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Case Report of a Tubo-ovarian Abscess Caused by Candida kefyr
CASE REPORT
Case Report of a Tubo-ovarian Abscess Caused by Candida kefyr Firat Okmen, MD; Huseyin Ekici, MD; Sabahattin Anil Ari, MD Department of Obstetrics and Gynecology, School of Medicine, Ege University, Izmir, Turkey
Abstract Background: Candida species are harmless commensals of hosts, including humans, but they can cause infection when the immune system is compromised. Infections with non-albicans species can occur, ranging from urinary tract infections to sepsis, especially among patients in intensive care units. Case: The patient, a 37-year-old woman, presented with severe abdominal pain, fever, and vomiting. The patient’s symptoms and fever continued in spite of treatment with antibiotics, and she underwent exploratory laparotomy. Cyst content culture results showed that Candida kefyr was present in the cyst. Conclusion: To the best of our knowledge, this is the first case report of a tubo-ovarian abscess caused by C. kefyr. Rare pathogens can be found in patients with a tubo-ovarian abscess, so culture of the abscess material is important for determining subsequent treatment, particularly in women who require an operation for tubo-ovarian abscess.
Résumé Contexte : Les espèces de Candida sont des organismes commensaux sans danger pour leurs hôtes, y compris pour les humains, mais elles peuvent causer des infections quand le système immunitaire est compromis. Des infections aux espèces non albicans peuvent survenir (allant de l’infection urinaire à la septicémie), surtout chez les patients dans les services de soins intensifs. Cas : La patiente, une femme de 37 ans, s’est présentée avec des douleurs abdominales intenses, de la fièvre et des vomissements. Ses symptômes et sa fièvre ont persisté malgré le traitement antibiotique, et elle a subi une laparotomie exploratoire. Les résultats de culture du contenu d’un kyste ont montré la présence de Candida kefyr dans celui-ci. Conclusion : À notre connaissance, il s’agit du premier cas rapporté d’abcès ovario-tubaire causé par C. kefyr. Comme des pathogènes rares peuvent être trouvés chez les patientes ayant un abcès ovario-tubaire, la culture du contenu de l’abcès est importante pour déterminer le traitement subséquent, surtout chez les femmes qui ont besoin d’une chirurgie. Key Words: Tubo-ovarian abscess, Candida kefyr, Candida pseudotropicalis, non-albicans Candida Corresponding Author: Dr. Sabahattin Anil Ari, Department of Obstetrics and Gynecology, School of Medicine, Ege University Hospital, Izmir, Turkey. [email protected] Competing interests: The authors declare that they have no competing interests. Received on April 5, 2018 Revised on April 16, 2018
1466 • NOVEMBER JOGC NOVEMBRE 2018
Copyright © 2018 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2018;40(11):1466–1467 https://doi.org/10.1016/j.jogc.2018.04.025
INTRODUCTION
A
tubo-ovarian abscess (TOA) is an inflammatory mass located among the fallopian tube, ovary, bowel, and bladder. Some case reports have highlighted Candida spp., Pasteurella multocida, Salmonella spp., and Streptococcus pneumoniae as rare potential pathogenic causes of TOAs.1–3 Here, we present a case report of a patient with a TOA caused by Candida kefyr. To the best of our knowledge, this is the first report of a TOA caused by C. kefyr. THE CASE
The patient, a 37-year-old woman, gravida 2 para 1, presented to the emergency department with severe abdominal pain, fever, and vomiting. Physical examination showed that her blood pressure was 119/69 mm Hg, pulse rate was 116 beats per minute, and axillary temperature was 39.3°C. On abdominal examination, a palpable, mobile, pelvic mass was noted in the left lower quadrant. On gynaecological examination, purulent endocervical discharge, cervical motion, and uterine and adnexal tenderness were observed. Transabdominal ultrasonography revealed a multilobular cyst 10 cm in diameter. White blood cell count was 25 000 mm3, and C- reactive protein was 29.34 mg/dL. The serum level of CA 125 was 138 (normal range <35). Computed tomography revealed a bilateral, multilobular, enhanced wall, 10 × 5 cm diameter cyst with an appearance compatible with that of an abscess (Figure). Administration of ceftriaxone (1 g intravenously every 12 hours), metronidazole (500 mg intravenously every 8 hours), and doxycycline (100 mg orally every 12 hours) was started for initial therapy. However, the patient’s complaints and the fever continued in spite of the antibiotics. The patient underwent an exploratory laparotomy, which revealed a TOA
Case Report of a Tubo-ovarian Abscess Caused by Candida kefyr
Figure. Computed tomography image of the whole abdomen demonstrating a tubo-ovarian abscess.
