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Candidal Pneumonia

Candidal Pneumonia. Case II. 70 y female seen in oncology clinic Jan 5/05 PMH : MDS  NHL IV large cell Initial Dx 2001  chemo 2001 & 2002 & XRT (axilla & groin) 2003  remission 2004 Nov  recurrence

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Candidal Pneumonia

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  1. Candidal Pneumonia

  2. Case II • 70 y female seen in oncology clinic Jan 5/05 • PMH : MDS NHL IV large cell Initial Dx 2001  chemo 2001 & 2002 & XRT (axilla & groin) 2003  remission 2004 Nov  recurrence Fludarapine & steroid

  3. History • 3/52 unresolving SOBE , Dry cough intermittent fever & sweating • No response to 2 courses of Abx Azithromycin & Cefuroxime • Wt loss 15 lb • No H/O TB or contact

  4. History • No travel , pets • Being receiving IVIG for ITP • PMH : HTN , Hpothyroidism Lt nephrectomy for persistent hydronephrosis from LN compression Baseline Creat 80 • Med : ASA , Ramipril , Predinsone

  5. Examination • Temp 37 BP 100/60 HR 100 RR 16 Sat 95 % No desaturation with walking • Palpable LN , central trachea • Chest : Good BS , Crackles Rt base • LL edema

  6. Investigation • WBC 8 N Diff Hb 95 MCV N Plt 25 PTT & INR N • Lytes , BUN & Creat N • LFT & UA N • CXR & CT chest

  7. Course • BAL Jan 6th /05 BAL  -ve PCP , AFB & cytology • Empiric Rx with Septra , Gatifluxacine • BAL C/S  Candid Albicans & Enterococcus • No improvement on Abx

  8. Course • Seen in St.B ER Jan 14th /05 Nausea , Vometing & Abdominal pain 2/7 • Seen by Gen Sx ? Bowel obstruction • Waiting CT  Increase work of breathing & Hypoxia & decrease LOC • Intubated , Hypotensive

  9. Course • CT Abdomen  extensive LN Non mechanical obstruction • Septic shock , Acute renal failure DIC & lactic acidosis • Empiric Abx Vanco , Cipro & Metro • Repeat Bronch

  10. Course • BAL  +ve Candida Albicans • Blood C/S 2/2  yeast • Empiric Ampho B • Yeast  Candida Albicans • Ampho B  Fluconazole

  11. Course • Persistent Shock , ARF • GI bleeding  ischemic colitis Vs CMV • Withdrawal of care upon family request

  12. Candida Pneumonia • Retrospective study 20 y of oncology pts • Isolation of Candida from lung tissue No candidemia • 31 cases 9 only neutropenic 84% mortality • High incidence of candida osophagitis ? Aspiration lead to pneumonia Medicine (Baltimore). 1993 May

  13. Candidemia • Fourth leading cause of blood stream infection  following staph aureus , C/N staph & enterococcus • Surrogate marker of deep seated infection • Untreated 15% endophthalmitis endocarditis ,arthritis & reanl candiadiasis NEJM Dec 2002

  14. Candidemia • Prospective Multicenter observational study 1997 1999 Adults & Pediatric Pt • Incidence of Candidemia & isolate Candidemia mortality : <24 of +ve C/S persistent +ve C/S postmortem • 1449 Adults & 144 peadiatric Pts Clinical Infectious Dis Sept 2003

  15. Candidemia • Overall 3 months mortality 40% Cause specific mortality 12% • Candida Albican was associated with higher mortality 47% Adults 23% peads • Candida Parapsilosis had the lowest • Risk factor associated with mortality  Underlying malignancy ,Neutropenia Steroid & Lines Clinical Infectious Dis Sept 2003

  16. Fluconazole Vs Ampho B • Prospective randomized Plcb Control • Multicenter 106 pateints • Ampho B 0.6 mg/kg / day Vs Fluconazole 800mg loading &400 mg/d • Switch to Ampho B in case of C.glabrata & C.crusie Eur J Clin Microbiol Infect Dis. 1997 May

  17. Fluconazole Vs Ampho B • Successful Rx Fluconazole 50% Vs Ampho B 57% P 0.39 • 14 day mortality 27% Vs 21% P 0.57 • Side effect 0% 4% Eur J Clin Microbiol Infect Dis. 1997 May

  18. High Dose Flucon Vs Flucon + Ampho B • Randomized multicenter 219 pts • Non neutropenic nor expected to br • Non Candida. Crusie • No Liver , renal impairment Clinical infectious Dis May 2003

  19. High Dose Flucon Vs Flucon + Ampho B • Flucon 800 mg + Plcb (first 7 days) Flucon 800 mg +Ampho B .07 mg/kg April 95  May 99 • Successful Rx  clinical improvement & -ve blood C/S • Failed Rx  no clinical improvement persistent fungemia side effects Clinical infectious Dis May 2003

  20. High Dose Flucon Vs Flucon + Ampho B • Candida Albicans most common • Persistent fungemia 53% • Renal Imapirment 3% Vs 23% • Successful Rx 56% Vs 69% P 0.43 • 90 Mortality 39% Vs 40% • Higher failure with Higher APACHE , TPN Clinical infectious Dis May 2003

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