An Unusual Immunological Reaction in Systemic Candidiasis in Man

Vol. 94, Aug. Printed in U.S.A.

THE .Jo-cRNAL OF UROLOGY

Copyright © 1965 by The Williams & Wilkins Co.

AN UNUSUAL EVIMUNOLOGICAL REACTION IN SYSTENIIC CANDIDIASIS IN MAN HARRY SENECA

AND

FRANK W. LONGO

From the Department of Urology, College of Physicians and Surgeons, Columbia University and the Presbyterian Hospital, New York, New York

In Koch's phenomenon the subcutaneous injection of virulent tubercle bacilli in a normal guinea pig results, after 10 to 15 days, in a local nodule at the site of the injection which breaks down and develops into an ulcer after several weeks. If the same dose of virulent bacilli is injected into a guinea pig which had been previously infected (a week at least), the local reaction appears within 24 to 48 hours, the ulceration is shallower, and healing occurs in 10 to 14 days. Although the local lesion heals, the animal which is sensitized eventually dies of tuberculosis. The Arthus' reaction, as originally reported by Arthus, was a local rather than systemic n1anifestation of allergic reaction. Horse serum injected subcutaneously at approximate intervals progressively gave rise to severe local reaction at the site of each succeeding injection. The early reactions were transient local edema, followed by hyperemia and hemorrhage and eventually by induration, necrosis and sloughing. Desensitization may be accomplished by the subcutaneous injection of massive doses of the antigen. Neither cortisone nor adrenocorticotrophic hormone (ACTH) will prevent or modify this reaction, but if given during the period of immunization, will reduce its severity. In Shwartzman's phenomenon, the subcutaneous injection of the filtrate of Salmonella typhosa in the rabbit, followed by the intravenous injection of the same material 24 hours later, results in a severe hemorrhagic, necrotic lesion at the site of the original skin injection. The reaction is non-specific, because the same lesion can be elicited by the injection of meningococcus filtrate. The lack of specificity rules out the possibility that this reaction is the result of antigen antibody union, and moreover, the interval between the preparatory and the eliciting injections is too short for the production of antibodies. In generalized Shwartzman's reaction, the preparatory and shocking doses are given intraAccepted for publication November 10, 1964. 172

venously. In this condition, there is a drop in platelets and white corpuscles. The reaction fails to develop in animals where these have been blocked or suppressed by the previous administration of x-rays, benzene, or nitrogen mustard. The kidneys of such animals show cortical necrosis and glon1.erular damage. Myocardial damage and lesions in other organs also occur. Cortisone and ACTH will suppress or abolish this reaction if administered between the preparatory and shocking doses. The characteristic hemorrhag,i.c necrosis may be prevented by previous treatment with heparin, dicumarol or tromexan, but heparin does not prevent the leukopenic, pyrogenic and lethal effects of endotoxins. Although Arthus' phenomenon and Shwartzman's reaction depend upon different immunological factors, the local hemorrhagic lesions appear to be somewhat similar. To obtain Arthus' phenomenon, the animal must have high precipitin titer. Only the local injection is necessary, and this must be made with the specific antigens to which the precipitins were formed. In Shwartzman's reaction, the preparatory injection of a suitable endotoxin damages the local vascular bed during 24 hours. The subsequent intravenous injection of the same or another endotoxin produces immediate neutropenia, thrombocytopenia and thrombocyte thrombi in the small veins of the prepared areas with the ensuing hemorrhages. Sanarelli, in 1924, observed that rabbits which were injected with sublethal doses of vibrion cholerae, and later on reinjected with a small number of E. coli, died of necrosis of the intestines and not of cholera. Accordingly, this is a type of Shwartzman's reaction, and in most European literature, it is referred to as the ShwartzmanSanarelli phenomenon. CASE REPORT

