A 68-year-old male with fevers, lethargy, and anorexia was admitted.
Discussion
This case highlights not only the benefit of rapid species identification with the T2Canida Panel but also timely diagnosis of Candida endocarditis that may present as culture-negative endocarditis. It also illustrates the potential role of T2Candida in monitoring clinical response in a persistently positive Candida endocarditis patient.
Presentation
A 68-year-old male with a past medical history of systolic heart failure with ICD placement, ulcerative colitis status post a colectomy, cirrhosis secondary to primary sclerosing cholangitis underwent a liver transplant. A few months later the patient was admitted with fevers, lethargy, and anorexia. Routine blood cultures were negative, however, Cytomegalovirus (CMV) levels were positive and IV ganciclovir was initiated. The patient remained in the hospital for five days and was discharged home. The patient was readmitted ten days later with fever, fatigue, and a blind spot in the right eye with improving CMV. Blood culture and T2Candida were drawn, and anidulafungin was started. T2Candida was reported positive for C. albicans/C. tropical and ophthalmology obtained intravitreal cultures which were positive for C. albicans. A TTE was obtained and was negative for vegetation. Blood cultures were pending but negative to date. ID recommended intravitreal voriconazole injections, fluconazole 800mg daily adjusted for renal function for six months and to continue IV anidulafungin for two weeks and discharged home. The patient was re-admitted for a 3rd time with fevers up to 104° F, dyspnea, and fatigue. CMV PCR was negative, blood cultures were drawn, and another T2Candida was obtained. T2Candida remained persistently positive whereas the blood cultures were persistently negative to date. The patient was continued on fluconazole and restarted on anidulafungin.
Pleural and pericardial effusions were identified and no organism was detected via multiple different diagnostic tests. A TEE was done due to the persistently positive T2Candida and mobile vegetation was identified on the pulmonic valve. The patient was considered to be too high risk for surgical removal of the vegetation thus an angiovac was done by interventional radiology. Tissue cultures of the vegetation were obtained and C. albicans and S. hominis grew out. Repeat ophthalmology evaluation showed retinitis improving.
Patient Selection Criteria
Empiric use of an echinocandin
Evaluation and Treatment
Diagnosis: Candida retinitis and Candida infective endocarditis
Empiric Therapy: The patient was started on anidulafungin
T2Candida Panel Result: Positive for C. albicans/C. tropicalis, negative for the remaining three pathogens.
Blood Culture Result: No growth
Decision making based on the T2Candida Result
A rapid and persistent T2Candida positive for C. albicans/C. tropicalis prompted the team start the patient on anidulafungin and fluconazole due to the source of the infection. Once Candida retinitis was confirmed it lead to the addition of intravitreal voriconazole. Due to the persistent T2Candida despite being on adequate therapy, it further prompted clinicians to investigate an alternate source of infection leading to the detection of fungal infective endocarditis. Post removal of the vegetation an additional T2Candida was obtained and was negative. Once stable the patient was discharged home with IV anidulafungin, fluconazole and vancomycin.