John Paul B.

Garrido Clinical Pharmacy

4BSPh

Fungal Infection Case Studies

1. BGKC is a 21-year-old college student who presents to the pharmacy at her
schools student health center. She reports a 2-day history of pain on
urination, vaginal itching, and a thick, white discharge. She denies having any
allergies to medications or other medical conditions. She reports she is
sexually active with 1 partner and uses latex condoms for birth control. She
recalls having a yeast infection once before a few years ago, which she
remembers taking a prescription to treat. To avoid another doctors office
visit, she reports purchasing the Vagisil Screening Kit the night before and
that the results indicated a vaginal pH of 4.0. Based on the results of the test
and her current symptoms, identify what condition she is likely suffering from.
Consider which OTC product you would recommend and what counselling
points you would want to reinforce to assure correct use.
2. SC, a 55-year-old man presents to the emergency department with a 2-week
history of an expanding ulcer on his left lower leg. He has a history of chronic
neutropenia and transfusiondependent anemia secondary to myelodysplastic
syndrome requiring chronic therapy with deferoxamine for hepatic iron
overload. He first noticed a red bump on his leg while fishing at his cabin in
the woods and thought it was a bug bite. It rapidly enlarged, first as a red
swollen area, and then began to ulcerate. He was given dicloxacillin orally,
but with no improvement. In the emergency department he is febrile to 39C
(102.2F), and looks unwell. On his left leg he has a 6 by 12 cm black ulcer
with surrounding swelling and erythema that is quite tender. His complete
blood count demonstrates an absolute neutrophil count of 300 and a total
white blood cell count of 1000. An immediate operative debridement yields
pathologic specimens demonstrating broad club-like nonseptate hyphae and
extensive tissue necrosis. What initial medical therapy would be most
appropriate?
3. JPG is a 67-year-old male complaining of painful white lesions in his mouth
and on his tongue that occasionally bleed when he pokes or scrapes them
with his toothbrush. He first noticed symptoms several days after starting a
new inhaler medication to control his chronic obstructive pulmonary disease
(COPD). He has never experienced symptoms like this in the past and would
like a recommendation for an OTC product to get rid of them. He has a history
of diabetes, hypertension, chronic kidney disease, and COPD, for which he
takes aspirin 81 mg, atorvastatin 20 mg, lisinopril 20 mg daily, amlodipine 5
mg daily, glipizide XL 10 mg once daily, tiotropium 18 mcg once daily,
fluticasone/salmeterol 250/50 mcg twice a day, and albuterol 2 puffs every 4
hours as needed for shortness of breath; he has no known medication
allergies. Is JPG a candidate for self-care? What treatment options can you
recommend?
4. SMK, a 56-year-old diabetic male with carcinoma of the oesophagus
undergoes sub-total oesophagectomy. He spends the early post-operative
period on surgical ITU and is sent to the surgical ward for further
management. On day 6, post-op, he begins to show signs of sepsis for which
antibiotics are commenced. However, 48 h later, he has difficulty in
breathing, takes a turn for the worse and is transferred to ITU. Imaging the
John Paul B. Garrido Clinical Pharmacy
4BSPh

chest revealed a leak from the oesophagectomy site and fluid collection in
the pleural space. Gram stain of aspirated pleural fluid revealed budding
yeast cells and sputum culture taken 2 days previously has grown Aspergillus.
How should this patient's infection be managed?
5. A 18-year-old boy with acute myeloblastic leukaemia sustained 20%
accidental burns injury on face, upper body and right arm at a family
barbecue. He had recently left hospital after successful antibiotic treatment
for a febrile neutropenic episode post-chemotherapy. Two weeks after
admission to ITU for management of burns, he undergoes a septic episode
with septic shock. A blood culture taken through a central line shows Gram-
negative bacilli. He is commenced on broad-spectrum antibiotics. His
peripheral blood count is 3 109/L and he has a markedly raised C-reactive
protein (CRP). The patient has suffered a moderate degree of renal failure.
Two days later, another blood culture is taken through an arterial line and
shows yeast cells on Gram stain. Intravenous fluconazole is added to his
treatment. Culture growth from the central line blood culture reveals
Pseudomonas aeruginosa and Candida albicans. The arterial blood culture
grows Candida krusei. Antifungal sensitivities are awaited. How should the
patient be managed?
John Paul B. Garrido Clinical Pharmacy
4BSPh

Fungal Infection - Answers:

1. Vaginal disorders are common ailments that send women into pharmacies
seeking self-treatment. In this case, BL is likely suffering from vulvovaginal
candidiasis (VVC), or a yeast infection. Her symptoms that are characteristic
of VVC include vulvar itching, dysuria, and having an abnormal thick, white
vaginal discharge. Vulvar edema, erythema, dyspareunia (painful
intercourse), and an absence of a malodor are other symptoms that may
occur with VVC. Although these symptoms are consistent with a diagnosis of
VVC, it is important to realize that symptoms alone may mimic other vaginal
conditions and are often nonspecific. In a young, sexually active woman, it is
important to rule out symptoms of sexually transmitted infection, including
trichomoniasis and bacterial vaginosis. These conditions are usually
associated with different symptoms, including odor and discolored or frothy
discharge, and tend to cause elevations in vaginal pH above 4.5. Our patient
reports utilizing a home vaginal pH test and obtaining a reading that is
consistent with a fungal infection, which typically does not cause elevations
in vaginal pH. Considering she also reports having a medically-diagnosed
yeast infection previously, the pharmacist can be confident in recommending
self-treatment with an antifungal preparation.
OTC imidazole antifungal products, including butoconazole, clotrimazole,
miconazole, or tioconazole, are appropriate for the self-treatment of VVC.
Product selection should be based on patient preference and symptoms.
Combination products are available for both internal and external application.
Rates of cure are similar among all products, regardless of duration of
therapy. It is important to counsel BGKC on appropriate application technique
ie, apply at bedtime to avoid product leakage and follow directions for
filling applicators and inserting vaginal creams and suppositoriesand also
remind her that these products can affect the integrity of latex condoms.
2. The club-like nonseptate hyphae observed in cultures of intraoperative
specimens from this patient are characteristic of Rhizopus , one of the agents
of mucormycosis. This patient should be treated with an initial, prolonged
course of therapy with liposomal amphotericin B and caspofungin and
subsequent chronic suppressive therapy with posaconazole.
3. JPGs symptoms are consistent with the presentation of oral thrush, which is
characterized by overgrowth of Candida albicans fungal species in the mouth.
This condition is likely to affect individuals who are immunocompromised,
wear dentures, or use inhaled corticosteroids.1 Symptoms of thrush can
include cottage cheeselike, white discolorations or plaques on the mouth
structures, oral pain, minimal bleeding with irritation, taste disturbances, or
John Paul B. Garrido Clinical Pharmacy
4BSPh

difficulty swallowing if the lesions have spread and have affected the
esophagus.1 JPGs risk factors for developing thrush may include recently
starting a combination inhaled corticosteroid/long-acting beta2-agonist for
the treatment of COPD and having diabetes, poor control of which may result
in this infection.
Counsel JPG to avoid self-care at this time and to follow up with his primary
care provider, as JM will likely need a topical oral antifungal agent, such as
clotrimazole troches, available by prescription only, to cure this condition.
Salt water gargles are the safest remedy for providing some symptomatic
relief while waiting to see his physician. Take this opportunity to reinforce
proper inhaler technique, including the importance of rinsing the mouth after
each use.
4. The immediate management of this patient would involve drainage of pleural
fluid through an intercostal drain and systemic antifungal therapy. The source
is very likely to be oral thrush as the patient is diabetic and the candida has
travelled from the mouth/oropharynx through the leak in the
oesophagectomy wound into the pleural space. Fluconazole at 400 mg twice
daily should be commenced awaiting full culture identification of the yeast
and antifungal sensitivities. Urgent review is indicated for surgical
intervention to close the leak. The duration of antifungal agent would be
normally be 1421 days.
5. Treatment of infections in burns patients can be challenging as the loss in
skin integrity increases the risk of being colonised with various endogenous
and hospital-acquired bacteria and fungi. Patients with haematological
malignancies and chemotherapy treatment are more vulnerable to
opportunistic infections, and this case has an additional co-morbidity on top.
Ideally, antibiotics should be avoided in a patient who has an invasive fungal
infection as it is believed that killing the bacterial flora helps fungi thrive in
the absence of commensal competition. In this case, the patient has
concomitant Gram-negative sepsis and lacks a strong bodily defence system
because of his underlying disease condition. Candida krusei is known to be
resistant to fluconazole. It is difficult to treat intravenous catheter and other
line infections with systemic antibiotics and antifugals alone. It is imperative
that these lines are taken out, and treatment given through temporary
peripheral lines for at least 48 h before a new central line is inserted. New
lines are very likely to get colonised with the same microorganisms if inserted
too early. Both Candida albicans and Candida krusei can be treated with a
lipid formulation of amphotericin (use of non-lipid conventional formulations
of amphotericin should be avoided as the patient has a moderate degree of
renal failure and his present condition could deteriorate). The duration of
treatment can be decided based on daily clinical follow-up that includes
imaging and echo cardiograms for up to 2 weeks to look for seeding of
Candida in other organs. Choice of antifungals can be reviewed after
antifungal sensitivity is made available and amphotericin can be switched to
caspofungin if necessary.