Candida krusei-induced colitis: A rare opportunistic infection...diarrhea, melena, and nausea....
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Journal of Case Reports and Images in Pathology, Vol. 6, 2020. J Case Rep Images Pathol 2020;6:100042Z11AA2020. www.ijcripathology.com Arfa et al. 1 CASE REPORT PEER REVIEWED | OPEN ACCESS Candida krusei-induced colitis: A rare opportunistic infection Ahmed Arfa, Danielle Harrell, Amitabh Suman, Jesse L Kresak ABSTRACT Introduction: Candida colitis is a very rare condition that affects mainly immunocompromised patients. Most of the reported cases are Candida albicans infections with only one reported case of Candida glabrata and Candida tropicalis. Case Report: Our patient, a 68-year-old man with multiple myeloma status post two autologous stem cell transplants and one allogeneic transplant, to the best of our knowledge is the first reported case in the literature of Candida krusei-induced colitis. C. krusei, best known for its role in the production of chocolate, is found as a commensal in the human microbiome and rarely presents as an opportunistic pathogen. It is intrinsically resistant to fluconazole and thus accurate diagnosis is critical for proper treatment. Severe immunodeficiency is a high- risk factor for the development of a C. krusei infection, particularly in patients with hematologic malignancies, stem cell transplants, and interestingly, in patients exposed to azole antifungals and corticosteroid therapy. Conclusion: This case illustrates the first example of C. krusei colitis. C. krusei is a rare cause of disseminated fungal infection and it is important to recognize due to its resistance to fluconazole and its mortality. Keywords: Candidemia, Candida colitis, Candida krusei, Fungal colitis Ahmed Arfa 1 , MD, Danielle Harrell 1 , DO, Amitabh Suman 2 , MD, Jesse L Kresak 1 , MD Affiliations: 1 Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL, USA; 2 Department of Medicine, Division of Gastroen- terology, Hepatology and Nutrition, University of Florida, Gainesville, FL, USA. Corresponding Author: Jesse L Kresak, MD, 1600 SW Archer Rd, PO Box 100275, Gainesville, FL 32610, USA; Email: [email protected] Received: 06 July 2020 Accepted: 09 September 2020 Published: 08 October 2020 How to cite this article Arfa A, Harrell D, Suman A, Kresak JL. Candida krusei-induced colitis: A rare opportunistic infection. J Case Rep Images Pathol 2020;6:100042Z11AA2020. Article ID: 100042Z11AA2020 ********* doi: 10.5348/100042Z11AA2020CR INTRODUCTION Candida colitis is a very rare condition that affects mainly immunocompromised patients [1–3]. While there are nearly 150 species in the genus Candida, C. albicans, glabrata, and tropicalis comprise greater than 80% of all clinically isolated Candida cases [3]. Most of the reported cases of Candida colitis are of C. albicans infections with only one reported case of C. glabrata [4] and C. tropicalis [5]. Our patient, to the best of our knowledge, is the first reported case in the literature of C. krusei-induced colitis. CASE REPORT A 68-year-old male with stage IIA kappa light chain multiple myeloma and a history of two previous complicated autologous peripheral blood stem cell transplants was admitted to the bone marrow transplant unit. After undergoing BEAM conditioning (carmustine, etoposide, cytarabine, and melphalan), the patient received a stem cell transplant from his human leukocyte antigen (HLA)-identical brother. Fifteen days post- transplant, the patient showed no signs of engraftment yet was pancytopenic and displayed altered mental status. He experienced nausea, vomiting, and fifteen to twenty large watery bowel movements per day without improvement with anti-diarrheal medications or octreotide. The patient experienced weight loss and developed acute kidney injury secondary to dehydration. Computerized axial tomography (CT) scan of the abdomen showed subtle
Transcript of Candida krusei-induced colitis: A rare opportunistic infection...diarrhea, melena, and nausea....
Journal of Case Reports and Images in Pathology, Vol. 6, 2020.
