Recovery of fluconazole sensitive Candida ciferrii in a diabetic chronic obstructive pulmonary disease patient presenting with pneumonia
A 55-year-old, female, bidi smoker, suffering from moderate COPD (GOLD guidelines) for 2 years, presented to the emergency room with progressive increase in dyspnea and cough with copious mucopurulent expectoration for 15 days and 10 days respectively. Before her exacerbation, her symptoms were well controlled with tiotropium and a fixed dose combination of formoterol and budesonide. On general examination, she was tachypneic (respiratory rate 30/min); had cyanosis and used her accessory muscles of respiration. Respiratory system examination revealed diminished vesicular breath sound with prolonged expiration on left lower zone; bilateral polyphonic rhonchi all over the chest and coarse biphasic crackles over bilateral lung bases more on the right side. Her peripheral oxygen saturation was 74% in room air during the admission and improved to 88-92% with oxygen through face mask at a flow of 8 L/min. Her arterial blood gas showed pH 7.43, PaO2 70 mmHg, PaCO2 36 mmHg, PaO2/FiO2 234, suggestive of acute lung injury. She was a known diabetic for 15 years and had needed insulin for the control of diabetes for the past 6 months. On admission blood culture; sputum for gram stain, Ziehl-Neelsen (Z-N) stain and pyogenic culture with sensitivity were asked for. She received piperacillin-tazobactum (4.5 g) 6 hourly and azithromycin (500 mg) once daily, along with nebulization by salbutamol + ipratropium, injectable deriphylline and intravenous fluids. Her chest X-ray showed bilateral lower zone heterogeneous opacity, more on left side with clear costophrenic angles on lateral chest X-ray suggestive of bilateral pneumonia []. Total leukocyte count was 11,700/mm3 with neutrophil 67%, lymphocytes 28%, eosinophils 2%, basophil 1% and monocytes 2%. Serum urea was 34 mg%, creatinine 0.7 mg%, sodium 138 mEq/L, potassium 3.5 mEq/L. Her glycosylated hemoglobin level was 11.8 indicating uncontrolled diabetes. Sputum gram staining and Z-N staining were negative. Since, her condition did not improve after 2 days a computed tomographic scan of thorax was requested for further evaluation, which revealed left lower lobe collapse with consolidation along with patchy pulmonary infiltrations in the right middle and lower lobe []. Fiber-optic bronchoscopy was carried out to know the cause of collapse, which showed patchy whitish lesion in the lateral wall of trachea just above the carina with a mucous plug occluding the lumen of the left main bronchus and purulent discharge from right main bronchus []. Bronchoalveolar lavage fluid (BAL) was taken from those segments with clearing of that mucous plug and BAL fluid was sent for cytological examination, gram staining, fungal staining, Z-N staining, malignant cells, mycobacterial culture, and fungal culture. The antimicrobial susceptibility test was performed by microbroth dilution method by VITEK-2. Fungal staining of BAL and mucosal biopsy specimen showed yeast forms suggestive of Candida species []. The fungal culture showed moderate growth of Candida ciferrii. Intravenous liposomal amphotericin B (150 mg daily) was initiated and changed to oral fluconazole (150 mg daily) after 4 days, when drug sensitivity revealed that the strain was fluconazole sensitive []. After 4 days, she showed remarkable recovery and maintained oxygen saturation on room air. Patient was discharged after 2 weeks on oral fluconazole 150 mg daily. Chest X-ray on follow-up after 6 weeks showed marked improvement []. Antifungal therapy stopped after 3 months.