|Year : 2006 | Volume
| Issue : 4 | Page : 160-162
Lung abscess due to pulmonary candidiasis
Prem Prakash Gupta1, Dipti Agarwal2, R Yadav3
1 Department of Tuberculosis & Respiratory Medicine, Postgraduate Institute of Medical Sciences, Rohtak., India
2 Department of Physiology, Postgraduate Institute of Medical Sciences, Rohtak., India
3 Department of Radiodiagnosis, Postgraduate Institute of Medical Sciences, Rohtak., India
Prem Prakash Gupta
9J/17, Medical Enclave, PGIMS, Rohtak-124001.
Source of Support: None, Conflict of Interest: None
Clinical trial registration None
| Abstract|| |
Here we describe a patient who developed lung abscess caused by Candida albicans. There was no evidence of disseminated/ extrapulmonary candidiasis or any immunodeficiency. However, he was taking high doses of inhaled corticosteroid for chronic airflow obstruction. CT guided percutaneous needle aspiration provided the specimen which confirmed the diagnosis of pulmonary candidiasis. His sputum culture was also positive for Candida albicans. The patient achieved favourable outcome with a 4 weeks treatment with fluconazole. The case is presented here due to unique possible association of pulmonary candidiasis with intake of high doses of inhaled corticosteroids.
Keywords: Pulmonary candidiasis, lung abscess, inhaled budesonide, CT guided percutaneous needle aspiration, fluconazole
|How to cite this article:|
Gupta PP, Agarwal D, Yadav R. Lung abscess due to pulmonary candidiasis. Lung India 2006;23:160-2
| Introduction|| |
Candida albicans is the most common cause of candidiasis. It is a common skin, oral, gastrointestinal saprophyte which is usually held in check by an intact mucosa and only become pathogenic when mucous membrane or skin is damaged or when the host is immunocompromised. C. parapsilosis is particularly notable for its ability to cause endocarditis. C. tropicalis is responsible for about one-third of the cases of deep candidiasis. Pulmonary candida infections may present as the manifestations of disseminated candidiasis spread by hematogenous route or as a primary bronchial or pulmonary process from the airways  . The latter condition is not reported frequently particularly because there are no established and reliable methods for making diagnosis  . Primary pulmonary candidiasis in normal hosts is extremely rare and inhaled corticosteroids as a predisposing factor for development of pulmonary candidiasis, to best of our knowledge, has not been described in medical literature.
| Case Report|| |
A 42-year male office worker, smoker (20 pack years), and a non-alcoholic presented for the first time at our Institute with a history of persistent fever upto 102 0 F for 20 days, cough with expectoration and pain chest for 12 days. There was no history of any intravenous drug use, diabetes mellitus, hospitalization or trauma. In past, he was diagnosed to have pulmonary tuberculosis at the age of 18 years and for which he took antitubercular chemotherapy for one year with favourable outcome. He developed symptoms suggestive of chronic obstructive pulmonary disease at the age of 32 years for which he took irregular treatment mostly comprising of the oral theophyline; however, he continued the smoking despite of medical advice to quit. His symptoms became more severe 5 years back when he started inhaled corticosteroid and salbutamol along with oral theophyline. For last 6 months, he was taking higher doses of inhaled budesonide (1200gg/day) without using any spacer device and also, the rinsing of mouth after inhalation was not regular. Physical examination of the patient was unremarkable except bilateral polyphonic wheezes and crackles over right infraclavicular region.