J Case Rep Images Pathol 2020;6:100042Z11AA2020. www.ijcripathology.com
Arfa et al. 1
CASE REPORT PEER REVIEWED | OPEN ACCESS
Candida krusei-induced colitis: A rare opportunistic infection
Ahmed Arfa, Danielle Harrell, Amitabh Suman, Jesse L Kresak
ABSTRACT
Introduction: Candida colitis is a very rare condition that affects mainly immunocompromised patients. Most of the reported cases are Candida albicans infections with only one reported case of Candida glabrata and Candida tropicalis.
Case Report: Our patient, a 68-year-old man with multiple myeloma status post two autologous stem cell transplants and one allogeneic transplant, to the best of our knowledge is the first reported case in the literature of Candida krusei-induced colitis. C. krusei, best known for its role in the production of chocolate, is found as a commensal in the human microbiome and rarely presents as an opportunistic pathogen. It is intrinsically resistant to fluconazole and thus accurate diagnosis is critical for proper treatment. Severe immunodeficiency is a high-risk factor for the development of a C. krusei infection, particularly in patients with hematologic malignancies, stem cell transplants, and interestingly, in patients exposed to azole antifungals and corticosteroid therapy.
Conclusion: This case illustrates the first example of C. krusei colitis. C. krusei is a rare cause of disseminated fungal infection and it is important to recognize due to its resistance to fluconazole and its mortality.
Keywords: Candidemia, Candida colitis, Candida krusei, Fungal colitis
Ahmed Arfa1, MD, Danielle Harrell1, DO, Amitabh Suman2, MD, Jesse L Kresak1, MDAffiliations: 1Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL, USA; 2Department of Medicine, Division of Gastroen-terology, Hepatology and Nutrition, University of Florida, Gainesville, FL, USA.Corresponding Author: Jesse L Kresak, MD, 1600 SW Archer Rd, PO Box 100275, Gainesville, FL 32610, USA; Email: [email protected]
Received: 06 July 2020Accepted: 09 September 2020Published: 08 October 2020
How to cite this article
Arfa A, Harrell D, Suman A, Kresak JL. Candida krusei-induced colitis: A rare opportunistic infection. J Case Rep Images Pathol 2020;6:100042Z11AA2020.
Article ID: 100042Z11AA2020
*********
doi: 10.5348/100042Z11AA2020CR
INTRODUCTION
Candida colitis is a very rare condition that affects mainly immunocompromised patients [1–3]. While there are nearly 150 species in the genus Candida, C. albicans, glabrata, and tropicalis comprise greater than 80% of all clinically isolated Candida cases [3]. Most of the reported cases of Candida colitis are of C. albicans infections with only one reported case of C. glabrata [4] and C. tropicalis [5]. Our patient, to the best of our knowledge, is the first reported case in the literature of C. krusei-induced colitis.
CASE REPORT
A 68-year-old male with stage IIA kappa light chain multiple myeloma and a history of two previous complicated autologous peripheral blood stem cell transplants was admitted to the bone marrow transplant unit. After undergoing BEAM conditioning (carmustine, etoposide, cytarabine, and melphalan), the patient received a stem cell transplant from his human leukocyte antigen (HLA)-identical brother. Fifteen days post-transplant, the patient showed no signs of engraftment yet was pancytopenic and displayed altered mental status. He experienced nausea, vomiting, and fifteen to twenty large watery bowel movements per day without improvement with anti-diarrheal medications or octreotide. The patient experienced weight loss and developed acute kidney injury secondary to dehydration. Computerized axial tomography (CT) scan of the abdomen showed subtle
Journal of Case Reports and Images in Pathology, Vol. 6, 2020.
J Case Rep Images Pathol 2020;6:100042Z11AA2020. www.ijcripathology.com
Arfa et al. 2
bowel wall thickening in the ascending colon and cecum. Esophagogastroduodenoscopy and colonoscopy (Figure 1) were performed and demonstrated white plaques within the esophagus and mucosal ulceration within the colon. Histologic examination of biopsy specimens showed yeast forms within the ascending colon and esophagus (Figures 2 and 3). Yeast forms were identified within mucosa, lamina propria, and within vascular spaces. Concomitant blood cultures were positive for C. krusei. Sensitivities showed the organism to be resistant to fluconazole, but susceptible to micafungin. The patient was initiated
on Micafungin 150 mg intravenously (IV) daily and follow-up blood cultures demonstrated no growth. Ophthalmology evaluation showed no endophthalmitis or eye involvement. Transthoracic echocardiogram was negative for presence of vegetation.