organic dairy products during her pregnancy. After finding C. kefyr sepsis in the preterm newborns, these investigators recommended that the consumption of organic dairy products during pregnancy should be considered.12 Our patient had started to consume organic unpasteurized dairy products 3 months before her signs and symptoms began. CONCLUSION
Culture of abscess material is important for determining subsequent treatment, particularly for patients who undergo an operation for TOA. Especially for patients with hematologic malignant diseases, risk factors for immunosuppression, or inadequate response to antibiotic therapy, Candida species and the addition of antifungals to the treatment regimen should be considered. with a 15-cm diameter on the pouch of Douglas between the bilateral tube and the ovary, uterus, and sigmoid colon, with dense adhesions. Cystectomy and right salpingectomy were performed. Cyst content culture results showed that the cyst contained C. kefyr. Administration of fluconazole (400 mg intravenously every 24 hours) was started and continued for 14 days. The patient’s condition improved, and fever was not observed during the course of antifungal therapy. Pathologic examination confirmed the diagnosis of a TOA. There were no associated complications, and the patient was discharged 2 weeks after the operation. DISCUSSION
C. kefyr, formerly known as Candida pseudotropicalis, is an opportunistic pathogen that can be isolated from dairy products and rarely causes systemic infection in humans.4 The first report in the literature of C. kefyr as a pathogen was in 1969 for a patient with cystitis caused by this organism.5 C. kefyr forms flat, soft, and yellowish colonies on Sabouraud dextrose agar medium and does not form colonies on Sabouraud medium containing meat juice.6 To the best our knowledge, this is the first case report of a TOA caused by C. kefyr. Sendid et al. reported that C. kefyr was isolated twice as frequently from patients in oncohematology units than from patients in other units.7 In the literature, there are four case reports of TOAs from which Candida species were isolated.8–11 Pineda et al.12 reported chorioamnionitis and sepsis caused by C. kefyr in a woman pregnant with twins who had regularly consumed
Acknowledgement
Consent to publish this case report was obtained from the patient. REFERENCES 1. Hsu WC, Lee YH, Chang DY. Tuboovarian abscess caused by Candida in a woman with an intrauterine device. Gynecol Obstet Invest 2007;64:14– 6. 2. Thaneemalai J, Asma H, Savithri DP. Salmonella tuboovarian abscess. Med J Malaysia 2007;62:422–3. 3. Myckan KA, Booth CM, Mocarski E. Pasteurella multocida bacteremia and tuboovarian abscess. Obstet Gynecol 2005;106:1220–2. 4. Valderrama MJ, de Silóniz MI, Gonzalo P, et al. A differential medium for the isolation of Kluyveromyces marxianus and Kluyveromyces lactis from dairy products. J Food Prot 1999;62:189–93. 5. Hodgin UG Jr. Cystitis due to Candida pseudotropicalis. Rocky Mt Med J 1969;66:30–2. 6. Larone DH. Medically important fungi: a guide to identification. 3rd ed. Washington, DC: ASM Press; 1995. 7. Sendid B, Lacroix C, Bougnoux ME. Is Candida kefyr an emerging pathogen in patients with oncohematological diseases? Clin Infect Dis 2006;43:666–7. 8. Krcmery V, Barnes AJ. Non-albicans Candida spp. causing fungaemia: pathogenicity and antifungal resistance. J Hosp Infect 2002;50:243–60. 9. Mikamo H, Ninomiya M, Tamaya T. Tuboovarian abscess caused by Candida glabrata in a febrile neutropenic patient. J Infect Chemother 2003;9:257–9. 10. Toy EC, Scerpella EG, Riggs JW. Tuboovarian abscess associated with Candida glabrata in a woman with an intrauterine device. A case report. J Reprod Med 1995;40:223–5. 11. To V, Gurberg J, Krishnamurthy S. Tubo-ovarian abscess caused by Candida albicans in an obese patient. J Obstet Gynaecol Can 2015;37:426–9. 12. Pineda C, Kaushik A, Kest H, et al. Maternal sepsis, chorioamnionitis, and congenital Candida kefyr infection in premature twins. Pediatr Infect Dis J 2012;31:320–2.
