Neonatal Candida Lusitaniae Septicemia

Neonatal candidemia is an increasing cause of neonatal morbidity and mortality. Most reported cases are due to Candida albicans, but non-albicans species are on the rise. Candida lusitaniae is infrequently reported opportunistic pathogen. It causes serious and fatal infection. Early diagnosis and proper antifungal therapy can prevent morbidity and mortality in premature neonates. DOI:  http://dx.doi.org/10.3126/jnps.v34i2.11161 J Nepal Paediatr Soc 2014;34(2):160-162


Introduction
C andida lusitaniae is infrequently reported opportunis c pathogen causing blood stream infec on in neonates 1 .It was fi rst described as a common organism in the gastrointes nal tracts of warm-blooded animals 2 .Most of the isolated cases have been resistant to commonly used an fungal Amphotericin B 3 .Pappagianis et al. 4 and Holzschu et al. 5 described the fi rst case of opportunis c infec on due to C. lusitaniae, reported in a pa ent with acute leukemia.There are very few ar cles in the medical literature that report on neonatal candida lusitaniae fungemia.Previously reported cases of serious infec on in adults have proven fatal and were associated with amphotericin resistance 6 .We report upon clinical characteris cs of two cases of fungal sepsis in the neonatal period caused by C. lusitaniae in an NICU.

The Cases
A 25-year-old lady at 31 + 5weeks gesta on delivered twin babies, fi rst baby 1500 gms female and second 1400 gms male.They were admi ed at local neonatal nursery for observa on.On the seventh postnatal day, they were referred to our intensive care unit for suspicion of sepsis.On admission, both neonates presented with complaints of poor feeding and lethargy.A so pan systolic murmur was audible over apical area in the elder twins, which was found to be due to ventricular septal defect (0.48 cm) by echocardiography.No other abnormal fi nding except for mild icterus was detected in physical examina on in both neonates.During the course of treatment both the neonates underwent nasogastric tube inser on, PICC, CPAP support, broad spectrum an bio cs and parenteral fat emulsions with amino acids and calcium supplementa ons.
During recovery, both developed thermal and hemodynamic instability, bradycardia, respiratory discomfort, feeding intolerance and lethargy.Blood culture was done in addi on to PICC p culture sensi vity, as rou ne inves ga on revealed granulocytopenia and increased CRP (C-reac ve protein).Candida lusitaniae was isolated in blood culture.It displayed sensi vity to all an fungal drugs including amphotericin B. Both neonates were treated with fl uconazole and discharged on 27 th day of admission a er nega ve blood culture reports along with drop in CRP level.

Discussion
Immaturity of immune system, increased need of interven ons and prolonged hospital stay predispose preterm infants to Candida infec ons.Transmission of Candida may be ver cal (from maternal vaginal infec on) or nosocomial.Studies including Manzoni et.al have suggested that low birth weight, low gesta onal age, use of third-genera on cephalosporin, endotracheal intuba on, dura on of stay in the NICU, bacterial sepsis, coloniza on of central venous catheter, and endotracheal intuba on were associated with an increased risk of invasive fungal infec ons. 7.This report describes two neonates with serious infec ons caused by C. lusitaniae that were successfully treated.During the course of fungemia both neonates became febrile, granulocytopenic with clinical manifesta ons consistent with serious fungal infec on.In each neoante, C. lusitaniae was isolated from blood only.Although both neonates had indwelling catheters, the catheter ps were nega ve for culture sensi vity, and were successfully treated without its removal.The possibility of nosocomial transmission was considered since both neonates developed fungemia a er 48 hours of hospital admission.No other neonate admi ed in the same ward developed fungemia during the same period.The an fungal suscep bility pa erns for both isolates were nearly iden cal.The role of nosocomial transmission in this instance remained specula ve.
The clinical characteris cs of the neonates reported with C.lusitaniae fungemia were quite similar to those of previously reported pa ents with C.lusitaniae fungemia.73 neonatal cases reported in the English or Chinese literature (Table 1).Most of the neonates were VLBW, increasing their suscep bility to C. lusitaniae fungemia.Most cases reported the use of broad-spectrum an bio cs, intravascular catheter, the use of, and the occurrence of granulocytopenia frequently.Both of the neonates received total parentaral nutri on, a known risk factor for the development of fungemia caused by other Candida species 8 .Both of the neonates had C. lusitaniae isolated in blood.Resistance to amphotericin B has been an important clinical fi nding in C. lusitaniae isolates in adults.On the contrary, isolates in this study were highly sensi ve to commonly used an fungal drugs including amphotericin B. Both pa ents demonstrated a clinical response to therapy.

Table 1 :
Published studies repor ng Candida lusitaniae fungemia in neonate *NA: Not Available