DISCUSSION
C. krusei was first discovered in 1839 [6]. It is considered a commensal organism in humans with very low pathogenicity [3]. It has been isolated from mucosal membranes of healthy individuals and has been found in soil and various foods. C. krusei is biotechnologically employed in the fermentation of cocoa to chocolate and the fermentation of milk and juices [6]. Interestingly, recent genome sequencing showed that C. krusei and Pichia kudriavzevii are the same species with P. kudriavzevii being the sexual teleomorph form, thus it is possible in the near future that one of these classifications is removed from the taxonomy [6]. Rarely, C. krusei is implicated as an opportunistic infection causing candidemia, candiduria, disseminated infection, including soft tissue infection, or endophthalmitis [7–9]. Fortunately, krusei is the least common of the non-albican Candida species to cause disseminated infection because it has the lowest 90-day survival rates (53.6%) among the common Candida spp. [10]. Severe immunodeficiency is a high-risk factor for the development of a C. krusei infection, such as azole prophylaxis, hematologic malignancies, stem cell recipients, and corticosteroid therapy [3, 11]. C. krusei is intrinsically resistant to fluconazole [12] due to decreased sensitivity of cytochrome p450 isoenzyme [13]. Therefore, the use of alternative azoles, including posaconazole or voriconazole, echinocandins or amphotericin B, is required for treatment [14].
The presenting patient had several risk factors including hematologic malignancy, neutropenia, and immunosuppression after three peripheral blood stem cell transplants, and previous azole anti-fungal therapy. He developed candidemia and Candida colitis with diarrhea without any abdominal pain or fever. On the contrary, the patient who had developed C. tropicalis colitis had developed large voluminous mucous diarrhea and high-grade fever of 39 °C. In addition, stool examination revealed a few white red blood cells [5]. In contrast, the C. glabrata colitis patient presented with bloody diarrhea associated with sepsis and multi-organ failure [4].
CONCLUSION
Candida colitis is rarely reported in literature and to the best of our knowledge our patient is the first reported case of C. krusei colitis. For patients who are considered to be at high risk for opportunistic infections, Candida species should be considered as a possible cause for colonic and other gastrointestinal symptoms, such as
Figure 1: (A) Esophagogastroduodenoscopy demonstrating esophageal mucosa with white plaque lesions. (B) Colonoscopy demonstrating erythematous mucosa with ulceration of the ascending colon.
Figure 2: (A) H&E stained section of colonic mucosa with aggregates of basophilic yeast forms and associated mucosal erosion, hyalinization of the lamina propria and withered crypts (ischemic pattern). (B) 60×, H&E stained section, showing hyphal forms within a vessel and invading into adjacent mucosa.
Figure 3: H&E stained section of esophageal squamous mucosa with hyperkeratosis, acute inflammation, and intraepithelial yeast forms. Concomitant blood cultures were positive for Candida krusei.
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diarrhea, melena, and nausea. Fungal cultures are vital to identify the specific fungal organism to determine the appropriate antifungal therapy taking into consideration drug sensitivity and intrinsic resistance, especially in cases of C. krusei.
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*********Author ContributionsAhmed Arfa – Conception of the work, Design of the work, Acquisition of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved
Danielle Harrell – Design of the work, Analysis of data, Interpretation of data, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved
Amitabh Suman – Analysis of data, Interpretation of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved
Jesse L Kresak – Acquisition of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved
Guarantor of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone.
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Conflict of InterestAuthors declare no conflict of interest.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Copyright© 2020 Ahmed Arfa et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
Journal of Case Reports and Images in Pathology, Vol. 6, 2020.
J Case Rep Images Pathol 2020;6:100042Z11AA2020. www.ijcripathology.com
Arfa et al. 4
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