Candida glabrataOropharyngeal Candidiasis in Patients Receiving Radiation Treatment for Head and Neck Cancer

Abstract

Candida glabrata colonization is common in patients receiving radiation treatment for head and neck cancer, but to our knowledge has never been described as the infecting organism with oropharyngeal candidiasis (OPC). This study presents the first three patients described with C. glabrata OPC in this patient population. Patient 1 developed C. glabrata OPC and required fluconazole, 800 mg/day, for clinical resolution. Antifungal susceptibility testing revealed a MIC of fluconazole of >64 g/ml. Elapsed time from initial culturing to treatment decision was 7 days. Patients 2 and 3 developed C. glabrata OPC. They were patients in a study evaluating OPC infections, and cultures were taken immediately. CHROMagar Candida plates with 0, 8, and 16 g of fluconazole/ml were employed for these cultures. Lavender colonies, consistent with C. glabrata, grew on the 0-and 8-g plates but not on the 16-g plate from patient 2 and grew on all three plates from patient 3. Based on these data, a fluconazole dose of 200 mg/day was chosen for patient 2 and a dose of 400 mg/day was chosen for patient 3, with clinical resolution in both. Elapsed time from initial culturing to treatment decision was 2 days. C. glabrata does cause OPC in head and neck radiation treatment patients, and the use of fluconazole-impregnated chromogenic agar may significantly reduce treatment decision time compared to that with conventional culturing and antifungal susceptibility testing. CASE REPORTS Patient 1. Patient 1 was a 47-year-old white male diagnosed with squamous cell carcinoma of the base of the tongue, stage T2N2M0. He was treated with a combination of 7,200 cGy of radiation over 8 weeks and concomitant cisplatin and 5-fluorouracil chemotherapy during weeks 1 and 5. During the fifth week of his treatment he developed oropharyngeal candidiasis (OPC) and was placed on fluconazole, 100 mg/day, with initial resolution. After 2 weeks the candidiasis recurred, and the fluconazole dose was raised to 200 mg/day. The OPC did not resolve, and so the fluconazole dose was raised to 400 mg/day, and a swab culture of lesions was taken. The OPC continued. The culture was plated on blood agar, and identification included germ tube evaluation and API-20C confirmation (bioMerieux, Marcy-l'Etoile, France). The culture grew Candida glabrata, and antifungal susceptibility testing was performed according to NCCLS-recommended techniques (1). The 48-h MIC of fluconazole was 64 g/ml. The patient's fluconazole dose was raised to 800 mg/day with clinical resolution of OPC. The total elapsed time for culture and antifungal susceptibility results was 7 days.Patients 2 and 3. Patients 2 and 3 were participating in a clinical study where they had cultures taken every week during their radiation treatment. With these patients, cultures employed an oral swab and a swish sample of 10 ml of normal saline instilled in the mouth for 10 s and then collected in a sterile container. These samples were plated on blood agar, RPMI medium, and CHROMagar Candida (CHROMagar Company, Paris, Fran...

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