Hepatosplenic Candidiasis Without Prior Documented Candidemia: An Underrecognized Diagnosis?

Autor: van Prehn J; Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, The Netherlands j.vanprehn@vumc.nl., Menke-van der Houven van Oordt CW; Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands., de Rooij ML; Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands., Meijer E; Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands., Bomers MK; Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands., van Dijk K; Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, The Netherlands.
Jazyk: angličtina
Zdroj: The oncologist [Oncologist] 2017 Aug; Vol. 22 (8), pp. 989-994. Date of Electronic Publication: 2017 May 03.
DOI: 10.1634/theoncologist.2017-0019
Abstrakt: Introduction: Patients with a history of chemotherapy or stem cell transplantation (SCT) and prolonged neutropenia are at risk for hepatic and/or splenic seeding of Candida . In our experience, hepatosplenic candidiasis (HSC) without documented candidemia often remains unrecognized.
Case Presentations: We describe three cases of HSC without documented candidemia and the challenges in establishing the diagnosis and adequately treating this condition. The first patient had a history of SCT for treatment of breast cancer and was scheduled for hemihepatectomy for suspected liver metastasis. A second opinion at our institute resulted in the diagnosis of hepatic candidiasis without prior documented candidemia, for which she was treated successfully with fluconazole. The second case demonstrates the limitations of (blood and tissue) cultures and the value of molecular methods to confirm the diagnosis. Case 3 illustrates treatment challenges, with ongoing dissemination and insufficient source control despite months of antifungal therapy, eventually resulting in a splenectomy.
Literature Review: A structured literature search was performed for articles describing any patient with HSC and documented blood culture results. Thirty articles were available for extraction of data on candidemia and HSC. Seventy percent (131/187) of patients with HSC did not have documented candidemia. The majority of HSC events were described in hematologic patients, although some cases were described in patients with solid tumors treated with SCT ( n  = 1) or chemotherapy and a history of leukopenia ( n  = 2). Current guidelines and practices for diagnosis and treatment are described.
Conclusion: Clinicians should be aware that HSC most often occurs without documented candidemia. In case of persistent or unexplained fever or lesions in the liver and/or spleen, a history of neutropenia should place disseminated candidiasis in the differential diagnosis. HSC is not limited to hematological patients and may occur in patients with solid tumors treated with bone marrow-suppressing chemotherapy or SCT. In the latter group, HSC as alternative diagnosis for hepatic metastasis should be considered when lesions are not typical for metastasis. This might prevent unnecessary surgery or inappropriate treatment.
Implications for Practice: Timely diagnosis of hepatosplenic candidiasis (HSC) is challenging, but can prevent further complications and dissemination, and may even prevent unnecessary invasive procedures. Clinicians should realize that HSC often occurs without documented candidemia and that sensitivity of blood cultures for candidemia is limited. HSC is not strictly limited to hematologic patients and might also occur in patients with solid tumors treated with intensive chemotherapy or stem cell transplantation. Increased awareness for HSC in patients with any history of neutropenia is of importance to increase detection and prevent serious sequelae.
Competing Interests: Disclosures of potential conflicts of interest may be found at the end of this article.
(© 2017 The Authors. The Oncologist published by Wiley Periodicals, Inc. on behalf of AlphaMed Press.)
Databáze: MEDLINE
Externí odkaz: