A Unique Case of Candida auris Infection Presenting With Hydropneumothorax and Bronchopleural Fistula: A Diagnostic and Therapeutic Challenge

Abstract

Candida auris is an emerging multidrug-resistant fungal pathogen that has become a significant global health concern, particularly in critically ill patients within hospital settings. It is known for its high mortality rates, diagnostic challenges, and frequent misidentification, which delays appropriate treatment. We present a case of a 72-year-old male with diabetes and hypertension who initially presented with a persistent cough, hemoptysis, and fever and was initially suspected of having pulmonary tuberculosis. Despite tests negative for tuberculosis, empirical anti-tubercular treatment and antibiotics were initiated. However, subsequently, the patient deteriorated, developing hydropneumothorax and bronchopleural fistula, suggesting a different diagnosis. Advanced fungal cultures from endotracheal secretions later confirmed Candida auris infection. Given the concern for antifungal resistance, initial treatment with caspofungin was switched to posaconazole, leading to marked clinical improvement. After 21 days of hospitalization, the patient was discharged and continued posaconazole for two months, with full recovery by the three-month follow-up. This case represents the first reported instance of Candida auris infection complicated by hydropneumothorax and bronchopleural fistula, a rare and severe pulmonary manifestation. It underscores the diagnostic difficulties associated with Candida auris, which often mimics other infections like tuberculosis, and highlights the importance of advanced diagnostic techniques. The case also emphasizes the utility of posaconazole in managing resistant Candida auris infections and the need for heightened clinical suspicion of this pathogen in critically ill patients who do not respond to conventional therapies.

Keywords: antifungal resistance; bronchopleural fistula; candida auris; critical care infection; fungal pleural effusion; hydropneumothorax; icu-acquired infection; invasive candidiasis; multidrug-resistant fungal infection; posaconazole.

Figure 1. Chest X-ray AP view showing a dependent opacity with lateral upward sloping of a meniscus-shaped contour on the right side suggestive of right-sided pleural effusion. It also shows a central venous catheter at the right internal jugular vein and endotracheal tube in situ.

AP view: Anterior-posterior view

Figure 2. Chest X-ray PA view shows right-sided horizontal air−fluid interface suggestive of hydropneumothorax along with rim of pleural thickening with fibrosis and intercostal chest tube in situ.

PA view: posterior-anterior view

Figure 3. A CT Thorax cut shows consolidation in the right lung, hydropneumothorax with pleural thickening, and volume loss of the right lung. The intercostal chest tube is in situ, and minimal surgical emphysema is present in the subcutaneous plane.

Figure 4. Chest X-ray PA view shows right-sided pleural effusion with resolution of air component of hydropneumothorax, with volume loss of lung on the right side with right intercostal chest drain in situ.