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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 4  |  Page : 219-221

Successful management of a cutaneous abscess caused by Candida albicans in a very low birth weight neonate


Department of Neonatology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission04-Apr-2022
Date of Decision16-May-2022
Date of Acceptance05-Jun-2022
Date of Web Publication04-Oct-2022

Correspondence Address:
Anitha Haribalakrishna
10th Floor, MSB, Department of Neonatology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.jcn_36_22

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  Abstract 


Fungal sepsis is a sinister infection in the neonatal intensive care unit associated with significant mortality and neurodevelopment sequelae. Very low birth weight and very preterm neonates are often predisposed and manifestations range from mucocutaneous to invasive organ involvement. Prompt recognition and treatment with appropriate antifungal improve survival and neurodevelopmental outcomes. In this report, we describe a neonate with rare dermatological manifestation in the form of a cutaneous fungal abscess with urinary tract involvement. The diagnosis was based on budding yeast cells seen on pus smear examination and culture suggestive of Candida albicans. Risk factors included birth weight <1500 g, placement of central vascular catheter, endotracheal tube, parenteral nutrition, surgical intervention, and use of broad-spectrum antibiotics. Amphotericin B deoxycholate and incision and drainage of the abscess were done to manage the abscess successfully. This report highlights the consideration of Candida as an etiological agent for cutaneous abscesses, in case of preterms with risk factors for fungal infection. Evaluation for systemic dissemination is mandatory and management with appropriate antifungal agents is critical for survival.

Keywords: Candida albicans, cutaneous abscess, premature infant, very low birth weight


How to cite this article:
Vaddi VK, Goyal M, Mascarenhas D, Haribalakrishna A. Successful management of a cutaneous abscess caused by Candida albicans in a very low birth weight neonate. J Clin Neonatol 2022;11:219-21

How to cite this URL:
Vaddi VK, Goyal M, Mascarenhas D, Haribalakrishna A. Successful management of a cutaneous abscess caused by Candida albicans in a very low birth weight neonate. J Clin Neonatol [serial online] 2022 [cited 2022 Dec 4];11:219-21. Available from: https://www.jcnonweb.com/text.asp?2022/11/4/219/357814




  Introduction Top


Fungal sepsis is a sinister infection in the neonatal intensive care unit (NICU) associated with significant mortality and neurodevelopment sequelae. Very low birth weight (VLBW) and very preterm neonates are predisposed to Candida infection, especially following administration of prolonged antibiotics, total parenteral nutrition, and invasive procedures. Usually, Candida infection ranges from mucocutaneous manifestations to invasive organ involvement. Prompt recognition and treatment with appropriate antifungal improve survival and neurodevelopmental outcomes. We report a case of Candida sepsis in a VLBW neonate with a rare dermatological manifestation of infection and its successful management.


  Case Report Top


A 29-week-old male preterm neonate weighing 1200 g was admitted to the NICU. The baby was born through vaginal delivery secondary to the preterm onset of labor in mother, who did not receive any antenatal steroid coverage and had an otherwise uneventful antenatal period. The neonate received resuscitation in the form of positive pressure ventilation for 30 s and APGAR scores were 6/10 and 8/10 at 1 and 5 min, respectively.

On admission to the NICU, at 3 h of life, he developed severe respiratory distress with Silverman–Anderson score of 8, and chest X-ray was suggestive of congenital pneumonia. He was supported with invasive ventilation, a single dose of surfactant instillation, and intravenous (IV) antibiotics (amoxicillin-clavulanic acid and amikacin). At 12 h, the shock was noted for which fluid bolus and inotropic support was given for 3 days. He was started on minimal enteral nutrition on day 1. Initial sepsis screen was positive with a total leukocyte count of 5900/mm3, absolute neutrophil count of 1700/mm3, no band forms, and C-reactive protein of 24 mg/l, and blood culture was sterile. A Peripherally inserted central catheter (PICC) was inserted for total parenteral nutrition infusion in the right saphenous vein. On the day of life (DOL) 5, the neonate deteriorated with a right-sided pneumothorax which was managed with intercostal drainage tube insertion and upgradation to second-line IV antibiotics (piperacillin and tazobactam). The neonate improved and was stepped down on 9th DOL to continuous positive airway pressure followed by heated humidified high-flow nasal cannula on day 12 of life.

However, on DOL-15, erythema along with edema measuring approximately 4 cm × 4 cm, evolved over 6 h on the right quadrant of the abdominal wall and progressed over to the left side of the abdomen and suprapubic quadrant with umbilical inversion and sparing of the inguinal region and lower limbs [Figure 1]. Initial differentials considered were abdominal wall cellulitis, necrotizing enterocolitis or rare migration, and extravasation from peripherally inserted central line inserted in the right saphenous vein. However, there was no tenderness, altered aspirates, bleeding from the rectum, periumbilical discoloration, or fever spikes. Sepsis workup showed an increase in C-reactive protein 30.6 mg/dl and high total leukocyte count of 27,000/mm3. Bedside abdominal X-ray suggested subcutaneous swelling with a normal intrabdominal gas pattern [Figure 2] which was confirmed on ultrasound where findings of subcutaneous edema without intra-abdominal collection were noted. The possibility of abdominal wall cellulitis was considered and IV antibiotics meropenem and colistin were started. Pediatric surgical opinion was obtained and magnesium sulfate dressing for decreasing edema was advised.
Figure 1: Neonate with abdominal wall cellulitis (left) and with Candida cutaneous abscess on the right abdominal quadrant (right)

