SYSTEMIC CANDIDIASIS AT AUTOPSY IN DUBLIN

R, Young* and D, O'B. Hourihane

School of Pathology, Trinity College, Dublin 2.

Summary At autopsy, Candida albicans was cul-

s EVEN cases of systemic candidiasis lured from heart, lungs and kidney, and are presented. In only one case was microscopic loci of fungi with surround- the diagnosis made antemortem, ing Jnflammation were identified in many

Attention is drawn to those patients at organs (myocardium, liver, adrenals, risk of developing this complication and prostate). Figs: 1 and 2 show renal to the importance of culturing intraven- lesions. There was no evidence of Hodg. ous cannulae and bladder catheters on kin's disease at autopsy. removal from such patients.

Introduction Opportunistic infections have become

increasingly common in recent years (Baker, 1971), especially in patients whose immunity has been suppressed either by natural disease processes or by therapy (Louria et al., 1962).

Disseminated fungal lesions have been prominent in some recent reports of opportunistic infections, and the oc- currence of seven patients in one year Fig. 1--Oandida p~udohyphae in Bowman's with fungaemia and systemic lesions has space. PAS. x 120. Case 1. prompted this report.

Case Reports Case I :

A male of 35 years was found to have Hodgkin's disease on histological exam- ination of an enlarged cervical lymph node 18 months before death. He was initially treated with radiotherapy, but received chemotherapy and steroids when a liver biopsy showed involvement.

During the lasL few weeks of life the patient developed fever (Temp. 101~ Fig. 2 ~ a m e case as Fig. 1. Bowman's space and Candida albicans was isolated by filled with fungi and cellular exudate. PAS. x 120. blood culture. The same organism was grown from an intravenous cannula, Case2 : which had been in position for some A g i r l o f t h r e e y e a r s w a s f o u n d t o h a v e time. a large mediastinal mass, diagnosed as

*Present address: Dept. of Pathology, Massachusetts Genera~ Hospital, Boston 02114, U.S,A

2 IRISH JOURNAL OF MEDICAL SCIENCE

mal ignant lymphoma of lymphocyt ic type Case 3 : ( " t ymphosarcoma" ) on biopsy. She re- A boy of 17 years developed an acute ceived chemotherapy, steroids and 18 i l lness with fever and deepening coma, months after d iagnosis developed pan- and d ied after three weeks. He was cytogenia and fever. At autopsy she found to have probable th rombot ic showed one gastr ic and several oeso- th rombocy topen ic purpura wi th mul- phageal ulcers, in wh ich fungi were t iple funga l lesions in brain and k idneys prominent , wi thout any ev idence of sur- (Figs. 4 and 5). round ing in f lammatory infi l trate (Fig. 3).

Fig. 3--Base of gastric ulcer, showing fungi with Fig. 5~Centre cf miliary nodule in kidney. Fungus ne celtular inflammatory reaction. P.A.S. x 4OO. is bordered by pus. PAS. x 4OO. Case 3.

Case 2,

Fig. 4--Kidney at autopsy shows a myriad of miliary focT, largeJy ~n cortex, with central cavitation in many. Case 3,

SYSTEMIC CANDIDIASIS AT AUTOPSY IN DUBLIN

Case 4 : A woman of 53 years d ied after a

wast ing i l lness of e ight months, and was found at autopsy to have tubercu lous bronchopneumonia , and a large malig- nant u lcer of the s tomach due to infi ltra- t ion by a carc inoma of the pancreas. The u lcer was extending into the ementum with fung i at its base (Fig. 6). The pat- ient had received steroids for some t ime before death.

Fig. 6--Gastric ulcer with attached omentum The dark strands in the uicer lioor are fungi

PAS • 32 Case 4.

Case 5 : A girl of 18 years who suffered from

Beh~et 's disease' received steroid ther- apy. At autopsy she was found to have a fungal pneumonia, with numerous oeso- phageal ulcers on which fungi formed plaque- l ike deposits.