Complete haemogram revealed Hb 14.2 g/dL, TLC 9800/mm 3 with polymorphonuclear cells (66%), lymphocytes (28%) and a normal peripheral blood film. Urinalysis and biochemical parameters including blood sugar were within normal limits. Chest roentgenogram [Figure 1] was suggestive of lung abscess over right upper zone abutting the mediastinum. Sputum microbiology for pyogenic organisms revealed normal airway commensals. There was no acid fast bacillus in 3 consecutive concentrated sputum smear. Tuberculin test produced an induration of the size 10x10mm at 48 hours. Clarithromycin 500mg bd along with inhaled salbutamol and ipratropium bromide and other supportive treatment were started. As there was no clinical or radiological improvement, computed tomography [Figure 2] was carried out and CT guided percutaneous needle aspiration was done. The specimens obtained were submitted for microbiological and mycological investigations. The culture using the sabouraud's glucose agar (at 25 o C) showed creamy smooth colonies at 48 hours. Candida albicans was presumably identified by chlamydoconidia (spherical macroconidia) production over cornmeal agar with Tween 80. Mycelial morphology, carbohydrate fermentation and carbohydrate assimilation tests were used to confirm the diagnosis. The specimen cytology did not contribute any further. At this time sputum was collected after the thorough cleaning of mouth by the patient and freshly collected sputum was inoculated for fungus culture and that also confirmed the diagnosis of Candida albicans. The serology for human immunodeficiency virus was carried out after obtaining the consent of the patient and it was negative. The patient was given fluconazole 400mg OD first day and 200mg OD thereafter, which was continued for a total period of 4 weeks. He was also given other supportive medication. The patient achieved good clinical as well as radiological improvement [Figure 3].
| Discussion|| |
Candida is wide spread in the environment and a common human commensal. The fungus is usually found in the human gastrointestinal tract, in the female genital tract, and on the skin. Alteration in the usual distribution occurs when the normal microbial flora is diminished by antibiotic therapy or when host defenses are impaired  . Normal host have only rarely been reported to develop pulmonary candidiasis and most reported cases are immunocompromised  . The known risk factors for invasive candidiasis include prolonged neutropenia, recent surgery, broad spectrum antibiotic therapy, the presence of intravascular catheters (especially when providing total parenteral nutrition), and intravenous drug use. Cellular immunodeficiency including that associated with HIV infection generally predisposes to mucocutaneous disease. Inhaled corticosteroids are known to cause oropharyngeal candidiasis with widely varying frequencies (up to 77%), though, dosing frequency as well as total dose may affect the incidence , . The use of a spacer with pressurized metered dose inhalers certainly diminishes the risk of candidiasis by reducing oropharyngeal deposition from about 80% to about 20% , . However, to best of our knowledge, pulmonary candidiasis in association with inhaled corticosteroids in an otherwise immunocompetent person has not been described in medical literature and our case is unique with such coexistence.
Candida is reported to colonize the preexisting pathological lesions as observed in present case where the preexisting tuberculous lesions were involved. Candida infections of the bronchi and the lungs are difficult to diagnose definitively. The isolation of yeast from sputum does not prove the presence of yeast in the respiratory tract due to contamination with commensals from the oropharynx  . Bronchial washings or bronchoalveolar lavage provide a more representative specimen, though they can still be contaminated with mouth flora. If other organisms are absent and abundant candida pseudohyphae are present, clinical suspicion of invasive candidiasis should be high. The demonstration of tissue invasion by candida on open lung biopsy is definitive; though not practically possible in all cases. Percutaneous needle biopsy and aspirate can be used to provide direct microscopic evidence of infection if the pulmonary lesion is abutting the chest wall as it was in present case in which a definitive diagnosis could be made on the basis of PCNA. Demonstration of fungemia and funguria may be suggestive of the diagnosis of disseminated disease but is not necessarily evidence of pathogenicity. Serological tests are not regarded as having much value in diagnosis. Recently, rapid nucleic acid assays with fungus specific sequences, using polymerase chain reaction (PCR) technology are also available for C. albican and specific DNA can be detected in culture positive urine, blood, respiratory tract and wound specimens  .
Amphotericin B has been the mainstay for treatment of candida infections along with reversal of factors affecting the immune status of the individual. [l3] But because of its possible toxicity, parenteral amphotericin B is only used when the fungal infection is progressive and potentially fatal. Fluconazole may be used as a less toxic alternative to amphotericin B for treatment in nonneurtropenic patient with disseminated candidiasis but without any major immunodeficiency. , In present case report the patient had good response to fluconazole.
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[Figure 1], [Figure 2], [Figure 3]