A 62-year-old woman undergoing chemotherapy through a subcutaneous port for locally advanced breast cancer comes to the physician with fever and malaise. She has no other symptoms.
There are no skin lesions on physical examination and cardiac examination is normal. The patient's abdomen is soft and nontender to palpation. She has a subcutaneous port in the left chest and there is no erythema, warmth, tenderness, or drainage at the catheter exit site.
Blood cultures grow yeast within 36 hours that is later identified as Candida albicans. Antifungal therapy is initiated, her port is removed, and blood cultures 48 hours later are negative.
Which of the following must be included in the initial diagnostic workup?

Question

A 62-year-old woman undergoing chemotherapy through a subcutaneous port for locally advanced breast cancer comes to the physician with fever and malaise.  She has no other symptoms.
There are no skin lesions on physical examination and cardiac examination is normal.  The patient's abdomen is soft and nontender to palpation.  She has a subcutaneous port in the left chest and there is no erythema, warmth, tenderness, or drainage at the catheter exit site.
Blood cultures grow yeast within 36 hours that is later identified as Candida albicans.  Antifungal therapy is initiated, her port is removed, and blood cultures 48 hours later are negative.
Which of the following must be included in the initial diagnostic workup?

Quizplus · Accepted Answer

This patient's presentation is consistent with catheter-associated candidemia, a frequent consequence of long-term central venous catheters and total parenteral nutrition. Catheters should be removed early in all cases of fungemia as catheter retention is associated with increased mortality and difficulty in eradicating fungemia. In addition, empiric antifungal therapy (until antifungal sensitivities are available) is always indicated in the setting of candidemia. All patients with candidemia should undergo an ophthalmic examination, even in the absence of ocular symptoms, to identify early signs of Candida endophthalmitis before progression to vision loss, which may be irreversible. (Choice A) Colonoscopy is generally not warranted in the setting of candidemia. Other pathogens associated with colon cancer, such as Streptococcus gallolyticus and Clostridium septicum, should prompt an evaluation for colonic malignancy. (Choice B) Candida is not typically associated with lower urinary tract infection or malignancy, and therefore cystoscopy is not warranted in the evaluation of patients with candidemia. (Choice C) Hepatosplenic candidiasis is an uncommon presentation of Candida infection and is limited to patients with hematological malignancies and neutropenia. Given the alternate explanation of candidemia, the central venous catheter, and the absence of neutropenia in this patient, liver biopsy would not be indicated. (Choice E) Echocardiography is used in the evaluation of Candida endocarditis. However, this patient has no characteristic clinical features of endocarditis, and the rapid clearance of fungemia would argue against an endovascular source of infection. Educational objective: All patients with candidemia should undergo a dilated retina ophthalmologic examination to evaluate for endogenous endophthalmitis. __________ References: Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/19191635) Current treatment strategies for disseminated candidiasis. (http://www.ncbi.nlm.nih.gov/pubmed/16355336)

A 62-Year-Old Woman Undergoing Chemotherapy Through a Subcutaneous Port for Locally