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An unusual case of candidemia presenting as acute respiratory distress syndrome after a small bowel bezoar removal operation.

Mun YS, Lee MS, Park JS, Lee JW, Jung SY, Yoon HJ, Han HY - Ann Surg Treat Res (2014)

Bottom Line: The patient was successfully treated with intensive care including mechanical ventilation and systemic antifungal therapy.A strong association was observed between the intestinal obstruction caused by the bezoar and candidemia presenting as ARDS.This is the first case in which candidemia has led to ARDS after a bezoar removal operation in a patient who was neither immunocompromised nor self-administering an illicit intravenous drug.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Eulji University Hospital, Daejeon, Korea.

ABSTRACT
We report a rare case of sepsis with acute respiratory distress syndrome (ARDS) caused by Candida parapsilosis and Candida famata after a small bowel bezoar operation. The patient was successfully treated with intensive care including mechanical ventilation and systemic antifungal therapy. A strong association was observed between the intestinal obstruction caused by the bezoar and candidemia presenting as ARDS. This is the first case in which candidemia has led to ARDS after a bezoar removal operation in a patient who was neither immunocompromised nor self-administering an illicit intravenous drug.

No MeSH data available.


Related in: MedlinePlus

(A) Chest x-ray on postoperative day 7. Diffuse ground glass opacity in the both upper lobe of the lung. (B) Chest x-ray on the seventh day of antifungal treatment. Disappearance of diffuse ground glass opacity in the both upper lobe of the lung.
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Figure 3: (A) Chest x-ray on postoperative day 7. Diffuse ground glass opacity in the both upper lobe of the lung. (B) Chest x-ray on the seventh day of antifungal treatment. Disappearance of diffuse ground glass opacity in the both upper lobe of the lung.

Mentions: A 51-year-old man presented with abdominal pain and vomiting and was admitted for a suspected diagnosis of an intestinal obstruction. Several days prior to symptom onset, the patient had eaten uncertain quantities of persimmon. His medical history was significant for a previous abdominal operation to repair a small bowel perforation 20 years ago. The admission laboratory studies were significant for leukocytosis (19,240/µL) and a hemoglobin concentration of 18.3 g/d, but normal for C-reactive protein (0.07 mg/dL). Body temperature was 36.5℃. Abdominal distension was observed with mild tenderness over the epigastric area was noted. A serologic investigation for the immunocompromised state (HIV antibody) was negative. An abdominal CT scan revealed a mechanical obstruction in the ileum with a 5.5 × 2.5-cm ovoid bezoar and mild splenomegaly (Fig. 1). Laboratory studies at 4 days after admission were significant for decrease of leukocytosis (7,690/µL), but increase for C-reactive protein (4.02 mg/dL). Because his symptoms had not resolved by day 5 of hospitalization despite spontaneous intermittent decompression of small bowel obstruction, the patient underwent a bezoar removal operation. An intraoperative examination revealed small bowel dilatation with no signs of small bowel ischemia. The bezoar was identified in the ileum and was extracted through an enterotomy, followed by decompression of the dilated bowel. The bezoar was a 6.0 × 3.5 × 3.0 cm, green and sclerous (Fig. 2). The patient tolerated the procedure well. However, the postoperative course was complicated by recurrent episodes of fever (>38℃) on day 2, which was thought to be caused by postoperative atelectasis. The patient began to pass flatus and started on a progressive diet by postoperative day 5. On postoperative day 7, the patient developed dyspnea, and chest radiography showed diffuse ground glass opacity. Subsequent, ARDS was diagnosed, based on the PO2:FIO2 ratio and diffuse, bilateral radiographic consolidation (Fig. 3A). The patient was transferred to the intensive care unit and was supported on mechanical ventilation. Blood cultures collected from postoperative day 4 revealed yeast, and the patient was started on an empiric therapy of 400-mg intravenous fluconazole (Oneflu, Choongwae Pharma, Seoul, Korea) daily pending identification of the yeast. The blood cultures from postoperative day 4 eventually grew C. famata, and those from postoperative days 6 and 7 grew C. parapsilosis. Despite 4 days of intravenous fluconazole treatment, the fever and leukocytosis persisted, and an additional history of antifungal treatment for tinea pedis 3 years ago was obtained from family members. Therefore, the empiric therapy was changed to intravenous 325-mg amphotericin B (Ambisome, Yuhan Pharma, Seoul, Korea) daily. Additionally, intravenous 125-mg methylprednisolone (Salon, Hanlym Pharma, Seoul, Korea) was administrated daily for 14 days, followed by a tapering over a 2-week period. The stool culture collected from postoperative day 12 grew Candida glabrata. On postoperative day 18, the antifungal treatment regimen was changed to 50-mg intravenous caspofugin (Cancidas, MSD Sharp & Dohme GmbH, Schweiz, Germany) daily, because of amphotericin-associated nephrotoxicity. On day 7 of antifungal treatment, the patient became afebrile and showed clinical improvement (Fig. 3B). Blood cultures from days 7, 10 and 14 after the initiation antifungal therapy were sterile. In total, the patient had undergone a 30-day course of antifungal therapy (4 days of fluconazole, 7 days of amphotericin B, and 19 days of caspofugin) and was discharged on postoperative day 37.


