Di Carlo et al. World Journal of Emergency Surgery 2013, 8:38 http://www.wjes.org/content/8/1/38 WORLD JOURNAL OF EMERGENCY SURGERY REVIEW Open Access Surgical pathology and the diagnosis of invasive visceral yeast infection: two case reports and literature review Paola Di Carlo1*, Gaetano Di Vita2, Giuliana Guadagnino1, Gianfranco Cocorullo3, Francesco D’Arpa3, Giuseppe Salamone3, Buscemi Salvatore2, Gaspare Gulotta3 and Daniela Cabibi1 Abstract Invasive mycoses are life-threatening opportunistic infections that have recently emerged as a cause of morbidity and mortality following general and gastrointestinal surgery. Candida species are the main fungal strains of gut flora. Gastrointestinal tract surgery might lead to mucosal disruption and cause Candida spp. to disseminate in the bloodstream. Here we report and discuss the peculiar clinical and morphological presentation of two cases of gastrointestinal Candida albicans lesions in patients who underwent abdominal surgery. Although in the majority of cases reported in the literature, diagnosis was made on the basis of microbiological criteria, we suggest that morphological features of fungi in histological sections of appropriate surgical specimens could help to detect the degree of yeast colonization and identify patients at risk of developing severe abdominal Candida infection. Better prevention and early antifungal treatments are highlighted, and relevant scientific literature is reviewed. Keywords: Surgical pathology, Gastrointestinal candidiasis, Diagnosis Introduction Several studies conducted over the last two decades Invasive mycoses are important healthcare-associated in- have shown that gastrointestinal surgeries are associated fections, and have become an increasingly frequent prob- with an increased risk of fungemia, and patients admit- lem in immunocompromised and severely ill patients [1]. ted to surgical intensive care units (ICUs) are considered Medical progress, which has resulted in a growing number to have a greater risk of developing it [3,4]. of invasive procedures, new dimensions in aggressive im- Candida spp. are the main fungal strains of gut flora. munosuppressive and immunomodulatory treatments and Gastrointestinal tract surgery might lead to mucosal dis- widespread use of broad-spectrum antibiotics, is the main ruption and cause Candida spp. to disseminate through catalyst for this development [1-3]. the bloodstream. Invasive fungal infections, Candida species in particu- Lastly, despite a strong index of suspicion in high-risk lar, are the fourth most common cause of nosocomial subjects such as patients who require surgical re- bloodstream infections, and are associated with high intervention, and international guidelines on the use of morbidity and mortality in critically-ill patients, particu- antifungal prophylaxis, the incidence and severity of can- larly those who have recently undergone extensive didiasis in post-surgical patients appears significant. More- gastro-abdominal surgery [4]. over, isolated species show virulence factors and exhibit varying levels of susceptibility to antifungal drugs [1,5,6]. In the present study, we report two cases of Candida albicans infection identified in abdominal specimens * Correspondence: [email protected] 1Department of Sciences for Health Promotion and Mother-Child Care from patients who had undergone gastro-abdominal “G. D’Alessandro”, University of Palermo, Via del Vespro 127, I- 90127 Palermo, surgery. Italy Full list of author information is available at the end of the article © 2013 Di Carlo et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Di Carlo et al. World Journal of Emergency Surgery 2013, 8:38 Page 2 of 5 http://www.wjes.org/content/8/1/38 Case presentation No layers or structures were identifiable on histological First case examination, but numerous fungal yeasts were identified In December 2012, a 54 year-old woman of Italian origin inside the necrotic areas with PAS and Gomori and nationality presented to the general surgery and emer- Silvermthenamina stains (Figure 1). gency unit of the “P. Giaccone” Teaching Hospital in Culture of the intra-operative surgical specimen con- Palermo, Italy, with severe epigastric left-upper-quadrant firmed the presence of Candida albicans. pain that was progressive and burning. Yeast isolates were identified to the species level by Her medical history was significant for hypertension, conventional morphological and biochemical methods, asthma and rectal cancer surgery (T1N0M0) involving as previously reported [3,7,8]. low anterior resection with total mesorectal excision and The yeast isolate was susceptible