RESUMO
This is a 24 year old man with profound chronic hydrocephalus found to have a cauda equina abscess composed of Candida albicans. Prior literature reveals a paucity of central nervous system candidiasis. In these previously reported cases, there was evidence of local invasion of surrounding structures; however, this case is a sentinel report of a fungal abscess without evidence of local structural invasion. The patient's course was complicated by clinical and radiographic worsening to cauda equina syndrome, requiring emergent surgical decompression, despite appropriate antifungal treatment. This case illustrates the diagnostic challenge of this rare entity and the need for close follow up with this patient population.
Assuntos
Abscesso/diagnóstico por imagem , Candida albicans , Candidíase Invasiva/diagnóstico por imagem , Síndrome da Cauda Equina/diagnóstico por imagem , Infecções Fúngicas do Sistema Nervoso Central/diagnóstico por imagem , Compressão da Medula Espinal/diagnóstico por imagem , Abscesso/tratamento farmacológico , Antifúngicos/uso terapêutico , Candida albicans/isolamento & purificação , Candidíase Invasiva/tratamento farmacológico , Síndrome da Cauda Equina/tratamento farmacológico , Infecções Fúngicas do Sistema Nervoso Central/tratamento farmacológico , Humanos , Masculino , Compressão da Medula Espinal/tratamento farmacológico , Resultado do Tratamento , Adulto JovemRESUMO
The mortality associated with invasive candidiasis remains unacceptably high. The T2 magnetic resonance (T2MR) assay is a novel US FDA-approved molecular diagnostic assay for the diagnosis of candidemia that can rapidly detect the five most commonly isolated Candida spp. In clinical trials, T2MR has exhibited good clinical sensitivity and specificity. Potential benefits from the adoption of T2MR technology in the diagnostic and therapeutic algorithms for invasive candidiasis can arise from timely diagnosis of disease, increased case detection, tailored therapy and decrease in empiric antifungal treatment. As everyday clinical experience with the assay is evolving, we discuss the utility of T2MR in invasive candidiasis with and without candidemia based on the currently available evidence regarding its performance.
Assuntos
Candidíase Invasiva/diagnóstico por imagem , Antifúngicos/uso terapêutico , Candida/classificação , Candida/fisiologia , Candidemia/diagnóstico por imagem , Candidemia/tratamento farmacológico , Candidíase Invasiva/tratamento farmacológico , Diagnóstico Precoce , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Espectroscopia de Ressonância Magnética/economia , Sensibilidade e EspecificidadeRESUMO
Background: Delay in treatment of candidaemia and invasive candidiasis remains a cause of significant morbidity and mortality in high-risk patients. Widespread empirical utilization of antifungal therapy often occurs in an effort to minimize this risk. Objectives: This study assessed the impact of the T2Candida Panel in a multi-hospital community health system on time to initiation of antifungal therapy in candidaemic patients as well as the utilization of micafungin. Methods: Outcomes were compared between those patients with candidaemia prior to T2Candida implementation and those after implementation. Micafungin utilization for patients with suspected candidaemia/invasive candidiasis was compared with that for patients with a negative T2Candida Panel post-implementation. Results: There was a significant decrease in time to appropriate therapy in the post-T2Candida group (34 versus 6 h, P = 0.0147). Empirical antifungal therapy was avoided in 58.4% of T2Candida-negative patients. Conclusions: These results support the implementation of T2Candida to improve time to appropriate therapy for candidaemic patients while simultaneously expanding antimicrobial stewardship efforts to appropriately utilize antifungals.
Assuntos
Antifúngicos/uso terapêutico , Candida/classificação , Candida/isolamento & purificação , Candidemia/diagnóstico , Candidemia/tratamento farmacológico , Candidíase Invasiva/diagnóstico , Candidíase Invasiva/tratamento farmacológico , Micafungina/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Gestão de Antimicrobianos , Candidemia/diagnóstico por imagem , Candidíase Invasiva/diagnóstico por imagem , Centros Comunitários de Saúde , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Objectives: We assessed the potential role of T2Candida MR (T2MR) and serological biomarkers [ß-d-glucan (BDG) or Candida albicans germ tube antibodies (CAGTA)], alone or in combination with standard cultures, for identifying patients with suspected invasive candidiasis (IC), who may benefit from maintaining antifungal therapy. Methods: Prospective observational multicentre study including all adult patients receiving empirical antifungal therapy for suspected IC, from January to June 2017. CAGTA, BDG and T2MR were determined at baseline and at +2 and +4 days after enrolment. Primary endpoint was the diagnostic value of CAGTA, BDG and T2MR, alone or in combination with standard culture, to predict diagnosis of IC and/or mortality in the first 7 days after starting antifungal therapy (poor outcome). Results: Overall, 14/49 patients (28.6%) had a poor outcome (7 died within the first 7 days of antifungal therapy, whereas 7 ended with a diagnosis of IC). CAGTA [3/14 (21.4%) versus 8/35 (22.9%), P = 1] and BDG [8/14 (57.1%) versus 17/35 (48.6%), P = 0.75] results were similar in poor- and good-outcome patients. Conversely, a positive T2MR was associated with a higher risk of poor outcome [5/14 (35.7%) versus 0/35 (0.0%) P = 0.0001]. Specificity and positive predictive value of a positive T2MR for predicting poor outcome were both 100%, with a negative predictive value of 79.6%. After testing the combinations of biomarkers/standard cultures and T2MR/standard cultures, the combination of T2MR/standard cultures showed a high capacity to discriminate patients with poor outcome from those with good clinical evolution. Conclusions: T2MR may be of significant utility to identify patients who may benefit from maintaining antifungal therapy.
Assuntos
Antifúngicos/uso terapêutico , Candidíase Invasiva/diagnóstico por imagem , Candidíase Invasiva/tratamento farmacológico , Candidíase/diagnóstico por imagem , Candidíase/tratamento farmacológico , Imageamento por Ressonância Magnética/métodos , Adulto , Idoso , Anticorpos Antifúngicos/sangue , Hemocultura , Candidíase/diagnóstico , Candidíase Invasiva/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , beta-Glucanas/sangueAssuntos
Abscesso Abdominal/diagnóstico , Candidíase Invasiva/diagnóstico , Nefropatias/diagnóstico , Neoplasias/diagnóstico , Infecções Urinárias/diagnóstico , Abscesso Abdominal/complicações , Abscesso Abdominal/diagnóstico por imagem , Abscesso Abdominal/terapia , Antibacterianos/uso terapêutico , Candida , Candidíase Invasiva/complicações , Candidíase Invasiva/diagnóstico por imagem , Candidíase Invasiva/terapia , Diagnóstico Diferencial , Drenagem , Evolução Fatal , Feminino , Humanos , Nefropatias/complicações , Nefropatias/diagnóstico por imagem , Nefropatias/terapia , Pessoa de Meia-Idade , Derrame Pleural/etiologia , Choque Séptico/etiologia , Infecções Urinárias/complicações , Infecções Urinárias/tratamento farmacológicoRESUMO
Invasive fungal disease (IFD) is a life-threatening condition, especially in immunocompromised children. The role of diagnostic imaging in children at risk for an IFD is multifactorial, including initially detecting it, evaluating for dissemination of infection beyond the primary site of disease, monitoring the response to antifungal therapy, and assessing for potential relapse. The objective of this review was to synthesize the published literature relevant to the use of various imaging modalities for the diagnosis and management of IFD in children.