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Figure 2: Abdominal X-ray of the neonate with subcutaneous swelling over right abdominal quadrant with normal intra-abdominal gas pattern

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On DOL-19, it evolved to an abscess of size 2 cm × 2 cm with pus point [Figure 1] for which an incision and drainage were performed. Surprisingly, the pus smear was suggestive of budding yeast cells and on culture grew Candida albicans. Immediately, IV amphotericin B deoxycholate was started at 1 mg/kg/dose, and workup for invasive candidiasis was initiated. Urine examination also suggested fungal hyphae and culture grew C. albicans. Blood culture, cerebrospinal fluid analysis, and retinal examination had no suggestion of candidiasis. Cranial, kidney, and urinary tract ultrasound and echocardiography of the heart did not reveal any dissemination. There was intermittent hyperglycemia but there was no thrombocytopenia. Following the administration of antifungal, there was a resolution of abscess by DOL-30. Repeat examination of urine also demonstrated clearance and IV amphotericin B deoxycholate was continued for 21 days. No complications of amphotericin B were noted. Neurological examination was suggestive of axial and appendicular hypotonia which could due to perinatal asphyxia in the preterm neonate. Neonate was discharged on DOL-40 and remains under follow-up with early intervention therapy and scheduled neurodevelopmental assessments.


  Discussion Top


The case reported herein involves a neonate who uncommonly developed a cutaneous fungal abscess with urinary tract involvement. Risk factors included birth weight <1500 g, placement of central vascular catheter, endotracheal tubes, and parenteral nutrition, surgical intervention, and use of broad-spectrum antibiotics. The source of cutaneous abscess in the index case could be secondary to hematogeneous dissemination or superficial infection following an invasive procedure (intercostal drain insertion) performed in the neonate. Although the blood culture was negative in our case, hematogeneous dissemination is still probable as blood culture sensitivity remains low.[1]

The incidence of candidiasis in VLBW infants is approximately 10%, although it varies as much as 20-fold between centers.[2] The overall mortality rate due to invasive fungal infection is about 30% and systemic dissemination is associated with poor neurodevelopmental outcomes.[3]

Invasive Candida infections present in neonates as congenital cutaneous candidiasis and late-onset cutaneous candidiasis, bloodstream infections, urinary tract infections, meningitis, peritonitis, and infection of bone and joints. Cutaneous Candida usually presents as maculopapular, papulopustular, and/or erythematous rashes or as scaling, peeling, flaking, or exfoliation. However, the case reported herein involves a neonate who uncommonly developed a cutaneous fungal abscess with urinary tract involvement. Risk factors included birth weight <1500 g, placement of central vascular catheter, endotracheal tubes, parenteral nutrition, surgical intervention, and use of broad-spectrum antibiotics. The source of cutaneous abscess in the index case could be secondary to hematogeneous dissemination or superficial infection following an invasive procedure (intercostal drain insertion) performed in the neonate. Although the blood culture was negative in our case, hematogeneous dissemination is still probable as blood culture sensitivity remains low.[1]

Isolation of Candida in neonates mandates evaluation for systemic dissemination to guide the selection of appropriate antifungal and for prognostication. Amphotericin B deoxycholate is often chosen for treatment due to its excellent coverage for almost all Candida species causing infections in neonates due to its efficacy, low cost compared with other antifungals, safety, and possible better renal penetration compared with lipid amphotericin preparations.[4] In our case, amphotericin B deoxycholate was chosen as there was urinary involvement along with a cutaneous abscess. The optimal dosing of amphotericin B deoxycholate in neonates is 1–1.5 mg/kg/dose. Candidemia is treated for a minimum of 14 days after sterilization of the infected site.[5]

Our case highlights the consideration of Candida as an etiological agent for cutaneous abscesses in case of preterms with risk factors for fungal infection.


  Conclusion Top


Candidiasis in very preterm and VLBW is ominous and rarely can develop cutaneous abscesses. Prompt evaluation for systemic dissemination is mandatory and management with appropriate antifungal agents is critical for survival.

Acknowledgment

The authors would like to thank Dr. Hemant Deshmukh, Dean, Seth G. S Medical College and KEM Hospital, Mumbai, for granting permission for publication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jones JM. Laboratory diagnosis of invasive candidiasis. Clin Microbiol Rev 1990;3:32-45.  Back to cited text no. 1
    
2.
Benjamin DK Jr., Stoll BJ, Fanaroff AA, McDonald SA, Oh W, Higgins RD, et al. Neonatal candidiasis among extremely low birth weight infants: Risk factors, mortality rates, and neurodevelopmental outcomes at 18 to 22 months. Pediatrics 2006;117:84-92.  Back to cited text no. 2
    
3.
Stoll BJ, Hansen NI, Adams-Chapman I, Fanaroff AA, Hintz SR, Vohr B, et al. Neurodevelopmental and growth impairment among extremely low-birth-weight infants with neonatal infection. JAMA 2004;292:2357-65.  Back to cited text no. 3
    
4.
Janknegt R, de Marie S, Bakker-Woudenberg IA, Crommelin DJ. Liposomal and lipid formulations of amphotericin B. Clinical pharmacokinetics. Clin Pharmacokinet 1992;23:279-91.  Back to cited text no. 4
    
5.
Bliss JM, Wellington M, Gigliotti F. Antifungal pharmacotherapy for neonatal candidiasis. Semin Perinatol 2003;27:365-74.  Back to cited text no. 5
    


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