INTRODUCTION
Lithiasic cholecystitis, which predominantly occurs in the elderly, is classically associated with the presence of enterobacteria, such as Escherichia coli, Enterococcus, Klebsiella, and Enterobacter, in the gallbladder. Cholecystitis associated with fungal infections is a rare event related to underlying conditions such as diabetes mellitus, steroid use, and broad-spectrum antibiotic use for prolonged periods, as well as pancreatitis and surgery of the digestive tract1. Candida famata is mostly nonpathogenic in humans2. It has been isolated in patients with large burn areas3, stem cell transplant recipients4, individuals undergoing peritoneal dialysis5, patients with retinopathy6, and patients with acute infections of the central nervous system7.
CASE REPORT
Herein, we describe the case of a 79-year-old woman, born in Recife, State of Pernambuco, Brazil, who visited our hospital because of abdominal discomfort, nausea, and vomiting for 3 days. She did not experience any changes in her bowel habits. She had had diabetes for 2 years, for which she was irregularly taking metformin. She had no other comorbidities or fever, but she was dehydrated and dyspneic. Cardiopulmonary auscultation indicated normal sounds, and the abdominal examination indicated distension with bowel sounds. Lab oratory tests revealed hyperglycemia (glycemia = 400mg/dL), neutrophil leukocytosis, impaired renal function (urea = 83.0mg/dL and creatinine = 2.1mg/dL), and a mild elevation in pancreatic enzyme levels. Urinalysis showed only mild proteinuria and glycosuria. Abdominal ultrasonography (USG) revealed thickening of the gallbladder wall and the presence of a calculus. No dilatation of the bile ducts was present, the pancreas had a normal texture, and no free liquid was present in the abdominal cavity. Blood and urine were collected for microbiological examination. Her clinical condition worsened with the aggravation of dyspnea and a decreased level of consciousness. She was admitted to the intensive care unit (ICU) for respiratory failure and hemodynamic instability, where she was provided with ventilatory support. Her hemodynamic condition deteriorated, and she was unresponsive to vigorous blood volume replacement.
The patient was administered a combination of meropenem and teicoplanin. She later presented with circulatory collapse, for which she received high doses of vasopressors. Her echocardiogram was normal. On her fifth day in the ICU, a new USG was performed to guide a percutaneous cholecystostomy, during which some pus-containing bile was drained. The drained material was cultured in 3 vials of blood using a medium for aerobic and anaerobic bacteria and fungi (Bact-Alert Bottles). The procedure was performed following the principles of safe surgery. However, after hemodialysis, her hemodynamic condition deteriorated again, and refractory metabolic acidosis occurred. The patient then died on the sixth day of hospitalization. Both blood and urine cultures were negative for pyogenic bacteria and fungi. Candida famata was identified in all 3 samples using the Vitek 2® automated system (degree of precision > 99%), which is a rapid and accurate method for the identification of yeast species in clinical mycology laboratories, some of which are relatively uncommon8.
DISCUSSION
Candidiasis often occurs in diabetic patients with inadequate glycemic control; however, this case is the first report of a gallbladder infection caused by Candida famata. We could not determine whether this infection was a primary or secondary infection of the gallbladder. The decompensation of her diabetes during hospitalization could have potentially favored a systemic infection by Candida famata, leading to a secondary infection of the gallbladder. Clinicians need to be aware of the possibility of this type of infection and judiciously administer antifungal agents in addition to surgical treatments in cases of biliary tract infection in diabetic patients, especially in those presenting with systemic clinical conditions.
