Deep-seated invasive candidiasis in a liver recipient

Patient with insulin-dependent diabetes mellitus, primary sclerosing cholangitis, multiple bacteremic episodes and recent liver transplant was admitted.

In this case, T2Candida® results could have permitted earlier focused therapy and aided with the diagnosis of invasive Candida infection and lead to appropriate antifungal therapy. Unfortunately, the T2Direct Diagnostics results were not in clinical use at the time and not obtained until after patient death.

Discussion

T2Candida retrospectively revealed C. albicans/C. tropicalis, even at the beginning of the process when the patient was asymptomatic. This case highlights the potential advantage of T2Direct Diagnostics aiding in the diagnosis of deep-seated infection in an immunosuppressed patient without confirmed infection, even before the onset of symptoms.

The two key findings were that arteritis and thrombosis of the hepatic graft resulted from an undocumented fungal infection in the explanted liver and that T2Candida was a suitable diagnostic tool for the diagnosis of deep-seated invasive candidiasis in the absence of positive blood culture results.

Presentation

A 57-year-old woman with insulin-dependent diabetes mellitus, primary sclerosing cholangitis, multiple bacteremic episodes, and recent liver transplant was admitted for sudden abdominal pain. After identification of intrahepatic abscesses the patient underwent a second liver transplant. Subsequently, non-purulent inflammatory tissue was observed in the liver with extensive clotting of the portal vein and hepatic artery and generalized hepatic ischemia. In the following hours, the patient developed graft failure, severe coagulopathy, and died.  

Evaluation and Treatment Decision

All of the cultures collected before death, including blood (obtained at admission and repeated 3 times during hospitalization), ascitic fluid at admission, and liver and abdominal tissues during the re-transplantation procedure, were sterile.

Final Diagnosis: Liver abscess

Empiric Therapy (May 31, 2017): Vancomycin, meropenem, caspofungin

T2Candida Panel Result: Retrospective T2MR performed on blood samples obtained on May 27th, May 31st, June 9th, June 16th, and June 26th showed C. albicans/C. tropicalis present in all samples.

Histology Result: Histopathology of explanted liver tissue revealed multiple ischemic areas with abundant filamentous fungal structures in their interior, and C. albicans was identified using multiplex PCR.

Decision making based on T2Candida Result

T2Candida result from May 27th (and subsequent results) could have permitted earlier focused therapy and aided with the diagnosis of invasive Candida infection. Unfortunately, the T2Direct Diagnostics results were not in use clinically and not obtained until after death.

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