Case 6 : A man of 39 years was receiv ing mel-

phalan and steroids for mul t ip le myel- oma, when he was admit ted acutely i l l with fever, leucopenia and thrombocy- topenia. At autopsy disseminat ion fun- gal lesions were noted throughout the gastrointest inal tract (Fig. 7) with mdiary loc i ~n liver, spleen and bone marrow (Fig. 8). These lesions showed fungus with sur round ing in f lammatory infi ltrate.

Case 7 : A man of 52 years d iagnosed as Q

fever endocard i t is because of posi t ive s~rology, died of a "s t roke" . At autopsy

Fig. T--Gastro-oesophaegealjunetionin Case 6 Feel of lungal infection v~sible as wh~tB spols in mucos~ el stomach, with larger oesophageBr

plaques in upper end of photograph.

Fig. 8~$ame case as Fig. ?. White miliary loci in vertebral marrow.

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a large intracerebral haemorrhage was present, together with a fungal vegeta- tion of the aortic valve (Fig. 9).

Discussion Strict mycological identification was

possible only in Case 1 (Ctancy, 1976), but the morphology of all seven exam- ples is identical, and Jt is l ikely that they are all examples of Candida infection.

In only ot~e case was the diagnosis of visceral fungal infection entertained dur- ing life, and the failure to institute thor- apy in any of our cases arises from a lack of sus#icion of the diagnosis of in- fection, and there does appear to be a lack of awareness of the importance of culturing catheter tips after removal.

The growth of Candida in one blood culture requires careful interpretation, and criteria for instituting therapy have been proposed (Ellis and Spivack, 1967; Young et aL, 1974). It is difficult to dis-

MEDICAL SCIENCE

tinguish between a transient fungaernia of little significance, and potentially fatal candidiasis with tissue involvement, but the importance of indwell ing bladder and venous catheters as a source of fungus should lead to culture of the catheter t ip as soon as a positive culture has been discovered (Young et al., 1974) and the examination of urine in case genito-urJnary involvement has devel- oped (Ellis and Spivack, 1976).

The portal of entry for systemic can- didiasis is generally thought to be muco- cutaneous lesions (~aker, 1971) but in- fection of indwell ing catheters has been emphasised in recent years, and three of our patients had no evidence of muco-cutaneous lesions at autopsy while demonstrating disseminated visceral les- ions.

The primary diseases in our patients compare with those in the literature (Young et ah, 1974) and obviously our

Fig. 9--Sagittal slice of non-coronary aortic cusp shows the large, fungal vegetation (a~row). Case 7.

SYSTEMIC CANDIOIASIS AT AUTOPSY IN DUBLIN 6

hospital populat ion conta ins patients tox ic drugs--e .g . Amphoter i c ln B in an who are suscept ib le to d isseminated c a n d i d i a s i s - - e.g. lympho-haemopoiet ic mal ignancies, immunosupress ion ther- apy, cort icosteroid administ rat ion and pro longed ant ib iot ic therapy.

The purpose of th is paper is to draw at tent ion to the deve lopment of visceral fungal in fect ions in pat ients whi le in hos- pital, and to emphasise the need for rJgeroLls superv is ion of indwe[l i f lg blad- der and venous catheters. The value of v ig i lance to suscept ib le patients l ies in the possibi l i ty of appropr iate therapy, a l though keen judgement is required in assessing whether d isseminat ion has occurred or not, and in whether it is thought appropr iate to use potent ia l ly

a l ready very il l patient.

We would like te thank Mr. F. A. Murray for photographic assistance.

References Baker, R. D. 1971. Fungal, actinomycetir and

algal infections: in "Anderson's Pathology", ~2, 421.

Clancy, M T, Gad-A -Rab, J. and Keane, C. 1976. Venous catheter assoclated candida albicans septicaemia. Irish J. Med. Sci. 145, 348.

Ellis, C A. and Spivack, M. L. 1967. The signific- ance of candidaemia. Ann. Int. Med. 3, 5111.

Louria, D B, Stiff, O. P. and Bennett, B. 1962. D;ssemi;~ated moniliasis in the adult. Medicine (BaJtlmire), 41, 317.

Youag, B C, Bennett, J. E., Geefhoed, G. W. and Levine, A S 1974. Fungaemia with comprom- ised host resistance. Ann, Int. Med. 80, 605.