H. K., No. 123-10-08, a 32-year old Jewess, was admitted to Columbia-Presbyterian Medical

IMMUNOLOGICAL REACTION IN SYSTEMIC CANDIDIASIS IN MAN

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Center on September 19, 1963 where a diagnosis of bilateral hydroureteronephrosis was made. At another hospital, the patient had passed 2 uric acid stones and had been treated intensively with antibiotics. She had had costovertebral pain on both sides, frequency of urination and hematuria since the beginning of August. Cystoscopic examination revealed severe inflammation of the bladder. On September 25 retrograde pyelograms revealed extensive generalized dilatation and disease in both ureters with inflammatory changes in the left kidney and ureter consistent with tuberculosis, probably most active on the left. Sedimentation rate ranged from 51 to 80 mm. per hour; blood sugar, 61 mg. per cent; blood urea nitrogen (BUN), 34 to 42 mg. per cent; cholesterol, 261; calcium, 9.6; phosphorus, 3.3; uric acid, 7.4; and VDRL test, negative. Alkaline phosphatase was 8 King-Armstrong units; protein-bound iodine, over 20 gm. per cent; urine culture, negative; urine albumin, 3 plus; benzidine, 4 plus; moderate red blood count and very numerous white blood cells. An electrocardiogram showed normal sinus rhythm, left axis deviation, diffuse ST-T segment changes, probably due to electrolyte imbalance or myocardial disease. X-rays of the chest showed numerous calcified tuberculous lesions or histoplasmosis of both lungs, but activity could not be determined. Barium enema demonstrated a normal colon. Lupus erythematous preparation was negative; stool guaiac test, positive; carbon dioxide, 21 mEq; chloride, 105 mEq; sodium, 141; potassium, 4.1; phenolsulfonphthalein test, 49.2 per cent; hemoglobin, 10 gm.; reel blood count, 3A million; and white blood count, 7,800. Urine culture on September 29 showed Candida albicans. Serum electrophoresis showed albumin 2.8, alpha-1 globulin 0.3, alpha-2 globulin 0.9, beta-globulin 0.8 and gamma-globulin 0.8 gm; total serum proteins, 5.7 gm. Tuberculin purified protein derivative, histoplasmin and coccidioidin tests were all negative. The patient was discharged on October 5 with a diagnosis of bilateral hydronephrosis, possible kidney infection. Chemotherapy included nitrofurantoin, tetracycline and streptomycin. She was readmitted on October 24 and discharged on February 14, 1964, with the final diagnosis of urogenital moniliasis. She had gradually become incontinent, with constant dripping of urine, marked loss of weight and urine culture showed C. albicans. Her condition

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gradually deteriorated, with the BUN constantly rising. Urine culture and guinea pig inoculation for acid-fast bacteria were negative. On December 31, 1963 her blood sugar was 198, but later tests showed that it was normal and even less (76). The multiple densities in the lungs persisted. On January 9, 1964 an excretory urogram showed blunting of the calyces of both however, function remained relatively good. X-ray findings 1Yere compatible 11·ith chronic pyelonephritis. The bladder appeared small. On one occasion, Proteus and K coli ,vere cultured front the urine. She received 280 mg. prednisone in 18 days because of the possibility of interstitial cystitis. In addition to madribon and gantrisin, she received a.mphotericin B irrigations of the bladder (75 mg. in 500 ml. saline), and nystatin orally. Commencing on December 31, 12 mg. amphotericin B was given intravenously in 1,000 ml. saline daily for 5 days; 60 mg. amphotericin B was injected. The bladder was also irrigated with 1: 16,000 concentration of hexylresorcinol because in vitro tests showed that the C. albicans was susceptible to this drug. Hexylresorcinol ,vas also given by mouth. The BUN rose to 84 mg. per cent; sodium, 136 mEq; chloride, 101; hemoglobin, 13 gm.; 11·hite blood count, 7,200; neutrophiles, 52 per cent; lymphocytes, 26 per cent; eosinophiles, 8 per cent; monocytes, 6 per cent; myelocytes, 2 per cent; sedimentation rate, 55 111111. per hour and serum glutamic oxalopyruvic transaminase (SGOT), 28. The cephalin flocculation and thymol turbidity tests were negative and the uric acid was 12.2 mg. per cent. The blood serum failed to show positive agar gel immune bands to Aerobacter, Klebsiella, Proteus, Escherichia, Pseudomonas, Staphylococcus, enterococcus and C. albicans. The patient's serum agglutinated Candida albicans in 1: 1280 dilution while the control serum agglutinated it in 1 :80. The susceptibility of the patient's C. albicans to am.photeriein B in Sabouraud agar was 100 µg./ml., while in Sabouraud broth, it was 25 µg./ml., but it was resistant at 100 µg./ml. nystatin. Intradermal injection of 0.1 ml. sonically lysed C. albicans (Kramer) on April 1 gave rise to a wheal after 30 minutes which reached 1 inch in diameter in 90 minutes, surrounded by an erythematous zone. There was an increase in the size of the local reaction overnight, with some tenderness in the axilla, but no nodes 1Yere palpable. The patient felt tired, ached all over and had chilly sensations

