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 Initial Dx 2001  chemo 2001 & 2002 & XRT (axilla & groin) & XRT (axilla & groin) 2003  remission 2003  remission 2004 Nov  recurrence 2004 Nov  recurrence Fludarapine & steroid Fludarapine & steroid

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

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

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

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

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

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

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

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

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

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

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

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

Candidemia  Overall 3 months mortality 40% Cause specific mortality 12% 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  Underlying malignancy,Neutropenia Steroid & Lines Steroid & Lines Clinical Infectious Dis Sept 2003 Clinical Infectious Dis Sept 2003

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 Vs Fluconazole 800mg loading &400 mg/d  Switch to Ampho B in case of C.glabrata & C.crusie Eur J Clin Microbiol Infect Dis May Eur J Clin Microbiol Infect Dis May

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

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 Clinical infectious Dis May 2003

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

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 Clinical infectious Dis May 2003