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Title : A 77-year old febrile woman with long term hospital care
Date : May 1, 2010
Contributed by
Jun Seong Son, M.D.
East-West Neo Medical Center, Kyung Hee University
Patient History
Age/Sex A 77-year old febrile woman
Chief complaint A 77-year old febrile woman with long term hospital care
Present illness 77-year-old woman with cerebral infarction was hospitalized to the department of rehabilitation medicine for the physical rehabilitation. The patient received subclavian venous catheter for TPN because she had the risk of aspiration when receiving tube feeding. On 43th day of hospitalization, the patient had a temperature of 38.3°C. The blood culture grew yeast and the subclavian venous catheter was removed. Intravenous fluconazole (400 mg once a day) was administered as empirical therapy, pending identification of the yeast. The qualitative culture of the catheter tip also grew yeast, too. The yeast from the blood cultures and catheter tip were idenditified as Pichia ohmeri by VITEK 1 system. However, the same isolate were identified as Candida sake by API 32C system. Despite continuous fluconazole treatment, mild fever was persistent, and the blood culture performed on 10th day of fluconazole therapy was still positive for yeast.
Initial laboratory findings Vital sign was stable and lab findings revealed a WBC of 11.4 x 109/liter, and a CRP of 12.8 mg/liter. The procalcitonin level was 24.7 ng/milliliter. The echocardiography, bone scan, abdominal CT, and doppler sonography didn\'t reveal significant finding. The sequence analysis was performed for further identification. The sequence of partial 26s rRNA gene (520 bp) of the isolate matched completely with the corresponding sequences of reference strain, Candida haemulonii strain TJY2d.

 
Question - ID Case of the Week ( May 1, 2010 )
What is your most reliable choice of antifungal agent for eradicating fungemia?
 
Correct Answer

Echinocandins (Caspofungin, Micafungin, etc)

 
Review

Candida haemulonii is not a frequently cause of human infection. 5~6 meaningful cases of Candida haemulonii fungemia were reported until now. In most previous cases, Candida haemulonii were microbiologically resistant to both fluconazole and amphotericin B. However, all susceptible to echinocandins such as caspofungin, micafungin and anidulafungin. Newer triazole such as voriconazole was not resistant to Candida haemulonii, although MIC level was relatively higher than echinocandins. Clinically, amphotericin B administerd empirically were all failed to eradicate candidemia.

 

Previous 1~2 studies showed that the identification results of the VITEK 2 system closely corresponded with those of tested molecular methods in identifying Candida haemulonii, while the VITEK 1 system and the API 32C system often failed to identify Candida haemulonii.

 


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