Invasive candidiasis presenting with multiple subcutaneous nodules mimicking sporotrichosis

ARTICLE

Auteur(s) : Yu-Wen Yeh^1,3, Wei-Ming Wang¹, Chien-Ping Chiang¹, Bai-Yao Wu¹, Pang-Yen Liu², Yu-Fei Chen¹

¹Department of Dermatology
²Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Neihu District, Taipei 11490, Taiwan
³Song-Shan Armed Forces General Hospital, Taipei 10581, Taiwan

Invasive candidiasis (IC) is the most common opportunistic systemic infection with a high mortality rate, up to 60%. However, the early symptoms and signs of IC are non-specific and the positivity rate of blood cultures is below 30%. Here, we report a rare case of an immunocompromised patient who developed sporotrichoid lesions caused by IC and was successfully treated with fluconazole and micafungin.

A 70-year-old Taiwanese woman was admitted to our hospital due to lower gastrointestinal tract bleeding, anemia and fever. Three days after admission, blood cultures showed the presence of Escherichia coli and systemic antibiotics were administered. An adenocarcinoma in the descending colon was found by colonoscopy. Surgical procedure was performed but the postoperative course was complicated by persistent fever, acute renal failure and acute respiratory failure. Hemodialysis and endotracheal intubation were subsequently given. Urine culture showed the presence of Candida albicans and C. tropicalis. Blood cultures and a culture derived from the central venous catheter also revealed C. albicans which was susceptible to fluconazole. IC was diagnosed and intravenous fluconazole (200 mg/day, patient body weight: 60 kg) was added to the prescriptions. After 7 days of fluconazole treatment, however, she developed numerous tender nodules on her right forearm. These subcutaneous nodules were well-circumscribed, deeply indurated, brownish to violaceous, 12-20 mm in diameter and were arranged in a linear pattern (figure 1A), resembling cutaneous sporotrichosis. Histopathological examination showed a central mixed-cell infiltration of lymphohistiocytes and neutrophils with adjacent granulomatous inflammation (figure 1B). Multiple spores in the deep dermis and subcutis were identified by Gomori methenamine-silver (GMS) stain (figure 1C). Skin cultures isolated C. albicans but the antibiotic sensitivity test was not done. Due to a suspicion of fluconazole resistance, micafungin was used instead. After a further 14-day course of micafungin, several blood cultures showed negative and the patient was discharged with hyperpigmentation and minimal induration over the sites of the lesions.

The prevalence of IC-associated skin lesions was estimated from 10-35.8% [1-3]. It typically comprises multiple bright red/purpuric maculopapules (3-5 mm in size) or nodules that sometimes have an erythematous base or a pale center. On the other hand, the characteristic presentation of sporotrichosis consists of suppurating subcutaneous nodules that progress proximally along the lymphatic channels [4]. The differential diagnoses for sporotrichoid lesions are listed in table 1.
Table 1 Differential diagnosis of sporotrichoid lesions

Our patient presented with multiple, well-demarcated, deeply infiltrated nodules in a sporotrichoid pattern, which was distinct from the typical cutaneous features of IC (purpura, maculopapules or cellulitis-like nodules or plaques) [3]. To our knowledge, this is the first case of IC presenting with a sporotrichoid lesion. C. albicans is usually highly susceptible to fluconazole, but the lesions of the right forearm appeared on day 7 of fluconazole treatment. It could be the result of an emerging resistant strain of C. albicans due to an insufficient dose (3.3 mg/kg/day), but a new resistant strain entering through a peripheral catheter insertion site to cause regional sporotrichoid spread was also possible.

In IC with cutaneous involvement, biopsy specimens may show focal areas of yeast in the dermis, the subcutis and within blood vessels [3]. The organism can be identified using periodic acid-Schiff (PAS) stain or GMS stain. There may be surrounding mononuclear cell infiltrates, leukocytoclastic vasculitis or a microabscess [5, 6].

We report the first case of a patient with IC complicated with sporotrichoid cutaneous lesions. Dermatologists should consider C. albicans as a possible cause of sporotrichoid dermatosis. A skin biopsy for histochemical stain and tissue culture should be done as soon as possible in such patients. Adequate and correct therapy at an early stage is important for reducing the risk of death.

Acknowledgements

References

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