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SENECA AND LONGO

but no fever. All of these symptoms subsided in 2 days. Thereafter, im.munization or desensiti-

zation was started, using 0.15 ml. subcutaneously, every other day. Following each injection, there was a constitutional reaction in the form of general weakness, pain and tenderness in the costovertebral regions, headache, fatigue, chills, but no fever; there also were focal activation of the urinary tract condition and marked local erythema at the site of the original skin test which broke down, oozing sanguineous material, became ulcerated and was associated with local necrosis. Within 24 hours, the local, focal and constitutional symptoms subsided and the patient felt very well. On some occasions, the BUN showed variation, but it remained elevated, ranging from 74 to 86 m.g. per cent. Since there was a certain amount of discoloration of the skin, the question of hypoadrenal cortex syndrome was raised. Accordingly, plasma corticosteroid determinations were made before and after ACTH; before ACTH, 29.6 mcg./ 100 ml., and after ACTH, 75.4 mcg./rnl. Urine culture on April 14 showed non-hemolytic Streptococcus, A. aerogenes and C. albicans. Total serum proteins were 6.7 gm. with 0.8 gm. gammaglobulin. The patient responded very well to Candida cell wall antigen, but the BUN could not be lowered. She felt well and while in the hospital, had 15 injections of Candida cell wall antigen from April 11 to May 9, the maximum dose being 0.25 which was then lowered to 0.2 ml. She was readmitted on June 14 because under the impact of immunization with Candida cell wall antigen, microscopic findings in centrifuged urinary sediment of C. albicans were reduced from over 100 µg./ml. to 3.125 µg./ml. Thus the pathogen had become drug-susceptible to amphotericin B. Her admission diagnosis was chronic azotemia, bilateral Candida pyelonephritis, contracted bladder, chronic constipation and polyneuropathy to nitrofurantoin. In the meantime, she was constantly dripping urine, day and night, and had extreme pain in the bladder region and in the back. Her admission laboratory data revealed CO2, 15 mEq; sodium., 140; chloride, 104; uric acid, 13.2; BUN, 106 mg. per cent and the sedimentation rate, 106 mm. per hour. The urine was loaded with pus cells; albumin, 2 plus; hemoglobin, 7.7 gm.; RBC, 2.5 million; WBC,

