Candida albicans endocarditis in a child with acute lymphoblastic leukemia: A dreaded complication of intensive chemotherapy
A 7-year-old boy presented with slowly progressive generalized lymphadenopathy and splenomegaly. Peripheral blood and bone marrow examination revealed diagnosis of t-cell ALL. Central nervous system was uninvolved. Chemotherapy was initiated as per MCP 841 protocol. He achieved remission after induction and received two cycles of high-dose cytarabine (I2A) and repeat induction (RI1). Following high-dose cytarabine, he developed febrile neutropenia and necrotizing cellulitis at left wrist requiring higher antibiotics. After the second dose of high-dose cytarabine, he had central venous catheter (CVC)-related blood stream infection with Candida parapsilosis. The organism was isolated both from the catheter (peripherally inserted central catheter) and peripheral blood. The organism was sensitive to fluconazole, amphotericin-B, and voriconazole in vitro, but he did not respond clinically or microbiologically to intravenous fluconazole given for 10 days. Hence, the catheter was removed.\nAt the end of repeat induction, he developed non-neutropenic fever. In view of impending neutropenia, he was started on piperacillin–tazobactum and amikacin. C-reactive protein was elevated on day 1 (76.5 mg/L). He became severely neutropenic by the fifth day of fever. As fever spikes continued, antibiotics were changed to meropenem and vancomycin. Multiple blood cultures did not detect any organisms. In absence of defervescence, liposomal amphotericin-B was added after 7 days of antibiotics. As fever still persisted, antibiotics were changed to ceftazidime and tiecoplanin. Abdominal ultrasound revealed hepatosplenomegaly with splenic infarcts and internal echoes in urinary bladder. Computed tomography revealed multiple wedge-shaped hypodense areas in spleen and both kidneys suggestive of infarcts []. Urine analysis was normal and urine culture was sterile. The fever persisted after resolution of neutropenia. A 2D echocardiogram revealed multiple vegetations (largest 1.4 × 0.7 cm) on the septal and anterior leaflets of the tricuspid valve (TV). All cultures were negative. In view of blood culture-negative infective endocarditis (BCNIE), vancomycin and gentamycin were started and liposomal amphotericin-B was continued.\nIn view of persistent fever spikes and the absence of reduction of vegetations after 13 days of vancomycin and gentamycin and 19 days of amphotericin-B, option of surgery was considered. Multiple vegetations were noticed intra-operatively on all three leaflets of TV, largest (2.5 × 2.0 × 2.5 cm) being on the septal leaflet and one each on anterior and lateral leaflet []. Surgical excision of the vegetations was done from anterior and lateral leaflets. The septal leaflet was excised due to large adherent vegetation. Postoperatively, he developed acute renal failure, metabolic acidosis, and refractory septic shock and succumbed on the third postoperative day. The culture from the vegetations grew C. albicans.