An unusual case of candidemia presenting as acute respiratory distress syndrome after a small bowel bezoar removal operation.

Mun YS, Lee MS, Park JS, Lee JW, Jung SY, Yoon HJ, Han HY - Ann Surg Treat Res (2014)

(A) Chest x-ray on postoperative day 7. Diffuse ground glass opacity in the both upper lobe of the lung. (B) Chest x-ray on the seventh day of antifungal treatment. Disappearance of diffuse ground glass opacity in the both upper lobe of the lung.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4279988&req=5

Figure 3: (A) Chest x-ray on postoperative day 7. Diffuse ground glass opacity in the both upper lobe of the lung. (B) Chest x-ray on the seventh day of antifungal treatment. Disappearance of diffuse ground glass opacity in the both upper lobe of the lung.
Mentions: A 51-year-old man presented with abdominal pain and vomiting and was admitted for a suspected diagnosis of an intestinal obstruction. Several days prior to symptom onset, the patient had eaten uncertain quantities of persimmon. His medical history was significant for a previous abdominal operation to repair a small bowel perforation 20 years ago. The admission laboratory studies were significant for leukocytosis (19,240/µL) and a hemoglobin concentration of 18.3 g/d, but normal for C-reactive protein (0.07 mg/dL). Body temperature was 36.5℃. Abdominal distension was observed with mild tenderness over the epigastric area was noted. A serologic investigation for the immunocompromised state (HIV antibody) was negative. An abdominal CT scan revealed a mechanical obstruction in the ileum with a 5.5 × 2.5-cm ovoid bezoar and mild splenomegaly (Fig. 1). Laboratory studies at 4 days after admission were significant for decrease of leukocytosis (7,690/µL), but increase for C-reactive protein (4.02 mg/dL). Because his symptoms had not resolved by day 5 of hospitalization despite spontaneous intermittent decompression of small bowel obstruction, the patient underwent a bezoar removal operation. An intraoperative examination revealed small bowel dilatation with no signs of small bowel ischemia. The bezoar was identified in the ileum and was extracted through an enterotomy, followed by decompression of the dilated bowel. The bezoar was a 6.0 × 3.5 × 3.0 cm, green and sclerous (Fig. 2). The patient tolerated the procedure well. However, the postoperative course was complicated by recurrent episodes of fever (>38℃) on day 2, which was thought to be caused by postoperative atelectasis. The patient began to pass flatus and started on a progressive diet by postoperative day 5. On postoperative day 7, the patient developed dyspnea, and chest radiography showed diffuse ground glass opacity. Subsequent, ARDS was diagnosed, based on the PO2:FIO2 ratio and diffuse, bilateral radiographic consolidation (Fig. 3A). The patient was transferred to the intensive care unit and was supported on mechanical ventilation. Blood cultures collected from postoperative day 4 revealed yeast, and the patient was started on an empiric therapy of 400-mg intravenous fluconazole (Oneflu, Choongwae Pharma, Seoul, Korea) daily pending identification of the yeast. The blood cultures from postoperative day 4 eventually grew C. famata, and those from postoperative days 6 and 7 grew C. parapsilosis. Despite 4 days of intravenous fluconazole treatment, the fever and leukocytosis persisted, and an additional history of antifungal treatment for tinea pedis 3 years ago was obtained from family members. Therefore, the empiric therapy was changed to intravenous 325-mg amphotericin B (Ambisome, Yuhan Pharma, Seoul, Korea) daily. Additionally, intravenous 125-mg methylprednisolone (Salon, Hanlym Pharma, Seoul, Korea) was administrated daily for 14 days, followed by a tapering over a 2-week period. The stool culture collected from postoperative day 12 grew Candida glabrata. On postoperative day 18, the antifungal treatment regimen was changed to 50-mg intravenous caspofugin (Cancidas, MSD Sharp & Dohme GmbH, Schweiz, Germany) daily, because of amphotericin-associated nephrotoxicity. On day 7 of antifungal treatment, the patient became afebrile and showed clinical improvement (Fig. 3B). Blood cultures from days 7, 10 and 14 after the initiation antifungal therapy were sterile. In total, the patient had undergone a 30-day course of antifungal therapy (4 days of fluconazole, 7 days of amphotericin B, and 19 days of caspofugin) and was discharged on postoperative day 37.

Bottom Line: The patient was successfully treated with intensive care including mechanical ventilation and systemic antifungal therapy.A strong association was observed between the intestinal obstruction caused by the bezoar and candidemia presenting as ARDS.This is the first case in which candidemia has led to ARDS after a bezoar removal operation in a patient who was neither immunocompromised nor self-administering an illicit intravenous drug.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Eulji University Hospital, Daejeon, Korea.

ABSTRACT
We report a rare case of sepsis with acute respiratory distress syndrome (ARDS) caused by Candida parapsilosis and Candida famata after a small bowel bezoar operation. The patient was successfully treated with intensive care including mechanical ventilation and systemic antifungal therapy. A strong association was observed between the intestinal obstruction caused by the bezoar and candidemia presenting as ARDS. This is the first case in which candidemia has led to ARDS after a bezoar removal operation in a patient who was neither immunocompromised nor self-administering an illicit intravenous drug.

No MeSH data available.


Related in: MedlinePlus