:10.1128/CMR.00013-08 REFERENCE #2: Tóth, Renáta, et al. "Candida Parapsilosis: from Genes to the Bedside." Clinical Microbiology Reviews, American Society for Microbiology Journals, 20 Mar. 2019, cmr.asm.org/content/32/2/e00111-18. REFERENCE #3: Fiore M, Cascella M, Bimonte S, et al. Liver fungal infections: an overview of the etiology and epidemiology in patients affected or not affected by oncohematologic malignancies. Infect Drug Resist. 2018;11:177-186. Published 2018 Jan 29. doi:10.2147/IDR.S152473 DISCLOSURES: No relevant relationships by Christopher Nemeh, source=Web Response No relevant relationships by Janki Thakker, source=Web Response