|Year : 2015 | Volume
| Issue : 2 | Page : 116-118
Candida tropicalis, an uncommon cause of pancreatic abscess: A case report
Beena Hemanth1, Partha Guchait2, Namrata Naithani2
1 Department of Microbiology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India
2 Department of Microbiology, M. S. Ramaiah Medical College and Teaching Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||31-Dec-2015|
Department of Microbiology M. S. Ramaiah Medical College, MSR Nagar, MSRIT Post,
Source of Support: None, Conflict of Interest: None
Candida is a ubiquitous fungus and can lead to various forms of infection like superficial, subcutaneous, and systemic-to-invasive infection. There are more than 20 species of Candida which can cause infection; of which, Candida albicans is the most common species. Candida can also cause deep-seated infection that can be due to hematogenous spread or through the direct introduction. Here, we report a rare case of pancreatic abscess in a 32-year-old male patient presenting with abdominal pain and fever. The pus aspirated from the abscess yielded the growth of Candida tropicalis and Pseudomonas aeruginosa. The patient was started on fluconazole and imipenem along with surgical necrosectomy. The patient recovered with subsidence of fever and abdominal pain.
Keywords: Candida tropicalis, pancreatic abscess, Pseudomonas aeruginosa
|How to cite this article:|
Hemanth B, Guchait P, Naithani N. Candida tropicalis, an uncommon cause of pancreatic abscess: A case report
. Int J Adv Med Health Res 2015;2:116-8
| Introduction|| |
Invasive fungal infections have recently emerged as one of the major causes of morbidity and mortality in immunocompromised people, and Candida species are the predominant fungi.  Occasionally, invasive candidiasis is also seen in immunocompetent host. Invasive candidiasis can manifest as an abscess in various organs in the form of deep-seated infections, and the organs affected are spleen, brain, lungs, liver, and occasionally pancreas. Pancreatic abscess is a localized infection with collection of pus and devitalized tissue in pancreas or around it. It is usually secondary to acute pancreatitis.  Pancreatic infections are mainly due to bacterial organism and may be polymicrobial, the origin being the gastrointestinal tract (GIT). Though uncommon, Candida can be a part of this polymicrobial infection or can be a cause by itself. Intra-abdominal candidal infection is common in patients who have undergone abdominal surgery or who are receiving peritoneal dialysis. They can cause diffuse infection with generalized peritonitis. ,
Among the few cases of pancreatic abscess caused by Candida, the most common species reported was Candida albicans, whereas Candida tropicalis and Candida krusei have been documented as a rare cause.  Hence, we report here a case of a 38-year-old male patient with pancreatic abscess who came with abdominal pain and fever. The pus aspirate sent for culture yielded the growth of C. tropicalis and Pseudomonas aeruginosa with a repeat sample also yielding the same isolate.
| Case Report|| |
A 38-year-old male patient came with abdominal pain and fever since 10 days. He was a known alcoholic and a diabetic. The patient was put on total parenteral nutrition and initially managed conservatively with intravenous (IV) cefuroxime. The patient was not relieved of the symptoms, so an ultrasonography (USG) guided pigtail catheter insertion was done. The USG showed the presence of minimal ascites, features of pancreatitis, and peripancreatic collection. A computed tomography (CT) scan of the abdomen showed enlarged pancreas, inflammatory changes, and necrosis around the pancreas [Figure 1]. A diagnosis of necrotizing pancreatitis was made, and pancreatic necrosectomy was performed. Pus was aspirated under CT guidance and sent to microbiology laboratory for culture and sensitivity. The patient continued to have spikes of fever and diffuse abdominal pain, so an exploratory laparotomy was done. The patient was started on fluconazole based on the preliminary report.
The blood investigation revealed the following values: Blood pressure-110/80 mmHg, pulse rate-100/min, hemoglobin-13.5 g/dL, total leucocyte count-22,600/mm 3 , aspartate aminotransferase-56 IU/mL (normal-30 IU/mL), alanine transaminase-74 IU/mL (normal-30 IU/mL), fasting blood sugar-186 mg/dL (normal 70-110 mg/dL), HbA1c-8.3% (normal <6%), serum creatinine-1.01 mg/dL (normal 0.7-1.2 mg/dL), sodium-136 mEq/L (normal 136-145 mEq/L), and potassium-4.8 mEq/L (normal 3.5-5.3 mEq/L). Patient was nonreactive for human immunodeficiency virus, hepatitis C virus, and hepatitis B surface antigen. No abnormality was seen in central nervous system, respiratory system, or cardiovascular system.
Gram-stain of the pus showed plenty of white blood cells, Gram-negative bacilli and Gram-positive yeast-like cells with pseudohyphae [Figure 2]. Potassium hydroxide wet mount showed the presence of yeast cells with pseudohyphae. No acid-fast bacilli were seen on Ziehl-Neelsen stain.
|Figure 2: Gram-stain showing Gram-positive yeast like cells with pseudohyphae|
Click here to view
The pus was inoculated on blood agar (BA), MacConkey agar, Thioglycollate media, Sabouraud's dextrose agar (SDA) with and without antibiotics, and incubated at 37C. After 24 h, tiny, cream-colored, yeasty colonies on SDA and BA were seen. The Gram-stain of these colonies showed oval yeast-like cells. P. aeruginosa was isolated from MacConkey and BA. Thioglycollate media did not yield any anaerobic organism.
