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Candidal Pneumonia

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					Candidal Pneumonia
                  Case II
 70 y female seen in oncology clinic Jan 5/05

 PMH : MDS NHL IV large cell
   Initial Dx 2001  chemo 2001 & 2002
                   & XRT (axilla & groin)
   2003  remission
   2004 Nov  recurrence
                Fludarapine & steroid
                 History
 3/52 unresolving SOBE , Dry cough
      intermittent fever & sweating

 No response to 2 courses of Abx
   Azithromycin & Cefuroxime
 Wt loss 15 lb

 No H/O TB or contact
                     History
 No travel , pets

 Being receiving IVIG for ITP

 PMH : HTN , Hpothyroidism
Lt nephrectomy for persistent hydronephrosis from LN
  compression Baseline Creat 80

 Med : ASA , Ramipril , Predinsone
             Examination
 Temp 37 BP 100/60 HR 100
  RR 16 Sat 95 %
  No desaturation with walking

 Palpable LN , central trachea

 Chest : Good BS , Crackles Rt base

 LL edema
           Investigation
 WBC 8 N Diff Hb 95 MCV N
  Plt 25 PTT & INR N

 Lytes , BUN & Creat N

 LFT & UA N

 CXR & CT chest
                 Course
 BAL Jan 6th /05
 BAL  -ve PCP , AFB & cytology

 Empiric Rx with Septra , Gatifluxacine

 BAL C/S  Candid Albicans
            & Enterococcus
 No improvement on Abx
                 Course
 Seen in St.B ER Jan 14th /05
  Nausea , Vometing & Abdominal pain 2/7

 Seen by Gen Sx ? Bowel obstruction

 Waiting CT  Increase work of breathing
  & Hypoxia & decrease LOC

 Intubated , Hypotensive
                  Course
 CT Abdomen  extensive LN
          Non mechanical obstruction

 Septic shock , Acute renal failure
  DIC & lactic acidosis

 Empiric Abx Vanco , Cipro & Metro

 Repeat Bronch
                    Course
 BAL  +ve Candida Albicans

 Blood C/S 2/2  yeast

 Empiric Ampho B

 Yeast  Candida Albicans

 Ampho B  Fluconazole
                 Course
 Persistent Shock , ARF

 GI bleeding  ischemic colitis Vs CMV

 Withdrawal of care upon family request
           Candida Pneumonia
 Retrospective study 20 y of oncology pts

 Isolation of Candida from lung tissue
  No candidemia

 31 cases 9 only neutropenic 84% mortality

 High incidence of candida osophagitis
  ? Aspiration lead to pneumonia
                           Medicine (Baltimore). 1993 May
               Candidemia
 Fourth leading cause of blood stream infection
   following staph aureus
            , C/N staph & enterococcus

 Surrogate marker of deep seated infection

 Untreated 15% endophthalmitis
  endocarditis ,arthritis & reanl candiadiasis
                                 NEJM Dec 2002
             Candidemia
 Prospective Multicenter observational
  study 1997 1999 Adults & Pediatric Pt

 Incidence of Candidemia & isolate
  Candidemia mortality : <24 of +ve C/S
                     persistent +ve C/S
                     postmortem
 1449 Adults & 144 peadiatric Pts
                     Clinical Infectious Dis Sept 2003
               Candidemia
 Overall 3 months mortality 40%
 Cause specific mortality 12%

 Candida Albican was associated with higher mortality
  47% Adults 23% peads

 Candida Parapsilosis had the lowest

 Risk factor associated with mortality
   Underlying malignancy ,Neutropenia
    Steroid & Lines
                            Clinical Infectious Dis Sept 2003
      Fluconazole Vs Ampho B
 Prospective randomized Plcb Control

 Multicenter 106 pateints

 Ampho B 0.6 mg/kg / day
 Vs Fluconazole 800mg loading &400 mg/d

 Switch to Ampho B in case of C.glabrata & C.crusie

                 Eur J Clin Microbiol Infect Dis. 1997 May
     Fluconazole Vs Ampho B
 Successful Rx
  Fluconazole 50% Vs Ampho B 57% P 0.39

 14 day mortality
            27% Vs 21%               P 0.57

 Side effect 0%       4%
             Eur J Clin Microbiol Infect Dis. 1997 May
High Dose Flucon Vs Flucon + Ampho B

 Randomized multicenter 219 pts

 Non neutropenic nor expected to br

 Non Candida. Crusie

 No Liver , renal impairment
                  Clinical infectious Dis May 2003
High Dose Flucon Vs Flucon + Ampho B

 Flucon 800 mg + Plcb (first 7 days)
  Flucon 800 mg +Ampho B .07 mg/kg
  April 95  May 99

 Successful Rx  clinical improvement
                & -ve blood C/S

 Failed Rx  no clinical improvement
            persistent fungemia
            side effects
                        Clinical infectious Dis May 2003
High Dose Flucon Vs Flucon + Ampho B
 Candida Albicans most common

 Persistent fungemia 53%

 Renal Imapirment 3% Vs 23%

 Successful Rx 56% Vs 69% P 0.43

 90 Mortality 39% Vs 40%

 Higher failure with Higher APACHE , TPN

                                 Clinical infectious Dis May 2003

				
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