Asian Annals
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kok, V. K.
Right arrow Articles by Lee, F. C.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Kok, V. K.
Right arrow Articles by Lee, F. C.
Asian Cardiovasc Thorac Ann 2000;8:384-386
© 2000 Asia Publishing EXchange Pte Ltd

CASE STUDY

Successful Treatment of Candida Pericarditis Following Sternotomy

Kok Va Kei, MD, Chu Ming Yuan, MD,1, Wong Ying Kit, MD,1, Lee Fa Chieh, MD,2

Department of Surgery
1 Department of Internal Medicine
2 Department of Laboratory
Far Eastern Memorial Hospital
Taipei, Taiwan
For reprint information contact: Kok Va Kei, MD Tel: 886 2 2351 1176 Fax: 886 2 2883 2699 email: kokvakei{at}ms29.hinet.net 5th Floor No. 17, Lane 12, Chin-Tien Street, Taipei 106, Taiwan, ROC.

   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 References
 
A 34-year-old man who was stabbed in the chest, underwent emergency sternotomy. Sternal dehiscence with pericardial tamponade developed by the 16th postoperative day. Pericardiotomy with drainage was performed and cultures of pericardial fluid yielded Candida tropicalis. The patient was treated successfully with fluconazole.


   Introduction
TOP
 Abstract
 Introduction
Case Report
 Discussion
 References
 
Purulent pericarditis caused by Candida species is a rare and often fatal infection that was first described in 1967.1 In a literature review, 12 of 14 patients with Candida pericarditis died.2 Several groups of patients have been identified as being at increased risk of Candida pericarditis, including those who have undergone thoracic surgery and immunocompromised hosts with systemic fungemia.2 We describe a case of purulent pericarditis due to Candida tropicalis that developed after sternotomy.


   Case Report
TOP
 Abstract
 Introduction
 Case Report
Discussion
 References
 
A 34-year-old healthy male truck driver was admitted because of a stab injury to his left chest. A penetrating wound was found near the sternal border on the left second intercostal space. Hypovolemic shock developed, which was judged to be due to intrathoracic hemorrhage. An emergency sternotomy was performed. The operative finding showed an intact mediastinum and a laceration of the left upper lobe of the lung. First-generation cefazolin sodium was given intravenously after the operation. No drug abuse or septic shock syndrome was recorded. The patient had an uneventful recovery without signs of infection and the intravenous antibiotic agents were stopped on the 8th postoperative day. The follow-up white blood cell count was within normal limits. Blood was collected intermittently via chest tube and the last chest tube was removed on the 12th postoperative day. He complained of pleuritic pain without fever after this chest tube was removed. Subsequent chest radiography demon-strated enlargement of the cardiac silhouette. Computed tomography scans of the chest (Figure 1Go) and transthoracic two-dimensional echocardiograms (Figure 2Go) indicated sternal dehiscence and pericardial effusion. Repeat sternotomy and pericardiotomy revealed pneumoperi-cardium with an air leak, turbid pericardial fluid was collected on the 16th hospital day. The pericardial fluid showed a yeast-like organism on the smear and Candida tropicalis in culture (Figure 3Go). Following the mediastinal culture, blood and urine cultures were sterile. Fluconazole (400 mg daily) was administered intravenously for 4 weeks. The patient's condition improved substantially after surgery. Postoperative two-dimensional echocardio-graphy showed no fluid accumulation in the pericardial sac. The patient has remained asymptomatic for over 18 months.



View larger version (168K):
[in this window]
[in a new window]
  		Figure 1. Computed tomography scan of the chest showing sternal separation with fluid accumulation, pericardial effusion, and bilateral pleural effusion.

 


View larger version (111K):
[in this window]
[in a new window]
  		Figure 2. Two-dimensional echocardiogram showing massive pericardial effusion (PE). LV = left ventricle, RV = right ventricle.

 





View larger version (360K):
[in this window]
[in a new window]
  		Figure 3. (A) The specimen was plated on chocolate agar and blood agar; the small white smooth colonies were seen after 48 hours of incubation. (B) The colonies of Candida tropicalis were bluish purple with a halo (arrowheads) on CHROM agar. (C) Identification of a yeast-like organism was achieved by performing a slide culture (original magnification xl00). (D) The organism formed single blastoconidia along long pseudohyphae (black arrows) on corn meal Tween 80 agar.