NOVEMBER JOGC NOVEMBRE 2018 • 1467
Case Report of a Tubo-ovarian Abscess Caused by Candida kefyr Firat Okmen, MD; Huseyin Ekici, MD; Sabahattin Anil Ari, MD Department of Obstetrics and Gynecology, School of Medicine, Ege University, Izmir, Turkey
Abstract Background: Candida species are harmless commensals of hosts, including humans, but they can cause infection when the immune system is compromised. Infections with non-albicans species can occur, ranging from urinary tract infections to sepsis, especially among patients in intensive care units. Case: The patient, a 37-year-old woman, presented with severe abdominal pain, fever, and vomiting. The patient’s symptoms and fever continued in spite of treatment with antibiotics, and she underwent exploratory laparotomy. Cyst content culture results showed that Candida kefyr was present in the cyst. Conclusion: To the best of our knowledge, this is the first case report of a tubo-ovarian abscess caused by C. kefyr. Rare pathogens can be found in patients with a tubo-ovarian abscess, so culture of the abscess material is important for determining subsequent treatment, particularly in women who require an operation for tubo-ovarian abscess.
Résumé Contexte : Les espèces de Candida sont des organismes commensaux sans danger pour leurs hôtes, y compris pour les humains, mais elles peuvent causer des infections quand le système immunitaire est compromis. Des infections aux espèces non albicans peuvent survenir (allant de l’infection urinaire à la septicémie), surtout chez les patients dans les services de soins intensifs. Cas : La patiente, une femme de 37 ans, s’est présentée avec des douleurs abdominales intenses, de la fièvre et des vomissements. Ses symptômes et sa fièvre ont persisté malgré le traitement antibiotique, et elle a subi une laparotomie exploratoire. Les résultats de culture du contenu d’un kyste ont montré la présence de Candida kefyr dans celui-ci. Conclusion : À notre connaissance, il s’agit du premier cas rapporté d’abcès ovario-tubaire causé par C. kefyr. Comme des pathogènes rares peuvent être trouvés chez les patientes ayant un abcès ovario-tubaire, la culture du contenu de l’abcès est importante pour déterminer le traitement subséquent, surtout chez les femmes qui ont besoin d’une chirurgie. Key Words: Tubo-ovarian abscess, Candida kefyr, Candida pseudotropicalis, non-albicans Candida Corresponding Author: Dr. Sabahattin Anil Ari, Department of Obstetrics and Gynecology, School of Medicine, Ege University Hospital, Izmir, Turkey. [email protected] Competing interests: The authors declare that they have no competing interests. Received on April 5, 2018 Revised on April 16, 2018
1466 • NOVEMBER JOGC NOVEMBRE 2018
Copyright © 2018 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2018;40(11):1466–1467 https://doi.org/10.1016/j.jogc.2018.04.025
INTRODUCTION
A
tubo-ovarian abscess (TOA) is an inflammatory mass located among the fallopian tube, ovary, bowel, and bladder. Some case reports have highlighted Candida spp., Pasteurella multocida, Salmonella spp., and Streptococcus pneumoniae as rare potential pathogenic causes of TOAs.1–3 Here, we present a case report of a patient with a TOA caused by Candida kefyr. To the best of our knowledge, this is the first report of a TOA caused by C. kefyr. THE CASE
The patient, a 37-year-old woman, gravida 2 para 1, presented to the emergency department with severe abdominal pain, fever, and vomiting. Physical examination showed that her blood pressure was 119/69 mm Hg, pulse rate was 116 beats per minute, and axillary temperature was 39.3°C. On abdominal examination, a palpable, mobile, pelvic mass was noted in the left lower quadrant. On gynaecological examination, purulent endocervical discharge, cervical motion, and uterine and adnexal tenderness were observed. Transabdominal ultrasonography revealed a multilobular cyst 10 cm in diameter. White blood cell count was 25 000 mm3, and C- reactive protein was 29.34 mg/dL. The serum level of CA 125 was 138 (normal range <35). Computed tomography revealed a bilateral, multilobular, enhanced wall, 10 × 5 cm diameter cyst with an appearance compatible with that of an abscess (Figure). Administration of ceftriaxone (1 g intravenously every 12 hours), metronidazole (500 mg intravenously every 8 hours), and doxycycline (100 mg orally every 12 hours) was started for initial therapy. However, the patient’s complaints and the fever continued in spite of the antibiotics. The patient underwent an exploratory laparotomy, which revealed a TOA
Case Report of a Tubo-ovarian Abscess Caused by Candida kefyr
Figure. Computed tomography image of the whole abdomen demonstrating a tubo-ovarian abscess.
