A rare case of breakthrough fungal pericarditis due to fluconazole‐resistant Candida auris in a patient with chronic liver disease

Abstract

Introduction: Candida pericarditis is a rare clinical entity with a high fatality, primarily attributed to difficulty in diagnosis. Unfortunately, the diagnosis is made post-mortem in more than 50 % of cases, and thus a high index of clinical suspicion is crucial.Case presentation: We report a rare case of fungal pericardial effusion caused by the recently recognized multidrug-resistant Candida auris, which was cultured from pericardial fluid, blood, bronchoalveolar lavage and urine of a chronic liver disease patient while on empiric fluconazole therapy. The yeast was misidentified as Candida haemulonii by the VITEK2 commercial identification system, and was confirmed as C. auris by internal transcribed spacer and large ribosomal subunit sequencing. In addition, the VITEK2 AST card erroneously revealed a high amphotericin B MIC (16 mg ml 21 ) and low caspofungin MIC (0.25 mg ml 21 ) that did not correlate with results from the reference Clinical and Laboratory Standards Institute (CLSI) microbroth dilution method. Based on VITEK2 MIC data, the patient was administered caspofungin. However, in vitro antifungal susceptibility data for C. auris by the CLSI method exhibited high MICs to fluconazole (64 mg ml 21 ) and caspofungin MIC (1 mg ml 21 ) but low MICs to amphotericin B (MIC range, 0.12520.5 mg ml 21 ). The patient's repeat pericardial fluid culture, despite caspofungin therapy for 12 days, grew C. auris and he died on day 13 of therapy.Conclusion: C. auris is a recently reported agent of fungaemia and deep-seated infections and is notable for its antifungal resistance. Although early species identification and rapid antifungal susceptibility testing are needed in cases of critical infections, the reporting of rare yeast isolates exhibiting high MICs to antifungals by automated systems needs a cautionary approach.

The Emerging Pathogen Candida auris: Growth Phenotype, Virulence Factors, Activity of Antifungals, and Effect of SCY-078, a Novel Glucan Synthesis Inhibitor, on Growth Morphology and Biofilm Formation

“…These findings are in agreement with those of recent studies from other investigators, who also reported that C. auris isolates were generally resistant or less susceptible to azoles but susceptible to echinocandins (2–6, 8, 9, 13, 14, 16). Our finding that amphotericin B demonstrated less activity against C.…”

“…auris appears to reside in its ability to develop resistance to multiple commonly used antifungal agents, leading to infections with high rates of mortality (2–6, 8, 9, 13–16). Therefore, the identification of agents that are effective against this species is critical.…”

Multidrug-Resistant Candida auris Misidentified as Candida haemulonii: Characterization by Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry and DNA Sequencing and Its Antifungal Susceptibility Profile Variability by Vitek 2, CLSI Broth Microdilution, and Etest Method

“…Therefore, accurate identification is important, because treatment strategies are often directed by species characterization of Candida. Further, a recent report of misleadingly high MICs of amphotericin B and caspofungin using the commercially available Vitek 2 automated system in a patient with pericarditis due to C. auris highlights issues of inappropriate treatment strategies if accurate susceptibility testing is not available (4). In the present era, molecular techniques and a growing database of fungal genome sequences have facilitated the reliable identification of phylogenetically related and phenotypically identical species.…”

“…The yeast C. auris, isolated from the external ear canal of a Japanese patient, was described as a new species in 2009 (2). This pathogen was recently recognized as an emerging multidrug-resistant (MDR) yeast that can cause a wide spectrum of infections, ranging from fungemia to deep-seated infections, especially in intensive care settings (3)(4)(5)(6)(7)(8). Candida auris is reported to be misidentified as C. haemulonii, Candida famata, and Rhodotorula glutinis by commercial identification systems, such as Vitek 2 and API20C-AUX, and exhibits a unique susceptibility profile (5)(6)(7)(8).…”

Insights into the Evolution of the Mutational Resistome of Pseudomonas Aeruginosa in Cystic Fibrosis

“…Since then, C. auris has been reported as an agent of candidemia in Japan, South Korea, India, Kuwait, South Africa, Pakistan and the UK and, more recently, in Venezuela, Colombia and the USA [61][62][63][64]. Multidrug resistance has been widely described in C. auris, with the majority of clinical strains reported as resistant to the widely used antifungal fluconazole, while some strains are resistant to azoles in general, to polyenes, and also to echinocandins [41,[65][66][67]. These strains present all the major Candida virulence factors, including germination, adherence, biofilm formation, and phospholipase and proteinase production [68].…”