 

   Discussion
TOP
 Abstract
 Introduction
 Case Report
 Discussion
References
 
Candida species are an infrequent but usually fatal cause of purulent pericarditis. In an extensive review of 425 cases of purulent pericarditis by Boyle and colleagues3 in 1961, none were found to be due to Candida organisms. To our knowledge, only 26 cases of Candida pericarditis were reported between 1967 and 1997 in the Englishlanguage literature.4 The pericardium is rarely the primary site of infection. Several considerations support the possibility that pericardial Candida infections are a form of hematogenously disseminated disease.5,6 Candida albicans was isolated in over half of the documented cases of fungemia, and Candida tropicalis was isolated in 17% to 25% of cases.5,6 All of the patients infected with Candida tropicalis died. Previous studies have suggested that Candida tropicalis is more pathogenic than other species of Candida in patients with hematological malignancies.7 Unless it is recognized early, Candida pericarditis causes severe systemic sepsis, cardiac tam-ponade, and death. The clinical problem and lethal risks in this patient were related to pericarditis with tamponade rather than sternal wound dehiscence. The sternal wound dehiscence was a technical error primarily due to lack of rigid wound closure and eventual wire disruption.

Echocardiography can indicate patients at risk of Candida pericarditis; positive culture for Candida in pericardial fluid or histologic evidence of yeast in pericardial tissue establishes the diagnosis. Therapeutic intervention should consist of adequate drainage and systemic antifungal treatment. Although amphotericin B was used in earlier reports, it has poor pericardial penetration.8 Fluconazole is less toxic and may be more effective than amphotericin B for Candida pericarditis. An intravenous fluconazole dosage of 800 mg per day may be considered as primary therapy for hematogenous candidiasis.5 The dosage may be decreased to 400 mg per day and given orally, depending on the rapidity of the response. The optimal duration of effective therapy for candidemia is not well-defined and ranges from 15 to 33 days.5 All patients whose diagnosis was overlooked, died of their disease, whereas patients who were diagnosed and treated survived for a mean follow-up of 19 months, with no signs of infection.4 Our patient survived after combined antifungal therapy and surgical intervention. This experience indicates that the thoracic cavity can be contaminated by a primary stab injury and inadequate drainage can make further infection likely.


   References
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. McConnell EM, Roberts C. Pathological findings in three cases of fungal endocarditis complicating open-heart surgery. J Clin Pathol 1967;20:555–60.[Abstract/Free Full Text]

  2. Kraus WE, Vatenstein P, Corey GR. Purulent pericarditis caused by Candida: report of three cases and identification of high-risk populations as aid to early diagnosis. Rev Infect Dis 1988;10:34–41.[Medline]

  3. Boyle JD, Pearce ML, Guze LB. Purulent pericarditis: review of literature and report of eleven cases. Medicine (Baltimore) 1961;40:119–44.

  4. Rabinovici R, Szewczyk D, Ovadia P, Greenspan JR, Sivalingam JJ. Candida pericarditis: clinical profile and treatment. Ann Thorac Surg 1997;63:1200–4.[Abstract/Free Full Text]

  5. Schrank JH, Doorely DP. Purulent pericarditis caused by Candida species: case report and review. Clin Infect Dis 1995;21:182–7.[Medline]

  6. Anaissie EJ, Darouiche RO, Abi-said D, Urun O, Mera J, Gentry LO, et al. Management of invasive candidal infections: results of a prospective, randomized, multicenter study of fluconazole versus amphotericin B and review of the literature. Clin Infect Dis 1996;23:964–72.[Medline]

  7. Fraser VJ, Jones M, Dunkel J, Storfer S, Medoff G, Dunagan WC. Candidemia in tertiary care hospital: epidemiology, risk factors and predictors of mortality. Clin Infect Dis 1992;15:414–21.[Medline]

  8. Gallis HA, Drew RH, Pickard WW. Amphotericin B: 30 years of clinical experience. Rev Infect Dis 1990;12:308–29.[Medline]





This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kok, V. K.
Right arrow Articles by Lee, F. C.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Kok, V. K.
Right arrow Articles by Lee, F. C.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS