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An obese 43-year-old, immunocompetent male presents to the emergency department after developing chest pain less than 24 hours previously. He suspects he has drug poisoning.

Over the past 12 years, he says, he has been admitted to the hospital many times after intentional drug intoxication. He says he is schizophrenic and suffering from depression, both of which were diagnosed some time ago. He is a smoker (with a 25-pack-year history of smoking) and a chronic alcoholic. He admits to drinking about 5 litres of beer every day.

Assessment in ER notes that his heart rate is 103/min, his blood pressure is 101/68 mmHg, and his temperature is 37.4°C. Current medications include diazepam, hydroxyzine, olanzapine, and clomipramine.

The Workup

A transthoracic echocardiography upon his presentation at the ER reveals abundant circumferential pericardial effusion of 20-mm thickness, normal left ventricular ejection fraction, and pre-tamponade signs.

Physical examination notes unremarkable cardiopulmonary findings: His pulse is regular, he has no heart murmurs, and he has symmetric positive bilateral airways entry.

Laboratory test results:

• Hemoglobin: 13.3 g/dL
• Platelets: 320 giga/L
• WBC: 15.73 giga/L
• CRP: 332
• Creatinine: 0.76 mg/dL
• Liver enzymes: Normal
• Positive troponin: 395 ng/L

An electrocardiogram reveals sinus tachycardia at 103, with diffuse upward ST segment elevation in most leads. Clinicians also request an enhanced CT scan of the thorax, abdomen, and pelvis. Findings of the CT include significant pericardial effusion with abnormal enhancement of the pericardium and few pockets of air within the effusion, and bilateral small pleural effusion.

Abnormal dilatation of the portion of the esophagus behind the heart suggests a pre-existing fistula. Two sets of blood cultures and a urine culture, immunological tests, syphilis, and HIV serologies are drawn.

Diagnosis and Treatment

Given the CT evidence of a previous esophageal fistula, the patient is diagnosed with infectious pericarditis with pre-tamponade status.

The patient is started on a treatment regimen of:

• PO amoxicillin-clavulanic acid 1,000 mg Q8H
• IV acetylsalicylate 1,000 mg Q8H
• SC enoxaparin 4,000 UI

Pericardiocentesis is performed and 400 cc of pericardial fluid and 50 cc of pleural fluid are drained and sent for culture. Results of all serologies and cultures come back negative with one exception: the pericardial fluid shows evidence of Candida.

An anti-fungigram reveals Candida albicans sensitive to fluconazole and caspofungin. The patient is started on fluconazole 800 mg/day as a loading dose, then 400 mg/day for 2-3 weeks, as recommended for the treatment of invasive candidiasis. Amoxicillin-clavulanic acid and acetylsalicylate is discontinued.

Follow-Up

The patient receives treatment with fluconazole for 3 weeks and is reassessed. A cardiac MRI shows a residual circumferential pericardial effusion with 8 mm thickness, without compressive signs, and normal myocardium. Later, follow-up endoscopy of the upper-GI tract confirms that the patient had an esophageal fistula. This is repaired with an endoluminal prosthesis (Figure).

Discussion

Clinicians reporting this (1) write that it is the first incident of Candida pericarditis in a young, immunocompetent adult without history of thoracic surgery. Despite its rarity, they write, fungal pericarditis does occur and can be associated with high rates of mortality and morbidity.

They note purulent pericarditis due to Candida represents 1% of cases of purulent pericarditis, according to one review of 660 cases of invasive pericarditis (2). Furthermore, another review found that 21 of 24 cases due to candida occurred in patients who had undergone thoracic surgery (3), and most cases of gastropericardial fistula occurred in patients with gastric adenocarcinoma (2).

Of 200 distinct strains included in genus Candida, only some types become pathogenic in a debilitated or impaired host immune system (4). Case authors suggest that the increasing complexity of patients has contributed to a growing incidence of invasive candidiasis, and potential mortality, especially in hospitalized patients (5).

Initial treatment of invasive candidiasis in non-neutropenic patients involves an echinocandin such as anidulafungin (200 mg loading dose, then 100 mg IV daily), caspofungin (70 mg loading dose, then 50 mg IV daily), and micafungin (100 mg IV daily). Alternatively, a regimen of fluconazole such as that used in the case of this immunocompetent patient, may be used in non-critical patients and those unlikely to have a fluconazole-resistant specifies of Candida such as C. krusei or C. glabrata (6,7).

Pericardiocentesis followed by operative drainage and anti-fungal agents appears to be the best approach for achieving a cure (5-8), the authors noted. Given fluconazole's high bioavailability, oral therapy is ideal for most patients, with intravenous treatment reserved for patients who are very ill or have dysphagia or poor gastrointestinal absorption (7).

As well, authors cite the Infectious Diseases Society of America 2016 update recommendation that stable patients sensitive to fluconazole be switched from an echinocandin to fluconazole.

Duration of anti-fungal therapy for Candida pericarditis has not been recommended, they note. Approach to treatment of in general has been evolving recently (8). Authors suggest that anti-fungal treatment of candidemia or invasive candidiasis should be continued for 2 weeks after the patient has a negative blood culture and is free of of symptoms (7).

In this case, blood culture was negative and Candida pericarditis was due to previous esophageal candidiasis thought to have emerged from a pre-existing esophageal in an obese, chronic alcoholic adult. Thus, after considering the guidelines and data, clinicians decided to treat the patient for 3 weeks.

References

1. Matta A, et al: A rare case of candida pericarditis associated with esophagopericardial fistula. Am J Case Rep 2019; 20: 975-979

2. Sung J, et al: A case report of purulent pericarditis caused by candida albicans Delayed complication forty-years after esophageal surgery. Medicine (Baltimore) 2018; 97(28): e11286

3. Schrank JH, Dooley DP: Purulent pericarditis caused by candida species: Case report and review. Clin Infect Dis 1995; 21(1): 182–87

4. Spampinato C, Leonardi D: Candida infections, causes, targets, and resistance. Mechanisms: Traditional and alternative antifungal agents. Biomed Res Int, 2013; 2013: 204237

5. Antinori S, et al: Candidemia and invasive candidiasis in adults: A narrative review. Eur J Intern Med 2016; 34: 21–28

6. Kauffman C: . UpToDate 2018

7. Pappas P, et al: Clinical practice guideline for the management of candidiasis: 2016 update by the infectious diseases society of America. Clin Infect Dis 2016; 62(4): e1–e50

8. Bassetti M, et al: What has changed in the treatment of invasive candidiasis? A look at the past 10 years and ahead. Journal of Antimicrobial Chemotherapy 2018; 73(1): i14–i25

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