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International Research Journal of Medical Sciences __________________________________________________
Vol. 1(1), 18-19, February (2013)

Mini Review Paper
Pneumonia caused by Candida kefyr in a Pediatric patient with Acute
Lymphoblastic Leukaemia: Case Report
Dinkar A.1, Bhattacharyya S.1, Kumar D.1, Kumar A.2, Gupta P.1, Banerjee G.1 and Singh M.1
1Departments of Microbiology, King George’s Medical University (KGMU), Lucknow-226003, UP, INDIA 2Departments of Pediatrics, King George’s Medical University (KGMU), Lucknow-226003, UP, INDIA Available online at:
Received 10th January 2013, revised 21st January 2013, accepted 5th February 2013 Abstract
Acute lymphoblastic leukaemia (ALL)is one of the commonest malignancies in children. The disease per se and
immunosuppressant cytotoxic drugs administered, together make the patients of ALL very prone to secondary infections.
Yeasts recovered from pulmonary tissue are mostly treated as colonisers and left unreported, though they can also be rarely
responsible for pneumonia, especially in settings of haematological malignancies. Here we report a case of lung infection
due to Candida kefyr in a patient with ALL.
Keywords: ALL, Candida kefyr, immunocompromised.

leucocyte count of the patient was 8000/µl and absolute Neutrophil count was 5200/ µl. The patient was put on Acute leukaemia, a tumour of the haematological progenitor Tetracycline, Tramadol, Fluconazole, Vincristine, Methotrexate cells of the Bone marrow, is the commonest paediatric and L-Asparaginase. Sputum sample was collected from the malignancy1. Of this, Acute Lymphoblastic Leukaemia (ALL) patient and sent to the Department of Microbiology for fungal comprises about 75%1. The disease commonly presents with culture. A 10% KOH smear showed multiple budding yeasts as neutropenia, which is a risk factor for secondary infections in well as pus cells, with a Quality (Q) score of +3(plus three). this group of patients2. An absolute neutrophil count of <500/µl Gram stain also showed similar findings. The sample was has been associated with significant risk of infection2. Infect, a inoculated in 2 Saboraud’s Dextrose agar (SDA) slants and patient with febrile neutropenia has a 60% likelihood of being incubated at 370C and 250C separately. After 48 hours of infected3. Most of these are bloodstream infections (BSI), incubation, opaque, smooth white colonies grew on both tubes. although other organs may also be affected3. Pulmonary A Lactophenol Cotton blue (LCB) mount of the colonies infiltrates develop in about 60-80% such patients, according to showed budding yeast cells. A loopful of the growth was scientific literature4. Such infiltrates can be due to infection, streaked onto Corn meal agar by slit inoculation (Dalmau haemorrhage or leukemic involvement of lung parenchyma5. In technique) and incubated at 250C for 48 hours. Germ tube test a study, about 12% of all episodes of infectious pneumonia in and Sugar fermentation and assimilation tests were also ALL are caused by fungi, most commonly by Aspergillus spp.6. performed. The isolate was Germ tube negative and showed Candida spp. is also a known cause of pneumonia in these elongated budding yeasts and pseudohyphae arranged in patients, although the incidence has decreased due to irregular parallel bundles (logs in stream appearance) on high prophylactic antifungal therapy7. power (40X) microscopic examination of the streaked Corn meal agar plate. Glucose, lactose and sucrose were fermented Case Report
but not maltose. Lactose, glucose and sucrose were assimilated but not maltose. Based on these phenotypic characteristics, the A 13 year-old male patient presented in the Paediatric outpatient isolate was identified as Candida kefyr8. Antifungal Department of the Medical University with respiratory distress susceptibility test was done by the disc diffusion technique on and hepatosplenomegaly. The patient was admitted and baseline Mueller-Hinton agar with 2% glucose and 0.5 µg/ml of haematological investigations were performed. Based on bone Methylene blue, as per CLSI protocol9. The yeast isolate was marrow analysis, a diagnosis of B cell ALL was achieved. The susceptible to fluconazole and voriconazole. The sample was patient was suffering from cough and breathlessness since 3 sent on 2 more occasions, which yielded the same results. There months, and also had 2 episodes of haemoptysis. A chest was no bacterial growth in the sputum samples. Blood culture roentgenogram (postero-anterior view) was carried out, which on biphasic media was sterile after 21 days of incubation. The revealed cavitatory lesions in lingular lobe of left lung with patient’s breathlessness improved on fluconazole therapy and patchy fibrosis, along with nodular infiltrates. The total there were no further bouts of haemoptysis. International Science Congress Association
