Ann Thorac Surg 2005;80:723-724
© 2005 The Society of Thoracic Surgeons
Case report
A Fatal Fungus
Ishtiaq M. Ahmed, MRCS
a
,
Ajay Gupta, MRCS
a
,
Kate Gould, FRCPath
b
,
Stephen C. Clark, FRCS
a
,
*
a Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle Upon Tyne, England, United Kingdom
b Department of Microbiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
Accepted for publication February 6, 2004.
* Address reprint requests to Dr Clark, Department of Cardiothoracic Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle Upon Tyne, NE7 7DN, UK (Email: stephen.clark{at}nuth.northy.nhs.uk).
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Abstract
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We report the case of a 66-year-old man who presented with a prodromal type illness and pre-sternal swelling after having coronary artery bypass grafts 4 years earlier. Computed tomography showed that the mass had a retrosternal extension, to join a collection anterior to the right ventricle. Candida famata was isolated from operative specimens and he was treated with aggressive antifungal therapy. We believe that this is the first reported case of mediastinal Candida famata.
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Introduction
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Non-albicans Candida spp. organisms are emerging pathogens, especially in immunocompromised hosts. Candida famata is an unusual cause of infection in humans. Of 1,663 candidemias in one report during 20 years [1] there were no reported cases of fungemia due to C. famata.
A 66-year-old man was admitted with a 2-week history of pre-sternal swelling (Fig 1) associated with tiredness and pyrexia. He had a mass that was 4 x 4 cm, fluctuant, nonpulsatile, and appeared to be fixed to deeper structures. Preceding this he had a gradual unexplained 8-month long weight loss. He had non-Hodgkin’s lymphoma, which was successfully treated with chemotherapy in 1993. This had been in complete remission since then.
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Fig 1. A lateral view of the pre-sternal swelling. The head of the patient is to the left of the photograph.
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In 1997, the patient had undergone coronary artery bypass grafting and also pericardiectomy for calcific constrictive pericarditis at another institution. His postoperative course at that time had been complicated by open cardiac massage. During the same hospital admission he had plastic surgical reconstruction of his chest wall using pectoral muscle flaps.
Computed tomography showed a dumbbell shaped collection extending from the subcutaneous area to the anterior mediastinum, but this did not communicate with the heart (Fig 2).
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Fig 2. A representative cut from the computed tomographic series showing the dumbbell shaped collection extending from the subcutaneous area to the anterior mediastinum.
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The patient underwent surgery to evacuate this collection. With cardiopulmonary bypass on standby, the median sternotomy incision was reopened. A cystic mass was found under the skin. This was incised to reveal a thick-walled cavity filled with pus and clotted blood. At the base of the cavity there was a 1.5 cm hole through the sternum that communicated with a large retrosternal cavity containing similar material. The lower part of the sternum was opened with a saw and the cavity was evacuated. After evacuation of the cavity, central venous pressure fell from 30 to 18 mm Hg . The cavity was left open and packed with bacteriocidal agent soaked gauze.
Candida famata was isolated from operative specimens and aggressive antifungal therapy was instituted using fluconazole, as well as empirical broad spectrum antibiotics. Unfortunately the patient continued to deteriorate with a septic picture and increasing inotropic requirements. He died 55 days after his admission with multiorgan failure.
A postmortem examination showed no evidence of lymphomatous infiltration of the spleen or other lymph nodes. An organizing hematoma with degenerative calcific change was found posterolateral to the right ventricle. One of the previous grafts was found to be occluded, and it was apparent that he had severe native coronary artery disease. There was no evidence of infarct or ischemia.
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Comment
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Fungal infections are usually nosocomial in origin, and usually present in people with predisposing factors such as patients on an immunosuppressive regimen, on intravenous catheters, or who have a malignancy. None of these were present in this patient.
Candida famata was first isolated in 1922. It is a saprophyte and usually grows on decomposing organic matter. It can be a contaminant of skin and mucous membranes and has very rarely been reported as a cause of human disease [2]. It has been reported in immunocompromised patients causing peritonitis and endophthalmitis [3] [4]. Of the reported cases, a consistent finding has been its sensitivity to Amphotericin B, imidazole antifungals, triazole antifungals, and flucytosine. It is unlikely that isolation of C. famata has been previously underreported as it readily grows on routine isolation media (horse blood agar). Surgery for infection due to C. famata has been limited to removal of an intraocular lens and sac after a cataract extraction, which was complicated by uveitis due to this fungus [
3]. Although the patient survived and the fungal infection was eradicated, postoperative visual acuity was severely reduced.
We believe that we have described the first documented case of C. famata mediastinitis.
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References
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- Clancy CJ, Kaufmann CA, Morris A, Nguyen H, Tanwer D, Snydman VL. Correlation of fluconazole MIC and response to therapy for patients with candidemia due to C. albicans and non albicans spp Clin Infect Dis 1998;27(4):98-99.
- Kitch TT, Jacobs MR, McGinnis MR, Appelbaum PC. Ability of rapid yeast plus system to identify 304 clinically significant yeasts within 5 hours J Clin Microbiol 1996;34:1069-1071.[Abstract]
- Rao NA, Nerenberg AV, Forster DJ.
Torulopsis candida (Candida famata) endophthalmitis simulating Proionibacterium acnes syndrome Arch Ophthalmol 1991;109:1718-1721.[Abstract/Free Full Text]
- Quindos G, Cabrera F, Arilla MC, et al. Fatal Candida famata peritonitis in a patient undergoing continuous ambulatory peritoneal dialysis who was treated with fluonazole Clin Infec Dis 1994;18:658-660.[Medline]
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Abstract
Introduction
