Chan, YW

Choi, WK

Lee, CC

Journal of Surgical Case Reports

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Title Candida parapsilosis associated with cervical necrotizingfasciitis and descending mediastinitisAuthor(s) Lee, CC; Choi, WK; Chan, YWCitation Journal of Surgical Case Reports, 2017, v. 2017 n. 4, p. 1-3Issued Date 2017URL http://hdl.handle.net/10722/243833Rights This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.Journal of Surgical Case Reports, 2017;4, 1–3doi: 10.1093/jscr/rjx065Case ReportC A S E R E PORTCandida parapsilosis associated with cervicalnecrotizing fasciitis and descending mediastinitisChung-ching Lee1,*, Wing-kei Choi2, and Jimmy Yu-wai Chan11Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong and 2Department ofSurgery, Tuen Mun Hospital, Hong Kong*Correspondence address. C.-C. Lee, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road, Hong Kong Island, HongKong. Tel: +852 22554394; Fax: +852 28193780; E-mail: georgelee1029@gmail.com.AbstractBackground: This report presents an immunocompetent lady suffering from Candida parapsilosis associated with polybac-terial cervical necrotizing fasciitis and descending mediastinitis. A literature review and management of invasive candidia-sis is discussed.Methods: A 57-year-old healthy lady presented with cervical necrotizing fasciitis and descending mediastinitis. She was promptlymanaged with emergency debridement. Both blood and tissue culture yielded multiple microorganisms including C. parapsilosis.Results: The patient recovered progressively. She was discharged 2 months later.Conclusions: Fungal infection is emerging in this medical era. Vigilance in patient management and as well as consideringatypical microorganisms in aetiology may improve patient outcome.INTRODUCTIONCervical necrotizing fasciitis is a serious and potentially lifethreatening head and neck infection. When it is complicatedwith descending mediastinitis and septic shock, the mortalitycan be doubled, up to 41% [1].We would like to describe a patient who suffered from syn-ergistic fungal and polybacterial cervical necrotizing fasciitiswith descending mediastinitis, complicated with empyemathoracis. To our understanding, there has been no previous lit-erature reporting Candida parapsilosis associated with cervicalnecrotizing fasciitis and descending mediastinitis.CASE REPORTA 57-year-old lady, a non-smoker and non-drinker with goodpast health, presented with a week’s history of sore throat, runnynose and productive cough. Upon admission, she was havinghigh fever and sinus tachycardia. Her neck had skin erythemaand crepitus on palpation. Oxygen saturation was maintained.Her lateral neck radiograph showed the presence of retropharyn-geal gas and chest radiograph noted consolidative changes at theright lower zone. A septic work-up was performed and herlaboratory evaluation revealed signiﬁcant metabolic acidosis.The urgent contrast computed tomography neck and thoraxrevealed multiple gas locules in bilateral deep cervical spaces,loculated right pleural effusion and right chest wall subcutane-ous emphysema. The overall radiological features were sug-gestive of underlying deep neck space infection by gas-formingorganisms complicated with descending mediastinitis andempyema thoracis (see Figs 1–3).Emergency surgical debridement and drainage were per-formed by combined bilateral transcervicotomy and rightvideo-assisted thoracoscopic approaches. All deep neck spacesdown to mediastinum were opened. A moderate amount of tur-bid ﬂuid was drained and necrotic fascia and muscle wereReceived: November 27, 2016. Accepted:March 16, 2017Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2017.