Yeast Fungaemia in Immunosuppressed Patients With Indwelling Catheters: Is It Always Candida? A Case Report

Abstract

SESSION TITLE: Other Infections SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Catheter related bloodstream infections caused by Cryptococcus species are rare. Our goal is to describe a case of Cryptococcus neoformans causing catheter-related bloodstream infection in a patient with Chronic Lymphocytic Leukemia. CASE PRESENTATION: A 62-year-old male with diabetes and CLL was admitted to the medicine service for pre-syncope. He had suffered a recent CLL relapse and Ibrutinib therapy was started. He had experienced fatigue, weight loss, dyspnea and cough. His oncologist prescribed Levofloxacin for presumed pneumonia. Upon admission, he had fever of 101.6 F. He was confused, tachypneic, tachycardic and had a rash on his trunk and face. He had a right subclavian central venous catheter. His lab values showed WBC count of 20.7 x 103 cells/mL, 90% lymphocytes, HgB: 8.7 g/dL, platelet count 131,000/mL. A chest radiograph showed densities consistent with interstitial pneumonia. IV fluids and broad spectrum antibiotics were given. Blood cultures were drawn from a peripheral vein and the central catheter. On day 3 blood cultures grew yeast; ophthalmologic examination and echocardiogram were normal. Subsequently the central catheter was removed and cultures were sent. Caspofungin was started empirically for presumed Candida. He remained febrile but stable otherwise. On day six, final culture speciation demonstrated Cryptococcus neoformans from blood and catheter tip. Amphotericin B and Flucytosine were started. The next day, he experienced respiratory distress and septic shock requiring intubation, mechanical ventilation and vasopressor support. Despite these efforts, he suffered a PEA cardiac arrest, and expired on hospital day seven. DISCUSSION: C. Neoformans can be differentiated from other yeasts on the basis of three direct tests: An India ink preparation may reveal the encapsulation of the yeast. A urease test is positive in most Cryptococcus species. C. neoformans possesses laccase activity, which can be detected in special media.(1) The two common sites for infection, the lung and the CNS, were emphasized in a review in HIV-negative patients. Cryptococcal fungaemia has been well-described in immunocompromised patients. In one study, among 165 cases of fungaemia, 7% were due to Cryptococcus. In another study of 28 patients with Cryptococcal fungaemia, the mortality was 41%. Catheter-related infections due to this yeast are rare. After a systematic search on several databases we found one case reported in Brazil. It is possible that the fungi entered the host through the respiratory tract with subsequent fungaemia leading to colonization of the catheter. CONCLUSIONS: We encourage clinicians to be more aware of Cryptococcus as a causative agent of fungaemia in immunocompromised hosts, particularly because echinochandins, which are not active against Cryptococcus species, are first-line therapy in the era of fluconazole-resistant candidiasis. Reference #1: Mandell, Douglas Principles and practice of infectious diseases. Elsevier/Saunders. DISCLOSURE: The following authors have nothing to disclose: Adiac Espinosa Hernandez, Raymonde Jean No Product/Research Disclosure Information