Chronic disseminated candidiasis in a patient with acute leukemia - an illustrative case and brief review for clinicians

Abstract

Chronic disseminated candidiasis (CDC) is a severe but rarely seen fungal infection presenting in patients with hematologic malignancies after a prolonged duration of neutropenia. A high index of suspicion is required to diagnose CDC as standard culture workup is often negative. While tissue biopsy is the gold standard of diagnosis, it is frequently avoided in patients with profound cytopenias and increased bleeding risks. A presumptive diagnosis can be made in patients with recent neutropenia, persistent fevers unresponsive to antibiotics, imaging findings of hypoechoic, non-rim enhancing target-like lesions in the spleen and liver, and mycologic evidence. Here, we describe the case of an 18-year-old woman with relapsed B-cell acute lymphoblastic leukemia treated with re-induction chemotherapy who subsequently developed CDC with multi-organ involvement. The diagnosis was made based on clinical and radiologic features with positive tissue culture from a skin nodule and hepatic lesion. The patient was treated for a total course of 11 months with anti-fungal therapy, most notably amphotericin B and micafungin, and splenectomy. After initial diagnosis, the patient was monitored with monthly CT abdomen imaging that showed disease control after 5 months of anti-fungal therapy and splenectomy. The diagnosis, treatment, and common challenges of CDC are outlined here to assist with better understanding, diagnosis, and treatment of this rare condition.

Keywords: Chronic disseminated candidiasis; Hematopoietic stem cell transplant; Hepatosplenic candidiasis; Immunocompromised; Neutropenia; Neutropenic fever.

Fig. 1

Multiple hypoenhancing lesions (red arrows pointing) in the liver and spleen shown in CT scan of thorax and abdomen with contrast

Fig. 2

Liver lesion pathologic images. (A) Periodic Acid-Schiff stain showing extensive necrotizing granuloma (red arrow pointing) due to fungal infection and (B) Grocott’s Methenamine Silver stain showing mixture of hyphae, pseudohyphae, and yeast (red arrow pointing)