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited.For commercial re-use, please contact journals.permissions@oup.com1Downloaded from https://academic.oup.com/jscr/article-abstract/2017/4/rjx065/3744735by University of Hong Kong useron 29 January 2018debrided. The remaining collection inside the thoracic cavitywas drained through thoracoscopic approach. The neck woundwas laid open and packed with gauze. Multiple right lower pos-terior teeth with severe periodontitis were extracted. Chestdrains were inserted at the conclusion of operation.The patient required high dose inotropes throughout theoperation. She was kept intubated in ICU afterwards. Dailywound examination and dressing was done. Second lookwound exploration and debridement were performed on Day 3.Residual collection over the superior mediastinum and rightparapharyngeal space was drained. The patient was tracheos-tomised. A feeding tube was inserted to help build up her nutri-tion. She was dependent on inotropic and ventilatory supportsduring the ﬁrst 4 weeks. Her neck wound was amenable to pri-mary closure 6 weeks after the ﬁrst debridement. The tracheos-tomy was successfully decanalised. She was provided with acourse of swallowing rehabilitation and was discharged 2months later.Histopathology sectioning of the right carotid sheath, fasciaand mediastinal tissue conﬁrmed necrotizing inﬂammation.Both blood and deep neck tissue cultures recovered C. parapsilo-sis. The carotid sheath tissue and pleural ﬂuid recoveredPeptostreptococcus micros, Bacteroides pyogenes and Prevotella buc-cae. Intravenous anidulafungin was added to her existingbroad-spectrum antibiotics.DISCUSSIONCervical necrotizing fasciitis may cause airway obstruction,jugular vein thrombosis, as in Lemierre’s syndrome, descend-ing mediastinitis, empyema and pleural or pericardial effusion.The vital and unique structures in the head and neck regiondemands precise and adequate debridement for organ preser-vation and control of infection. The standard treatmentincludes prompt diagnosis, aggressive resuscitation, adequatedebridement, broad-spectrum antimicrobials, intensive careservice, and organ-speciﬁc rehabilitation and reconstruction.The most common infective foci are from dental–oral or pha-ryngeal origins. The Streptococcus milleri group bacteria is com-monly isolated from either dental or pharyngeal origin, whilethe Prevotella species is more likely isolated from dental origin[2]. The pathogens are usually mixed aerobic and anaerobic. Itis believed that immunocompromised individuals are moresusceptible with risk factors such as diabetes, alcoholism andsmoking.Fungal infection in cervical necrotizing fasciitis is exceed-ingly rare. Reported cases usually involved immunocomprom-ised individuals such as uncontrolled diabetics. They sufferedfrom polybacterial and invasive fungal infections, and most ifnot all had fatal outcomes. Candida albicans was once reportedto be the sole organism on a diabetic patient having Fournier’sgangrene [3]. Non-albicans Candida is believed to be lesspathognomic. However, there is an increasing incidence ofnon-albicans infection and can be associated with a mortalityrate of up to ~45% [4]. Candida parapsilosis is one of the ﬁve com-mon Candida species encountered in clinical practice and thoseﬁve species account for 90% of all cases of invasive candidiasis.Candida parapsilosis predominantly affects preterm neonates,especially those with indwelling catheters. The mortality rate isup to 10% [5].Candidaemia is by far the most frequent clinical syndromeof invasive candidiasis. It can be associated with deep tissueinfection, such as intra-abdominal candidiasis, candida endo-carditis, ocular candidiasis and candida meningitis. The goldstandard for diagnosis of invasive candidiasis is tissue or bloodculture. However, the sensitivity of picking up deep tissueinfection using culture based tests alone is low. Various non-culture based diagnostic tests, namely the 1-3-beta-d-glucan(BDG), the mannan Ag/anti-mannan Ab assay, and polymerasechain reaction (PCR) are employed to enhance the sensitivity todiagnose invasive candidiasis and they may have the potentialto identify patients with deep-seated candidiasis missed byblood cultures in clinical practice [6].Candida parapsilosis is known for its ability to form bioﬁlmsand has a higher minimal inhibitory concentration (MIC) toechinocandins when compared with other Candida species. Inthe laboratory, the higher MIC is evidenced by its naturallyFigure 1: Extensive involvement to all deep neck spaces.Figure 2: Infection extending down to superior mediastinum and chest wall.2 | C.