Candida albicans : An Unusual Cause of Osteomyelitis and Empyema Post Cholecystectomy

Abstract

INTRODUCTION: Candida albicans is a commensal organism of the gastrointestinal tract. A breach in the mucosa may predispose to candidemia and secondary complications. We present a case of Candidal osteomyelitis and empyema presenting 3 months after cholecystectomy. CASE PRESENTATION: A 74 year old Caucasian male with a history of hypertension, diabetes, hypothyroidism and cholecystectomy 3 months prior to admission presented to an outside hospital after a fall. He complained of fever, back pain and lower extremity weakness. CT of the spine showed discitis, osteomyelitis, fracture of T12 with a paraspinal phlegmon and a moderate right pleural effusion. CT of the abdomen/pelvis showed no other focus of infection. Malignancy workup was negative. Initial sampling of the pleural effusion revealed an exudate with negative cultures and cytology. He was treated empirically with broad spectrum antibiotics and was transferred to our facility for neurosurgical intervention. Biopsy of the vertebral lesion showed Candida albicans and fluconazole was started. His pleural effusion was resampled, showing a pH of 6.8 with culture positive for Candida albicans. A chest tube was placed with eventual resolution of effusion. After undergoing T12 laminectomy, corpectomy and discectomy, his hospital course was complicated by renal failure requiring dialysis, bacterial pneumonia and respiratory failure requiring mechanical ventilation. He was eventually transferred to a ventilator supported facility. DISCUSSION: Risk factors for candidemia include central venous catheters, total parenteral nutrition, broad-spectrum antibiotics, abdominal surgery, gastrointestinal perforation, surgical anastomotic leaks and an immunocompromised state. In this patient, we speculate that his vertebral infection could have resulted from one of the two mechanisms: 1) transient candidemia during surgery that caused subsequent seeding of the vertebra, or 2) retroperitoneal candidal translocation to the spine following surgery, as his blood cultures were negative. Candidal empyema may present either due to hematogenous seeding, contiguous spread or instrumentation of the pleural cavity. Contiguous infection from esophageal origin is more common and has a lower mortality rate (40%) compared to non-contiguous infection (60%). Candida albicans is the most common isolate when contiguous infection occurs (75%), but bacterial co-infection is possible. Definitive treatment includes antifungals and complete evacuation of pleural fluid. CONCLUSIONS: This case is unique because our patient did not have the most common known risk factors for candidemia. His empyema likely arose from contiguous spread from his paraspinal phlegmon that presented subacutely after routine cholecystectomy. Practitioners should be cognizant of the potential for subacute, or delayed presentation.