Candida parapsilosis fungaemia treated unsuccessfully with amphotericin B and fluconazole but eliminated with caspofungin: a case report

A case of Candida parapsilosis Hickman catheter infection with fungaemia presenting with severe hypoxia, lactic acidosis and renal failure is described. Four months previously, the Hickman catheter had become infected with Candida parapsilosis (sensitive to fluconazole and amphotericin B) with blood cultures remaining positive despite an intravenous course of fluconazole 200 mg 12-hourly increasing to 400 mg-12-hourly. Subsequently, treatment with an amphotericin B infusion (30 mg over 24 hours) for five days was associated with a progressive increase in serum creatinine from 0.042 mmol/L to 0.278 mmol/L with blood cultures remaining positive. While arrangements were being made to remove and replace the catheter via a thoracotomy, the patient developed severe hypoxia, lactic acidosis and renal failure and was admitted to the intensive care unit for further management. An intravenous course of caspofungin (70 mg over 1 hour followed by 50 mg over 1 hour, daily) was associated with negative blood cultures and a normal plasma C-reactive protein for the first time in four months. The hypoxia was managed with spontaneous ventilation and high inspired oxygen concentrations, and the anaemia was treated with red blood cell transfusions. A rapid reversal of the respiratory failure and lactic acidosis occurred and the patient was discharged home from the intensive care unit after 10 days to continue the caspofungin infusions for a total of 6 weeks. She has subsequently remained well with negative blood cultures two months later.