-C. Lee et al.Downloaded from https://academic.oup.com/jscr/article-abstract/2017/4/rjx065/3744735by University of Hong Kong useron 29 January 2018occurring polymorphism at the hotspot Region 1 of the FKS1gene [7]. Hence, in the past, ﬂuconazole and other azoles werethe preferred agents over echinocandins. However, the empir-ical use of echinocandins has not been translated into clinicalfailure and is not necessarily leading to worse outcomes asfound by a Spanish study [8]. According to the recommenda-tions in Infectious Diseases Society of America 2016 guidelines,they suggest using echinocandins as the initial therapy fornon-neutropenic patients with candidemia, while ﬂuconazolestill remains as a valuable alternative and a step-down medica-tion [9].CONCLUSIONWe have described an immunocompetent lady who sufferedfrom polybacterial cervical necrotizing fasciitis with descendingmediastinitis and empyema thoracis complicated by C. parapsi-losis. The source of infection was likely from the oral cavity, asevidenced by the presence of poor dentition and various tissueand blood culture results. This patient demonstrated the emer-ging importance of complicated fungal infections. We suggestsending tissue samples not only for bacterial cultures but alsofungal cultures routinely. The use of non-culture based assaysfor recovering fungal infection may be useful for early diagnosisand hence treatment, but this is dependent on the availabilityof hospital resources.FINANCIAL DISCLOSURENone.CONFLICT OF INTEREST STATEMENTNone declared.REFERENCES1. Sarna T, Sengupta T, Miloro M, Kolokythas A. Cervical necro-tizing fasciitis with descending mediastinitis: literaturereview and case report. J Oral Maxillofac Surg 2012;70:1342–50.2. Fihman V, Raskine L, Petitpas F, Mateo J, Kania R, Gravisse J,et al. Cervical necrotizing fasciitis: 8-years’ experience ofmicrobiology. Eur J Clin Microbiol Infect Dis 2008;27:691–5.3. Perkins TA, Bieniek JM, Sumfest JM. Solitary Candida albi-cans infection causing Fournier Gangrene and review of fun-gal etiologies. Rev Urol 2014;16:95–8.4. Leroy O, Gangneux JP, Montravers P, Mira JP, Gouin F, Sollet JP,et al. Epidemiology, management, and risk factors for death ofinvasive Candida infections in critical care: a multicenter, pro-spective, observational study in France (2005–2006). Crit CareMed 2009;37:1612–8.5. Pammi M, Holland L, Butler G, Gacser A, Bliss JM. Candidaparapsilosis is a signiﬁcant neonatal pathogen: a systematicreview and meta-analysis. Pediatr Infect Dis J 2013;32:e206–216.6. Nguyen MH, Wissel MC, Shields RK, Salomoni MA, Hao B,Press EG, et al. Performance of Candida real-time polymerasechain reaction, beta-D-glucan assay, and blood cultures inthe diagnosis of invasive candidiasis. Clin Infect Dis 2012;54:1240–8.7. Pfaller MA, Diekema DJ, Ostrosky-Zeichner L, Rex JH,Alexander BD, Andes D, et al. Correlation of MIC with out-come for Candida species tested against caspofungin, anidu-lafungin, and micafungin: analysis and proposal forinterpretive MIC breakpoints. J Clin Microbiol 2008;46:2620–9.8. Fernandez-Ruiz M, Aguado JM, Almirante B, Lora-Pablos D,Padilla B, Puig-Asensio M, et al. Initial use of echinocandinsdoes not negatively inﬂuence outcome in Candida parapsilo-sis bloodstream infection: a propensity score analysis. ClinInfect Dis 2014;58:1413–21.9. Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA,Ostrosky-Zeichner L, et al. Executive summary: clinical prac-tice guideline for the management of candidiasis: 2016update by the infectious diseases society of America. ClinInfect Dis 2016;62:409–17.Figure 3: Loculated right empyema thoracis.Candida parapsilosis associated cervical necrotizing fasciitis | 3Downloaded from https://academic.oup.com/jscr/article-abstract/2017/4/rjx065/3744735by University of Hong Kong useron 29 January 2018

Candida parapsilosis associated with cervical necrotizing fasciitis and descending mediastinitis

Lee, C.C.

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Candida parapsilosis associated with cervical necrotizing fasciitis and descending mediastinitis

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