Hepatic Candidiasis Following Drug-Induced Neutropenia in ANCA-Associated Vasculitis: A Diagnostic Challenge

An 82-year-old woman with antineutrophil cytoplasmic antibodies-associated vasculitis and previous azathioprine-induced neutropenia presented with 5 days of right upper quadrant pain, nausea, and vomiting. Laboratory evaluation revealed leukocytosis (34.14/nL) and cholestasis (alkaline phosphatase 2,296 U/L, total bilirubin 4.3 mg/dL). Computed tomography demonstrated a 16.4 × 12.0 cm multiloculated perihepatic fluid collection. Blood cultures were negative. Hepatic candidiasis was diagnosed by culture of drained fluid, which grew Candida albicans. Treatment with fluconazole and percutaneous drainage with adjunctive fibrinolytics achieved complete resolution at 9 weeks. This case underscores the importance of considering hepatic candidiasis in immunocompromised patients with persistent or atypical liver lesions, even in the absence of candidemia or typical imaging findings.