Case study
Candida albicans causing cervical pyomyositis: A case report
Piomiositis cervical por Candida albicans: A propósito de un caso
Patricia Corriols Noval
, Eugenia Carmela López Simón, Nathalia Castillo Ledesma, Carmelo Morales Angulo
Corresponding author
Otorrinolaringologist Department, Marqués de Valdecilla University Hospital, Cantabria's University, Santander, Cantabria, spain
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A propósito de un caso y revisión de la literatura" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 372 "Ancho" => 1305 "Tamanyo" => 54343 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Otomicroscopy and computerised tomography where the lesion is shown with density of soft tissues adhering to the right tympanic membrane.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Paula Cruz Toro, Margarita Mesa Marrero, Elena Hernández Montero, María Pané Foix" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Paula" "apellidos" => "Cruz Toro" ] 1 => array:2 [ "nombre" => "Margarita" "apellidos" => "Mesa Marrero" ] 2 => array:2 [ "nombre" => "Elena" "apellidos" => "Hernández Montero" ] 3 => array:2 [ "nombre" => "María" "apellidos" => "Pané Foix" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173573520300983?idApp=UINPBA00004N" "url" => "/21735735/0000007100000006/v1_202011170657/S2173573520300983/v1_202011170657/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case study</span>" "titulo" => "<span class="elsevierStyleItalic">Candida albicans</span> causing cervical pyomyositis: A case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "396" "paginaFinal" => "398" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Patricia Corriols Noval, Eugenia Carmela López Simón, Nathalia Castillo Ledesma, Carmelo Morales Angulo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Patricia Corriols" "apellidos" => "Noval" "email" => array:1 [ 0 => "patri16.92@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Eugenia Carmela López" "apellidos" => "Simón" ] 2 => array:2 [ "nombre" => "Nathalia Castillo" "apellidos" => "Ledesma" ] 3 => array:2 [ "nombre" => "Carmelo Morales" "apellidos" => "Angulo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Otorrinolaringologist Department, Marqués de Valdecilla University Hospital, Cantabria's University, Santander, Cantabria, spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Piomiositis cervical por <span class="elsevierStyleItalic">Candida albicans</span>: A propósito de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 792 "Ancho" => 750 "Tamanyo" => 133163 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Photomicrograph ×400 shows H&E pseudohyphae (arrow) and spores within muscle fibers and also necrotizing inflammation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 62-year-old-man was assessed by our Ear, Nose and Throat (ENT) department because of a two-month history of progressive growth of a right laterocervical mass. 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.</p><p id="par0010" class="elsevierStylePara elsevierViewall">On physical examination, there was a 2.8<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2.7<span class="elsevierStyleHsp" style=""></span>cm tender mass, with fibrotic consistency in the third half of the right sternocleidomastoid muscle (SCM) which sinus tract to the skin and constant drainage.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Computed cervical tomography scan (CT) revealed a rim-enhancing low attenuation heterogeneous mass in the inside measuring 2.8<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2.4<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2.5<span class="elsevierStyleHsp" style=""></span>cm 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>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">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 <span class="elsevierStyleItalic">Candida albicans</span>, 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>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">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<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3.8<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm 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 <span class="elsevierStyleItalic">C. albicans</span>.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Cervical 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 <span class="elsevierStyleItalic">Staphylococcus aureus</span> in 80% followed by <span class="elsevierStyleItalic">Streptococci</span> and enterobacteria, been fungal etiology less the 2%, where <span class="elsevierStyleItalic">Candida</span> spp.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a> is the most frequent pathogen implicated.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The pathophysiology consists on asymptomatic and transitory bacteremia/fungemia of whatever origin, with posterior developing of muscle involvement.</p><p id="par0040" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">3,4,7,8</span></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"><span class="elsevierStyleSup">1</span></a> Other predisposing factors, above all, for fungal infection are previous fungal infection, broad-spectrum antibiotic exposure or parenteral nutrition catheter.</p><p id="par0045" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">1,2</span></a> In our case, the central venous catheter that the patients had been carrying, could be the portal of entry for the infection.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The pathogenesis of pyomyositis involves a bloodstream infection of whatever origin, that use to be asymptomatic and transitory.</p><p id="par0055" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">1</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">5</span></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"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">1</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">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.</p><p id="par0080" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">4</span></a> Most cases finally require surgical management to remove necrosis and detritus into the muscle.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">8</span></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.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conclusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Fungal 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.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Authors’ contribution</span><p id="par0095" class="elsevierStylePara elsevierViewall">All 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.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">Besides, all authors declare not having any conflict of interest or having received any financial relationship or support by external sources or enterprises.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Discussion" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conclusion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Authors’ contribution" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-08-18" "fechaAceptado" => "2019-09-24" "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 558 "Ancho" => 750 "Tamanyo" => 42907 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Computerize tomography shows a heterogeneous mass extending throughout the right SCM (arrow) and a skin fistulous tract.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 792 "Ancho" => 750 "Tamanyo" => 133163 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Photomicrograph ×400 shows H&E pseudohyphae (arrow) and spores within muscle fibers and also necrotizing inflammation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pyomyositis in North America: case reports and review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L. 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