A Rare Case of Candida Brain Abscess in a Patient with Cirrhosis

1Beth Israel Medical Center, New York, NY
2Beth Israel Medical Center, New York, NY
3Beth Israel Medical Center, New York, NY
4Beth Israel Medical Center, New York, NY
5Beth Israel Medical Center, New York, NY

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 358

Case Presentation:

A 41‐year‐old man with insulin‐dependent diabetes and hepatitis C cirrhosis with multiple variceal bandings presented with progressive right‐sided weakness had been seen at an outside hospital 6 months prior to admission, where ring‐enhancing lesions in the left frontal lobe were noted on CT and MRI. CSF and serum analyses for toxoplasmosis and a rapid HIV test were negative. A diagnosis of probable CNS toxoplasmosis was empirically treated with pyrimethamine, sulfadiazine, and leucovorin. The patient completed the prescribed course. His symptoms initially improved minimally but then deteriorated over 6 months to hemiparesis, at which time he presented to our hospital. CT scan of the brain revealed multiple ring‐enhancing lesions. The patient was continued on presumptive toxoplasmosis treatment along with cefepime and metronidazole. An MRI demonstrated enlarging lesions with mass effect and dexamethasone was added. Serum studies for toxoplasmosis and blood cultures were negative. HIV‐1/2 enzyme‐linked immunoassay was negative. HIV‐1 viral load was undetectable. When he failed to improve; he had a brain biopsy revealing gross pus. Both histopathogy and culture were consistent with Candida albicans. Treatment with liposomal amphotericin and 5‐flucytosine were started but the patient expired after 7 weeks of antifungal treatment.

Discussion:

Fungal brain abscesses are rare. Candida albicans is the most frequently isolated pathogen. Risk factors include increasing use of broad spectrum antibiotics, DM, corticosteroids and immunosuppressive agents. Candida has also been shown to be an important pathogen when the integrity of the gut is compromised. In this case, it is postulated that this occurred during variceal banding leading to transient candidemia and seeding of the brain. They should be especially considered in patients with significant liver disease. In HIV‐infected patients the standard of care is to presumptively treat ring‐enhancing brain lesion as toxoplasmosis and then reevaluate the patient after two weeks of therapy. In our patient, this therapeutic route was initially used despite a negative HIV test. Pyrimethamine and sulfadiazine both have some in vitro antimycotic effects that may have slowed the evolution of symptoms.

Conclusions:

Candida brain lesions should be suspected in patients with brain lesions compatible with abscesses not improving on broad‐spectrum antibiotics. HIV‐negative patients with brain lesions should not be treated presumptively for CNS toxoplasmosis and should undergo biopsy.

CT brain with contrast showing dense lesions, vasogenic edema, and 5‐mm right midline shift

A Gomori–Grocott methenamine silver stain of aspirated brain abscess showing hyphal elements.

To cite this abstract:

Oleng N, Francis G, Krupka M, Calabrese R, Gomez T. A Rare Case of Candida Brain Abscess in a Patient with Cirrhosis. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 358. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/a-rare-case-of-candida-brain-abscess-in-a-patient-with-cirrhosis/. Accessed May 22, 2019.

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