organic dairy products during her pregnancy. After finding C. kefyr sepsis in the preterm newborns, these investigators recommended that the consumption of organic dairy products during pregnancy should be considered.12 Our patient had started to consume organic unpasteurized dairy products 3 months before her signs and symptoms began. CONCLUSION
Culture of abscess material is important for determining subsequent treatment, particularly for patients who undergo an operation for TOA. Especially for patients with hematologic malignant diseases, risk factors for immunosuppression, or inadequate response to antibiotic therapy, Candida species and the addition of antifungals to the treatment regimen should be considered. with a 15-cm diameter on the pouch of Douglas between the bilateral tube and the ovary, uterus, and sigmoid colon, with dense adhesions. Cystectomy and right salpingectomy were performed. Cyst content culture results showed that the cyst contained C. kefyr. Administration of fluconazole (400 mg intravenously every 24 hours) was started and continued for 14 days. The patient’s condition improved, and fever was not observed during the course of antifungal therapy. Pathologic examination confirmed the diagnosis of a TOA. There were no associated complications, and the patient was discharged 2 weeks after the operation. DISCUSSION
C. kefyr, formerly known as Candida pseudotropicalis, is an opportunistic pathogen that can be isolated from dairy products and rarely causes systemic infection in humans.4 The first report in the literature of C. kefyr as a pathogen was in 1969 for a patient with cystitis caused by this organism.5 C. kefyr forms flat, soft, and yellowish colonies on Sabouraud dextrose agar medium and does not form colonies on Sabouraud medium containing meat juice.6 To the best our knowledge, this is the first case report of a TOA caused by C. kefyr. Sendid et al. reported that C. kefyr was isolated twice as frequently from patients in oncohematology units than from patients in other units.7 In the literature, there are four case reports of TOAs from which Candida species were isolated.8–11 Pineda et al.12 reported chorioamnionitis and sepsis caused by C. kefyr in a woman pregnant with twins who had regularly consumed
Acknowledgement
Consent to publish this case report was obtained from the patient. REFERENCES 1. Hsu WC, Lee YH, Chang DY. Tuboovarian abscess caused by Candida in a woman with an intrauterine device. Gynecol Obstet Invest 2007;64:14– 6. 2. Thaneemalai J, Asma H, Savithri DP. Salmonella tuboovarian abscess. Med J Malaysia 2007;62:422–3. 3. Myckan KA, Booth CM, Mocarski E. Pasteurella multocida bacteremia and tuboovarian abscess. Obstet Gynecol 2005;106:1220–2. 4. Valderrama MJ, de Silóniz MI, Gonzalo P, et al. A differential medium for the isolation of Kluyveromyces marxianus and Kluyveromyces lactis from dairy products. J Food Prot 1999;62:189–93. 5. Hodgin UG Jr. Cystitis due to Candida pseudotropicalis. Rocky Mt Med J 1969;66:30–2. 6. Larone DH. Medically important fungi: a guide to identification. 3rd ed. Washington, DC: ASM Press; 1995. 7. Sendid B, Lacroix C, Bougnoux ME. Is Candida kefyr an emerging pathogen in patients with oncohematological diseases? Clin Infect Dis 2006;43:666–7. 8. Krcmery V, Barnes AJ. Non-albicans Candida spp. causing fungaemia: pathogenicity and antifungal resistance. J Hosp Infect 2002;50:243–60. 9. Mikamo H, Ninomiya M, Tamaya T. Tuboovarian abscess caused by Candida glabrata in a febrile neutropenic patient. J Infect Chemother 2003;9:257–9. 10. Toy EC, Scerpella EG, Riggs JW. Tuboovarian abscess associated with Candida glabrata in a woman with an intrauterine device. A case report. J Reprod Med 1995;40:223–5. 11. To V, Gurberg J, Krishnamurthy S. Tubo-ovarian abscess caused by Candida albicans in an obese patient. J Obstet Gynaecol Can 2015;37:426–9. 12. Pineda C, Kaushik A, Kest H, et al. Maternal sepsis, chorioamnionitis, and congenital Candida kefyr infection in premature twins. Pediatr Infect Dis J 2012;31:320–2.
NOVEMBER JOGC NOVEMBRE 2018 • 1467