Candida albicans causing cervical pyomyositis: A case report

Noval, Patricia Corriols; Simón, Eugenia Carmela López; Ledesma, Nathalia Castillo; Angulo, Carmelo Morales

doi:10.1016/j.otoeng.2019.09.006

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He underwent a bilateral lung transplantation due to interstitial lung disease and has been administrated immunosuppresive drugs. The patient had a central venous catheter in the right internal jugular vein for parenteral nutrition.On physical examination, there was a 2.8×2.7cm tender mass, with fibrotic consistency in the third half of the right sternocleidomastoid muscle (SCM) which sinus tract to the skin and constant drainage.Computed cervical tomography scan (CT) revealed a rim-enhancing low attenuation heterogeneous mass in the inside measuring 2.8×2.4×2.5cm extending throughout the right SCM with increased layer thickness. Besides, a skin fistulous tract was confirmed according to abscessed pyomyositis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Fine-needle aspiration under local anesthetic yielded poor purulent material and was examined by the pathologist and microbiologist. Henceforth, the patient was decided to be treated with empiric intravenous antibiotics covering staphylococcus and anaerobic bacteria with piperacillin–tazobactam therapy. The results of the cultures revealed the fungus Candida albicans, so caspofungin was added to the treatment. On microscopic examination, necrotizing inflammation, pseudohyphae and blastospores were found in the muscle tissue (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The patient was clinically asymptomatic, albeit with persistence of oozing of the cervical mass. At this point, surgery was scheduled and patient underwent incision and drainage. Intraoperative finding confirmed the presence of encapsulated fibrotic 5.4×3.8×1cm lesion and fistulous tract was also removed. He was discharged home one week after surgery exclusively under oral antifungic treatment, even though the second culture from the intraoperative biopsy was positive for C. albicans.DiscussionCervical pyomyositis (CP) is rare skeletal muscle infection, usually developing intramuscular abscess formation. It mostly affects lower limbs, followed by chest and abdomen, been infrequent cervical compromised. CP is commonly caused by bacteria, specifically Staphylococcus aureus in 80% followed by Streptococci and enterobacteria, been fungal etiology less the 2%, where Candida spp.<a class="elsevierStyleCrossRefs" href="#bib0045">1,2</a> is the most frequent pathogen implicated.The pathophysiology consists on asymptomatic and transitory bacteremia/fungemia of whatever origin, with posterior developing of muscle involvement.The main risk factor is immunodeficiency state, due to immunosuppressive drugs (as our case) or systemic pathologies such as HIV infection, diabetes mellitus, malignancy tumors and chemotherapy, cirrhosis or renal insufficiency,<a class="elsevierStyleCrossRefs" href="#bib0055">3,4,7,8</a> Steroid therapy, injection drug use or recent muscular trauma may produce myopathy and muscle hematoma which increase the likelihood for suffering from pyomyositis.<a class="elsevierStyleCrossRef" href="#bib0045">1</a> Other predisposing factors, above all, for fungal infection are previous fungal infection, broad-spectrum antibiotic exposure or parenteral nutrition catheter.CP use to present with pain and cramping localized to a single muscle group. Multifocal muscle infection could be present in even 20% of cases, increasing the risk if there are other predisposing factors associated.<a class="elsevierStyleCrossRefs" href="#bib0045">1,2</a> In our case, the central venous catheter that the patients had been carrying, could be the portal of entry for the infection.The pathogenesis of pyomyositis involves a bloodstream infection of whatever origin, that use to be asymptomatic and transitory.Laboratory findings include typical infectious alterations as leukocytosis and acute phase proteins raised up, but in some immunocompromised patients, the analytic parameters use to reveal leucopenia and poor inflammatory markers elevation. Creatine kinase and other muscle enzyme levels are often normal.<a class="elsevierStyleCrossRef" href="#bib0045">1</a>Fungal pyomyositis is mostly diagnosed in advanced stages requiring prolonged hospitalization and treatment. Recurrent infection is rare but has been described in those immunocompromised individuals.<a class="elsevierStyleCrossRef" href="#bib0060">4</a>Radiographic imaging is the most useful tool, defining the site of infection, and ruling out other entities. Magnetic resonance imaging (MRI) is the best imaging technique, due to it is highly sensitive to demonstrate the extension and involvement of the soft tissues, even prior to the formation of a frank abscess. The close relationship between MRI and histopathology results suggests that is the ideal image tool during the follow-up.<a class="elsevierStyleCrossRef" href="#bib0065">5</a> If not available, CT is helpful for detecting muscle swelling and well-delineated areas of fluid attenuation as well as for radiographic-guided drainage of purulent material if necessary. Ultrasonography (US) is also a potentially useful diagnostic and therapeutic tool, particularly during the purulent stage of infection.<a class="elsevierStyleCrossRefs" href="#bib0070">6,7</a>Bacteriologic diagnosis can be made by cultures of drainage or blood test in case of fungaemia, and it is almost always helpful for obtaining optimal microbiologic data and susceptibility testing to direct specific therapy.<a class="elsevierStyleCrossRef" href="#bib0045">1</a>CP may be confused with other pathologies as muscle contusion or hematoma, cellulitis, deep vein thrombosis, osteomyelitis, or neoplasm. It must also be distinguished from other forms of myositis as clostridial myonecrosis, necrotizing fasciitis, spontaneous gangrenous myositis and diabetic muscle infarction.When pyomyositis is suspected broad-spectrum antibiotic for Staphylococcus and anaerobic germs is mandatory. For immunocompromised individuals, antifungal coverage should always be considered. Amphotericin B is the drug of choice, however, its high kidney toxicity limits its use, so others like Micafungina and Caspofungina could be chosen, as it happened in our patient.<a class="elsevierStyleCrossRef" href="#bib0060">4</a> Most cases finally require surgical management to remove necrosis and detritus into the muscle.<a class="elsevierStyleCrossRefs" href="#bib0045">1–3</a>Prognosis of CP depends on the state the diagnose has been done and in the comorbidities of the patient. In general lines the mortality should oscillate between 0.9% and 14%, it is most likely in severe immunocompromised hosts.<a class="elsevierStyleCrossRef" href="#bib0080">8</a> Even so, a high suspicion is mandatory, above all if fungal etiology could be involved, because if infection spreads to other organs, the effectiveness of the treatment will be lower and the rate of mortality notably higher.ConclusionFungal pyomyositis is a rare entity which produces purulent infection of skeletal muscle, typically in immunocompromised patients, that use to appear in lower limbs, been extremely unusual cervical infection. Clinical suspicion and imaging studies are mandatory to achieve the diagnosis, and cultures are necessary to determine the germ etiology and drugs sensibility. Candida species should be considered potential pathogens, especially when there are predisposing factors, so empirical antibiotic and antifungal coverage should always be considered. Most patients require both medical and surgical debridement.Authors’ contributionAll authors have access to the data during the research process and have developed a huge and hard work in the edition and writing of the manuscript.Conflict of interestBesides, all authors declare not having any conflict of interest or having received any financial relationship or support by external sources or enterprises." 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Acta Otorrinolaringológica Española, the official publication of the Spanish Society of Otolaryngology and Head and Neck Surgery and the Ibero-American Society of Otorhinolaryngology, is the most important journal in Spanish dedicated to Otorhinolaryngology, which reflects the continuous scientific and technical progress of the specialty. It has become an important tool to be kept up to date. The Journal publishes Original Articles (articles on basic research and clinical investigation), reviews, brief communications, case studies and images, which are subjected to a rigorous peer review process.

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