Candidiasis: An unusual cause of persistent high-grade fever in mid-pregnancy
A 29-year-old female in 27th week of her gestation presented to obstetrical emergency ward with chief complaints of high-grade fever for the last 8 days. Initially, she was treated as an outpatient at the community hospital by a primary physician for fever and mild cough. She was prescribed tablet Amoxicillin 500 mg four times daily for 5 days on suspicion of upper respiratory tract infection on an empirical basis. In addition, her routine investigations done at a community hospital revealed a hemoglobin value of 10.8 g%, a random blood sugar value of 132 mg%, a blood count value of 10,600/cumm. No abnormality was detected in the routine urine examination. On the basis of investigation reports, she was discharged home on the same day by the primary care physician after the routine examination. In spite of taking the prescribed medication, no clinical improvement occurred and fever could be controlled only intermittently by administration of antipyretics. However, after completion of the prescribed duration of antibiotic therapy, fever remained persistently high in the range of 100–102 °F. The pregnant state, persistent fever refractory to treatment, discomfort, and resulting anxiety were the main decisive factors, which forced the primary physician to refer the patient to a higher center instead of going for the battery of tests for PUO during the follow-up visit. The entire treatment was carried out at home, and she was never admitted at the community hospital.\nOn admission at our tertiary care center, besides fever, she did not give any history of bowel symptoms but dysuria was one of the presenting features. After a thorough initial clinical evaluation, all the requisite investigations for possible causes of pyrexia were sent for. Her general physical examination revealed numerous maculopapular lesions over the upper abdomen including the inframammary region. [] On local examination of genitalia, a purulent and foul smelling discharge was present at the vagina along with extensive vulval ulceration as well as the presence of papular lesions on the perineum, groin, and inguinal region. The most striking feature during her physical examination were the presence of rashes which the patient did not convey to the primary care physician as these were thought to be of little significance and unrelated to pregnancy by the parturient. Moreover, in an Indian set-up, female pregnant patients are reluctant to allow for complete examination by the attending primary physician. Ultrasonography (USG) examination of the abdomen was not informative of any significant pathology and a live foetus of approximately 27 weeks gestation was confirmed by USG report. Awaiting the laboratory investigations, an urgent physician and dermatologist consultation was sought. She was provisionally diagnosed to be a case of PUO with possibility of systemic bacterial infection and local fungal infection (intertrigo). On the basis of provisional diagnosis, she was prescribed tablet cefoperazone in an empirical manner and local application of clotrimazole powder. The laboratory profile turned out to be absolutely normal including blood count, urine complete and culture sensitivity examination, blood culture and sensitivity, erythrocyte sedimentation rate, malaria parasite film, renal function panel, liver function tests, sputum culture and sensitivity, viral markers for HIV and hepatitis, VDRL, and other pathologies. Other routine investigations such as blood sugar were absolutely normal, but peripheral blood film revealed the presence of normochromic normocytic anemia. In spite of administration of antibiotic therapy, she had persistent fever in the range of 101–102°F with occasional remissions of few hours after administration of antipyretics.\nThe clinical scenario of refractory fever and the laboratory findings enforced us to review our diagnosis. After thorough discussion among the physician, dermatologist and the obstetrician, a possible diagnosis of intertrigo with severe invasive and systemic candidiasis infection was thought of. The clinical scenario was thought of as a flare-up of opportunistic fungal infection in the context of systemic administration of antibiotics. However, the contradictory fact to this clinical scenario was the presence of these rashes for the last one month. The diagnosis was further confirmed by the presence of candida growth on KOH preparation and she was treated with fluconazole tablet 150 mg once a week, washing with KMnO4 and local application of clotrimazole powder besides the administration of ongoing antibiotic regimen. She responded to this therapeutic regimen and fever subsided gradually over a period of 2 days. The entire later course of gestation was uneventful, and the patient delivered a normal healthy baby at term pregnancy.