to fluconazole and end to end anastomosis in October 2012. Recovery from echinocandin, according to CLSI cut off values [9,10]. It surgery was hampered by recurrent episodes of fever but is noteworthy that blood cultures were negative. no specific infectious agent was detected; in view of this, Echinocandin (70 mg on the first day, i.e., day 103, the patient showed clinical improvement after empirical followed by 50 mg/day) was administered parenterally treatment with fluconazole. for a total of 14 days, followed by maintenance therapy Physical examination revealed a soft abdomen with posi- with 400 mg of oral fluconazole per day. tive bowel sounds, and tenderness to palpation in the left The patient was discharged in stable condition and an- upper quadrant. Rectal examination was guaiac-negative, tifungal therapy was continued in an outpatient setting. and a complete blood count indicated leukocytosis with She has been doing well since then. left shift. CT scan of abdomen showed a gastric dilatation, marked thickening of the anterior wall and necrotic areas within. Second case An exploratory upper laparotomy confirmed acute In January 2013, a 62 year-old woman of Italian origin gastric dilatation and necrosis of the anterior surface of and nationality with BMI of 35 kg/m2, presented to the the stomach. A “sleeve” gastrectomy to ablate the nec- general surgery and emergency unit of the “P. Giaccone” rotic area was performed and a feeding jejunostomy. Teaching Hospital in Palermo, Italy, with complicated The gastric wall appeared very thin and totally nec- midline incisional hernia, nausea, vomiting and abdom- rotic upon macroscopic examination by the pathologist. inal distension. Figure 1 Histological section. A) Very thin and totally necrotic gastric wall. B, C) Numerous fungal yeasts were present. PAS stain (A) ×100; (B) ×200; (C) ×400. Di Carlo et al. World Journal of Emergency Surgery 2013, 8:38 Page 3 of 5 http://www.wjes.org/content/8/1/38 Her initial vital signs were notable for a temperature Some yeasts were present across vessel walls of the of 38°C, respiratory rate of 22 breaths per minute, heart small bowel, suggesting systemic blood dissemination rate of 110 beats per minute and blood pressure of 90/ (Figure 2C). 60 mmHg. She was suffering from severe abdominal These findings were in keeping with culture results of pain and breathing difficulties. On clinical examination, intraoperative specimens and serial drainage fluids, show- she presented a tender abdomen, ulcerated skin with as- ing fluconazole-resistant Candida albicans, susceptible to sociated necrosis and dry skin. echinocandin according to CLSI cut off values [8]. Her past medical history showed three caesarean sec- Echinocandin (70 mg on the first day, i.e., day 103, tions, treatment for arterial hypertension, COPD and a followed by 50 mg/day) was administered parenterally diagnosis of type II diabetes mellitus (DM) about 15 for a total of 21 days. years previously, treated with insulin. The patient’s clinical conditions improved, fever Emergency surgery was required, and surgical explor- disappeared and she was subsequently discharged in a ation showed a congested, edematous and necrotic good clinical state. strangulated intestinal tract. The section of necrotic in- testine was removed and ileo-ileostomy was performed. Discussion The surgery was successful, without additional complica- We have reported two cases of abdominal surgery pa- tions, and an abdominal subcutaneous drain was tients who developed systemic candidiasis, and whose inserted. The surgical specimen was sent to the Path- clinical symptoms improved following the initiation of ology Laboratory for histological examination. therapy with 70/50 mg/day echinocandin. Oral thrush During the postoperative period, the patient remained and esophageal candidiasis are the most common mani- febrile but two routine blood cultures were negative. festations of Candida infection in the GI tract, with only Furthermore, histological examination of both the skin occasional involvement of the colon and rectum. Despite and the small bowel specimens using special histochem- the high concentration of Candida spp. in the lower GI ical stains (PAS, Gomori Silvermethenamine) showed se- tract, infection does not occur under normal circum- vere inflammation and massive areas of necrosis stances, owing to innate defense mechanisms. containing fungal spores and numerous budding hyphae In this manuscript, we have described abdominal le- (Figure 2). sions due to Candida albicans infection. In a previous Figure 2 Histological section. A) Necrotic tissue from the cutaneous specimen,