International Research Journal of Medical Sciences ________________________________________________________________
Vol. 1(1), 18-19, February (2013)
Int. Res. J. Medical Sci. Discussion
ALL is the commonest pediatric malignancy worldwide1. This 1. Esparza S.D. and Sakamoto K.M., Topics in Pediatric
haematological malignancy is often complicated by secondary
Leukemia – Acute Lymphoblastic Leukemia, Medscape infections, which may be due to neutropenia due to the disease Gen. Med., 7, 23 (2005)
itself or chemotherapy or functional defects of the neutrophils, 2. Meckler G. and Lindemulder S., Fever and Neutropenia in
like defective superoxide production and chemoattraction2. patients with Cancer, Emergency Med. Clin. North Am., 27,
Secondary infections in this setting are mostly caused by Gram 529-44 (2009)
negative bacilli and Aspergillus spp. along with other
angioinvasive fungi3,7. Candida spp. can cause pneumonia in 3. Chong C.Y., Tan A/.M. and Lou J., Infections in Acute
these patients, although primary pulmonary candidiasis is
Lymphoblastic Leukaemia, Annals Acad. Med. Singapore, extremely rare and Candida spp. isolated from sputum of 27, 491-95 (1998)
patients without immunosuppression is mostly treated as 4. Rosenow E.C., Wilson W.R. and Cockerill F.R., Pulmonary
commensal or colonisers10. Candida kefyr is an emerging disease in the immunocompromised host, Mayo Clin. infectious agent in patients having oncohematological Proc., 60, 473-487 (1985)
malignancies, being significantly more frequently isolated from
oncohematology wards than other wards as reported in some 5. Hildebrand F.L. Jr., Rosenow E.C., Habermann T.M. and
studies11. The reason for this preponderance of this pathogen for
the immunocompromised host is unknown, although there are leukemia, Chest, 98, 1233-1239 (1990)
speculations that mucositis induced by chemotherapeutic agents 6. Vento S., Cainelli F. and Temesgen Z., Lung infections
may favour its colonisation and infection, and that dietary habits after cancer chemotherapy, Lancet Oncol., 9, 982-92 (2008)
may play a role since this species is mostly found in dairy 7.
products11,12. Chest X ray in pulmonary candidiasis mainly Souza C.A., Muller N.L., Marchiori E., Escuissato D.L. and Franquet T., Pulmonary Invasive Aspergillosis and shows lobar involvement and reticulonodular shadows11. Our case is the first report of pneumonia due to this pathogen in a patient with Acute Lymphoblastic Leukaemia and highlights Comparative Study of the High-Resolution CT findings, J. that this yeast species must be considered as a causative agent in Thorac. Imaging, 21, 184–189 (2006)
infections in haematological malignancies when other 8. Larone D.H., Medically important Fungi: A guide to
aetiologies have been ruled out.
Identification, 5th Edition, ASM press, Washington DC Conclusion
9. NCCLS, Method for antifungal disk diffusion susceptibility
Candida kefyr should be suspected as a possible cause of testing of yeasts, Approved Standard M44-A2 (2008)
pneumonia in patients with haematological malignancies and 10. Falcone M., Accarpio F., Venditti M., Vena A., Sibio S.,
should not be regarded as a mere coloniser. The pathogenic Sammartino P., Di Giorgio A., Septic bilateral pulmonary potential of this yeast species needs to be studied further. candidiasis successfully treated with anidulafungin therapy in two patients with peritoneal carcinomatosis, J. Acknowledgement
Antimicrob. Chemother (2010)
The authors are heartily thankful to Mr Mayank Agnihotri, 11. Sendid B., Lacroix C. and Bougnoux M., Is Candida kefyr
junior technician and Dr Akhilesh, Junior Resident, Department
an Emerging Pathogen in Patients with Oncohematological of Microbiology, KGMU for their assistance in identifying the Diseases?, Clin. Inf. Dis., 43, 666–67 (2006)
12. Weichert S., Reinshagen K., Zahn K., Geginat G., Dietz A.
, Kilian A.K., Schroten H. and Tenenbaum T., Candidiasis caused by Candida kefyr in a neonate: Case report, BMC
, 12, 61 (2012)
International Science Congress Association


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INTRODUCCIÓN*Imperio y canon en William Henry HudsonLeila Gómez University of Colorado, Boulder En 1941, se publica en Argentina la pionera Antología de Guillermo Enrique Hudson con estudios críticos sobre su vida y su obra , con textos de Fernando Pozzo, E. Martínez Estrada, Jorge Casares, Jorge Luis Borges, H. J. Massingham, V. S. Pritchett y Hugo Manning. Fue este uno de los principales

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