Blood and urine samples remained sterile. The fungus was identified as C. tropicalis by germ tube test, sugar assimilation and fermentation, cornmeal agar, and CHROMagar [Figure 3]. Repeat culture of the pus and necrosectomy tissue again yielded the growth of C. tropicalis that was sensitive to fluconazole and amphotericin B. The patient was started on oral fluconazole 200 mg daily for 2 weeks and imipenem 1 g IV, BD for 5 days. The patient improved with subsidence of fever and discharged after 4 weeks.
| Discussion|| |
Candidal infection can range from nonlife threatening mucocutaneous disease to invasive disease that can involve any organ.  Candida is a ubiquitous fungi occurring in the gut and other regions on the body in healthy individuals. Pancreatic abscess is a late complication of acute necrotizing pancreatitis occurring more than 4 weeks after initial attack and occurs in 3% of these patients.  The pancreas is generally protected from invasion by fungus due to its retroperitoneal location. During abdominal surgery, a breach in its protective barrier can lead to invasion by Candida from the GIT through blood. ,,, Other modes of access to the pancreas could be through IV lines.
Normally, the level of Candida in the gut is maintained by commensal bacteria. If this ratio is disturbed due to antibiotics and decreased immunity, Candida can overgrow which may result in pancreatic infection due to the associated risk factors and predisposing condition. , The predisposing factors are cholelithiasis, alcohol abuse, infection, trauma, and diabetes. Most often, the enteric organisms like Escherichia coli and anaerobes play a role, so the role of Candida in causing pancreatic abscess is rare.  Diabetes is one of the risk factors, as in this condition, there is a shift toward TH2 axis and a fall in the TH1 mediated immune response, along with decreased cytokine response, low complement factor 4 which can lead to decreased humoral immunity. Reduced functions in chemotaxis and phagocytosis in diabetes may also be another reason.  Here, the patient was a diabetic and an alcoholic, which are the known risk factors.
The agents causing pancreatic abscess are E. coli, Klebsiella pneumoniae, Enterococcus faecalis, Staphylococcus aureus, P. aeruginosa, Proteus mirabilis, and Streptococcus species.  Bacteria can help in a favorable environment for the growth of Candida species leading to further injury of the organ. Though, in a few cases of pancreatic abscess, Candida was the sole cause, other studies have shown mixed growth of Candida with E. coli, S. aureus, and Enterobacter species. In this case, there was growth of C. tropicalis and P. aeruginosa.
Primary drainage of the abscess and debridement of the infected tissue are crucial. The significance of candidal isolation for the 1 st time in the sample received is questionable as they are a part of normal commensals of GIT. They can also colonize the drains used in the abdominal surgery. Clinical findings are similar to bacterial abscess. These factors can further delay the treatment leading to poor outcome. Therefore, a quick diagnosis with an early treatment can prevent the complications associated with pancreatic abscess.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ahmad S, Khan Z. Invasive candidiasis: A review of nonculture-based laboratory diagnostic methods. Indian J Med Microbiol 2012;30:264-9.
James MR, George AJ, Robert HS, Andrew LW. Pancreatic abscess due to Candida albicans
. Ann Intern Med 1982;97:221-2.
Kumar S, Bandyopadhyay MK, Bhattacharyya K, Ghosh T, Bandyopadhyay M, Ghosh RR. A rare case of pancreatic abscess due to Candida tropicalis
. J Glob Infect Dis 2011;3:396-8.
Keiser P, Keay S. Candidal pancreatic abscesses: Report of two cases and review. Clin Infect Dis 1992;14:884-8.
Zalilah M, Irfan M, Khairul BJ, Azian H. Candida albicans
retropharyngeal abscess. Pak J Otolaryngol 2014;30:29-31.
Abraham M. Pancreatic Necrosis and Pancreatic Abscess. Available from: http://www.emedicine.medscape.com/article/181264-overview. [Last accessed on 2015 June 07].
Chakrabarti A, Rao P, Tarai B, Shivaprakash MR, Wig J. Candida
in acute pancreatitis. Surg Today 2007;37:207-11.
Shanmugam N, Isenmann R, Barkin JS, Beger HG. Pancreatic fungal infection. Pancreas 2003;27:133-8.
Isenmann R, Schwarz M, Rau B, Trautmann M, Schober W, Beger HG. Characteristics of infection with Candida
species in patients with necrotizing pancreatitis. World J Surg 2002;26:372-6.
Gloor B, Müller CA, Worni M, Stahel PF, Redaelli C, Uhl W, et al.
Pancreatic infection in severe pancreatitis: The role of fungus and multiresistant organisms. Arch Surg 2001;136:592-6.
Malhotra S, Sharma S, Bhatia NJ, Kumar P, Hans C. A rare case of Candida
perforation peritonitis following analgesic use for fracture lower limb. Glob Adv Res J Microbiol 2013;2:211-2.
Sonavane A, Baradkar V, Salunkhe P, D'Souza D, Kumar S. Acute necrotizing pancreatitis with pancreatic abscess due to Prevotella
species in a diabetic. Indian J Med Microbiol 2010;28:64-7.
Song Z, Papanicolaou N, Dean S, Bing Z. Localized candidiasis in kidney presented as a mass mimicking renal cell carcinoma. Case Rep Infect Dis 2012;2012:953590.
[Figure 1], [Figure 2], [Figure 3]