Download Pulmonary Mycetoma Due to Candida albicans: Case Report and

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Pulmonary Mycetoma Due to Candida albicans: Case Report and Review
Mark A. Shelly, Robert H. Poe, and Louis B. Kapner
From the Department of Medicine, Highland Hospital, and the
University of Rochester School of Medicine and Dentistry,
Rochester, New York
A pulmonary mycetoma is a round to oval-shaped mass of fungi situated within a cavity in the
lung. Most mycetomas are caused by Aspergillusspecies. Other fungi have occasionally been reported
to cause clinically and roentgenographically similar lesions. We report a case of pulmonary mycetoma caused by Candida albicans. Review of the literature suggests that pulmonary mycetoma due
to this species is uncommon, and when it has been suspected, specific documentation has been
lacking.
A pulmonary mycetoma usually results from saprophytic
growth of an Aspergillus species in a chronic cavity in the
lung; however, other fungal species have been infrequently
involved [1]. Although Candida species are common pathogens, they have rarely been associated with this type of infection. We report a case of pulmonary mycetoma due to Candida
albicans.
Case Report
A 50-year-old man was referred for evaluation of a change
that had been noted on his chest roentgenograph. He did not
have any symptoms. Four years earlier, he had been admitted
to a community hospital with cavitary pneumonia of the right
upper lobe. He was treated for aspiration pneumonia with intravenous penicillin, and a chronic cavitary deformity remained
in the right upper lobe. He had received follow-up by means
of serial chest roentgenography that was performed annually.
The third chest roentgenograph showed a mass lesion within
the cavity (figure I). A CT scan of the chest confirmed the
presence of an oblong, dependent soft-tissue mass within the
cavity (figure 2).
A tuberculin test with PPD and positive anergy control was
negative. Bronchoscopy with brush biopsy and bronchoalveolar
lavage was performed under fluoroscopic guidance. The collected material showed short nonseptate hyphal elements and
budding yeast forms suggestive of Candida species. Culture
yielded pure growth of Candida albicans. Identification of the
species was confirmed by the New York State Department of
Received 1 May 1995; revised 5 July 1995.
Reprints or correspondence: Dr. Robert H. Poe, Highland Hospital, 1000
South Avenue, Rochester, New York 14620.
Clinical Infectious Diseases 1996;22:133-5
© 1996 by The University of Chicago. All rights reserved.
1058-4838/96/2201-0021$02.00
Health Mycology Laboratory. No acid-fast bacilli were recovered by smear or culture. Serum antibody tests were negative
for C. albicans, Aspergillus fumigatus, and Aspergillus niger.
No specific treatment was rendered. Findings on repeated
chest roentgenography at 8 months were unchanged. The mycetoma persists, but the patient has remained asymptomatic more
than 24 months after evaluation.
Review and Discussion
Although Candida species have been mentioned as an occasional cause of pulmonary mycetoma, most reports are old,
confirmation of the pathogen by culture has been lacking, and
when culture is successful, species other than C. albicans have
been recovered [2, 3].
Aspergillus species cause most pulmonary mycetomas. Other
fungi can cause similar lesions; reports mention Pseudallescheria boydii, Mucoraceae, Coccidioides immitis, Histoplasma capsulatum, Blastomyces dermatitidis, Sporothrix
schenckii [4], and Blastochizomyces capitatus [5] as causes of
pulmonary mycetoma. In many reports little distinction is made
between invasive fungal infection and the minimally invasive
fungus ball.
C. albicans is a common fungal pathogen that infects mucocutaneous and urinary sites more often than it infects the lung.
In contrast to Aspergillus species, it generally grows as a budding yeast; mycelial forms can also be seen in clinical specimens. Candida species have caused fungus balls in other organs, including the gallbladder [6] and the urinary tract [7]. In
spite of its ubiquitous distribution, convincing evidence for
pulmonary mycetoma due to this pathogen is rare.
A MEDLINE search of the English-language literature did
not reveal any recent reports of Candida species as a cause of
pulmonary mycetoma. Schwarz et al. [8] reported four cases
of pulmonary mycetoma and reviewed the literature of socalled aspergillomas in 1961. Among 58 cases, they identified
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Shelly, Poe, and Kapner
two in which a fungus ball was possibly due to Candida species. In one case, originally reported by Graves and Millman
[9], a "monilial-like" organism was recovered from the sputum of a man with a large lung cavity. A needle biopsy was
performed, and the lesion was subsequently resected. The organism was described as resembling Aspergillus morphologically, but cultures of the tissue were sterile.
In the other case, which was one of four involving fungus
balls that were originally reported by Levin [10], the organism
was morphologically "possibly Candida or a Phycomycetes
species." Attempts at culture were unsuccessful. In another
two of the four cases, organisms were found at resection that
were "indistinguishable" from those found in the first case.
All cultures were negative, and the fungi were termed "unidentified."
Lodin [11] reported a 1956 case of pulmonary mycetoma
that contained a calcified mass from which Candida species
were recovered. There is no reference to culture, and it is
presumed that identification was morphological. Kennedy [12]
reported a case of bronchopulmonary moniliasis in a patient
with a cavity in the superior segment of the left lower lobe.
C. albicans was recovered from the sputum, but no fungus ball
was found on resection, although the cavity contained spore
forms with mycelia that were consistent with C. albicans. Distinct "small black particles" seen in the sputum that are not
typical of Candida species suggest that another pathogen
caused this case of pulmonary mycetoma.
em
1996;22 (January)
Figure 2. Confirmatory CT scan of the chest of the patient described in figure I showing a dependent mass lesion lying within a
cavity, consistent with pulmonary mycetoma.
More recently, Watanakunakom [13] reported a case of acute
pulmonary mycetoma due to C. albicans in a patient with a
relapse of acute myelogenous leukemia. However, in this case
the patient was granulocytopenic and had no preexisting cavity;
the lesion, including the cavity, responded to systemic antifungal therapy.
In the case described herein, C. albicans was identified morphologically on pathological examination of specimens, and
this identification was confirmed by culture. No other organisms were identified. Mycetomas are rarely visualized endoscopically [14], but there was no question that the specimens
obtained by bronchoscopy were representative of pulmonary
mycetoma since the procedure was performed with fluoroscopic guidance. Virtually all patients with aspergillus pulmonary mycetoma have serum precipitins to Aspergillus species
[15]. Our patient's negative test for serum precipitins to
A. fumigatus and A. niger made concomitant aspergillus infection unlikely. Our patient also was negative for agglutinins to
Candida species. Precipitins to Candida species are formed
only in response to systemic infections, and hence this finding
is expected [16]. We believe that this is the first case of
C. albicans pulmonary mycetoma in which the diagnosis was
established beyond a reasonable doubt both by morphology
and by culture.
References
Figure 1. Posteroanterior roentgenograph of the chest showing a
large cavity containing an intracavitary mass in the right upper lobe
of a patient with pulmonary mycetoma due to Candida albicans.
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