9,400; neutrophiles, 66 per cent; lymphocytes, 30 per cent; eosinophiles, 2 per cent; and monocytes, 2 per cent. On June 23, her BUN was 125 mg. per cent; CO 2, 16 mEq; chloride, 102; sodium, 135 and potassium, 7. SGOT was 40; calcium, 9.5 mg. per cent and phosphorus, 5.4 mg. She had marked weakness, generalized tremors and substernal discomfort, was unable to breath and had dropping of the eyelids. The blood potassium (K) was 7.5 mEq. She was given a kayexalate resin enema which reduced the potassium to 5.6. On June 25, potassium rose to 7.7; the DUN was 130 mg. per cent; CO 2, 12 mEq.; sodium, 136 and potassium, 6. On June 27, calcium was 9.8 and phosphorus, 6.6. On June 28, an electrocardiogran1 (EKG) showed evidence of atrial activity, wide slurred QRS deflections (0.16 to 0.20), peaked T waves, indicating typical changes of hyperkalemia. The blood chemistry values were: CO2, 13 mEq; chloride, 95; sodium, 129 and potassium, 9.5. mEq. On June 28 at 7 :55 p.m. potassium was 9.7 mEq; sugar, 630 mg. per cent. At 8: 15 potassium was 9.6 mEq.; sugar, 880 mg. per cent. At 8:20 potassium was 9.8 mEq.; sugar, 1010 mg. per cent. At 8 :40 an EKG showed ventricular fibrillation. The patient died immediately after the EKG was made. Final medications consisted of darvon, demerol, and intravenous aramine in 5 per cent dextrose 1,000 ml. At 7 :30 p.m. 50 ml. 50 per cent glucose plus 10 units of regular insulin was given intravenously, aramine intravenously, kayexalate enema and oxygen tent, but all of no avail. The patient's past history was completely negative except for a goiter at the age of 23 years. Two years later, in 1955, she underwent total thyroidectomy with paraglandular dissection for carcinoma of the thyroid, which proved histologically to be a mixed papillary and adenoma malignum type of carcinoma of thyroid (grade 1). Her family history was negative. Both parents were living and healthy. She was married and had 3 healthy children. The patient was a heavy smoker. Preparation of cell wall antigen. The C. albicans was grown on Sabouraud agar for 48 hours. The growth was then washed in saline and the suspension was sonically lysed in a Raytheon sonic oscillator (model DF 101, 250 watts, 10 kc, 115 volts and 60 cycles).

D1MUNOLOGICAL REACTION IN SYSTEMIC CANDIDIASIS IN MAN

DISCUSSION

This patient's urinary tract infection beom1 spontaneously. She had· two cystoscopic exa~1inations, one followed by retrograde riyelograrns. Her medication in the hospital included streptomycin, tetracycline, nitrofurantoin, sulfonamides, amphotcricin B systemically and locally, nystatin locally, and hexylresorcinol irrigations of the bladder as ·well as hexyhesorcin;l orallv. As a private patient, she was giyen chloram1;henicol and penicillin plus streptomycin injections. The case was apparently one of candidiasis due to the unopposed overgrowth of C. albicans following chemotherapy with antibiotics. The unusual features in this case require analysis. The fact that the site of the primary skin test broke clown and gave rise to an ulcerative lesion with necrosis and oozing of serosanguineous fluid with eYery subcutaneous injection of the Candida antigen does not fit into either Koch's phenomenon, Arthus' reaction or Shwartzman's reaction. It should not be forgotten that this is the first time that the cell walls have been used in the process of immunization in a human case. Since we were not sure what fraction to use, it was decided to use the whole lysate following sonic lysis of Candida culture, Phenol aqueous extract of the bacterial cell walls contains lipopolysaccharides. These bacterial lipopolysaccharides are highly immunogenic and give rise to protective antibodies. The second noteworthy feature is the fact that

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under the impact of cell-wall therapy, drugresistant C. albicans became susceptible to amphotericin B. Unfortunately, amphotericin B could not be used at this phase of the disease, because the patient's renal function was de .. teriorating fast, as manifested the marked elevation of BUN and mic acid in the blood. The patient died of renal failure with marked elevation of toxic, metabolic end products and hyperkalemia. Immediately before death, the blood sugar was 1010 mg. per cent and there was ventricular fibrillation. This elevation of blood sugar may be due in part to the fact that she was receiving an injection of 50 per cent glucose, when the blood was obtained for chemistry determination. SUMMARY

In a case of severe Candida pyelonephritis, cell wall Candida antigen was used for the active immunization. With each injection, the site of the initial skin test on the forearm broke down ulcerated and discharged serosanguineous fluid and healed until the next injection. Amphotericinresistant C. albicans became drug-susceptible (in vitro) through immunization. REFERENCES S.: Immunity. New York: Appleton Century Crofts, 2nd edit., 1961. lVIrLNER, K. C., ANACKER, R. L., FuKusHr, K., HASKINS, w. T., LANDY, JVI., ]VL.\.LMGREN, N. AND Rrnr, E.: Structure and biological properties of surface antigens from gram negative bacteria. Bact. Rev., 27: 352-368, 1963. R.uFEL,