146 G. Stryjewska-Makuch et al.

Grażyna StryjewSka-MakuchBogdan kolebaczMarcelina NieMiecMaria huMeNiuk-araSiewicz

Independent Public Research Hospital No. 7 of Silesian Medical University in Katowice, Upper Silesian Medical Centre, Department of Laryngology and Laryngological Oncologyhead:Dr Bogdan Kolebacz

Additional key words:candidiasishead neck infectioncase report

Dodatkowe słowa kluczowe: kandydozainfekcja głowy i szyiopis przypadku

Address for correspondence:Grażyna Stryjewska-Makuchul. Ziołowa 45/47, 40-635 Katowice, Polandtel. +48 32 359 80 00e-mail: makuch_mg@wp.pl

Conflict of interest not declared

Received: 06.07.2017Accepted: 17.11.2017

cAse reports

Invasive candidiasis in the head and neck region

Inwazyjne kandydozy w obrębie głowy i szyi

Deep tissue infections with Can-dida fungus in the head and neck region are rare outside the intensive care unit. The most common is Can-dida albicans, followed by Candida glabrata, parapsilosis or tropicalis. At the Department of Laryngology, fun-gal infections are observed in the oral cavity, within the skin of the external ear or paranasal sinuses. The authors present two cases of invasive life--threatening fungal infection in diffe-rent locations.

Niniejsza praca finansowana jest ze środków własnych.

Zakażenia tkanek głębokich w obrębie głowy i szyi grzybami typu candida występują rzadko poza oddziałami intensywnej opieki medycznej. Najczęściej spotykana jest Candida albicans, dalej Can-dida glabrata, parapsilosis czy tro-picalis. W oddziałach laryngologii zakażenia grzybicze obserwujemy w obrębie jamy ustnej, skóry ucha zewnętrznego czy zatok obocznych nosa. Autorzy pracy prezentują dwóch chorych, u których wystąpiło zakażenie grzybicze, w odmiennej lokalizacji o ciężkim, zagrażającym życiu przebiegu.

IntroductionCandida belongs to the order Saccharo-

mycetales. Under normal conditions, Candi-da species are saprophytes that live in the natural environment and also colonize the mucous membranes and human skin. They do not cause disease in immunocompetent people. They are classified as opportunistic fungi that cause serious infections in patients with immune deficiency, cachexia, endocrine disorders, after surgery, chemotherapy, ra-diotherapy and infections [1] or on immuno-suppressive therapy [2]. At least 70% of all infections with yeasts belonging to the genus Candida in humans are caused by Candida albicans, and the others by Candida tropi-calis, Candida kefyr, Candida guilliermondii, Candida catenulata, Candida parapsilosis, Candida krusei, Candida utilis, Candida in-termedia as well as Candida famata and Candida glabrata. The incidence of a particu-lar species of yeast can vary depending on the geographical region [3].

Fungal infections in the head and neck region may have a turbulent and life-thre-atening course if not recognized in time. In the material of the Department of Laryngo-logy and Laryngological Oncology, fungal infections of the paranasal sinuses were most common. In the years 2009-2016, 22 cases of dead fungus ball and 2 cases of Aspergillus fumigatus were diagnosed by histopathology. All the patients underwent surgical treatment and reported no symp-toms during follow-up. The authors present two cases of life-threatening fungal infec-tion, of the deep tissues of the neck and of the central nervous system.

Case report 1In July 2016, a 72-year-old patient was

urgently admitted to hospital. The patient

was transferred to the Department of La-ryngology from the Gastrointestinal Surge-ry Clinic, which he contacted a few days earlier because of the increasing difficulty in swallowing solid foods. The patient had been under the constant care of the Clinic since 1997 when he underwent total ga-strectomy because of adenocarcinoma. The performed CT of the neck showed in-filtrates with gas bubbles around the thyro-id cartilage and the hyoid bone as well as thickening of the soft tissues of the back of the hypopharynx on the left side. In diffe-rentiation, it was recommended to take into account the tumour necrosis or phlegmon of soft tissues.

The patient was subjected to trache-ostomy, and a specimen was taken from the thyroid cartilage area for bacteriological examination. Aspiration biopsy of the tissu-es of the neck was performed without taking a specimen. Intravenous administration of ampicillin with clavulanic acid at a dose of 1.2 g every 8 hours and 100 ml of 0.5 % Metronidazole every 12 hours was recom-mended. On the second day of treatment, inflammation of the neck skin yielded, the amount of purulent content in the bottom part of the pharynx decreased. The left half of the larynx was still motionless. Leucocy-tosis dropped to 8.08, D -dimer - 1713.85 ng/ml, CRP and procalcitonin decreased slightly. The treatment was continued. On the fourth day after patient’s admission to the Department, the value of CRP was 87.5 mg/l and the other parameters were normal. The result of inoculation from the lesion was obtained - Staphylococcus epi-dermidis sensitive to penicillin with inhibi-tors. The patient did not have a fever but still complained of difficulty in swallowing food. The oedema of the left aryepiglottic

Przegląd Lekarski 2018 / 75 / 03 147

fold and the arytenoid still persisted. The left vocal fold was still motionless.

CT of the neck was performed showing irregular areas of fluid from the level of the hyoid bone to the thyroid cartilage involving the epiglottis, mostly on the left side, piri-form recess and preepiglotic space (Fig. 1).

A decision was made to incise the la-ryngeal abscess. The abscess cavity was gently rinsed with saline, a drain and lay-ered sutures were placed on the subcuta-neous tissue and skin. The result of bac-teriological examination from the abscess cavity was Candida glabrata. Antifungal therapy with fluconazole was recommen-ded. On the fourth day the drain was re-moved from the wound. On the sixth day after the incision and evacuation of the la-rynx abscess, mobility of the left vocal fold returned and the laryngeal oedema disap-peared. The next day the tracheotomy tube was removed, and on the fourteenth day following the admission to the Department of Laryngology, the patient, after perfor-ming a CT scan, was discharged home in good condition.

Case report 2A 60-year-old patient was qualified for

endoscopic sinus surgery, in accordance with the EPOS 2012 guidelines, because

of chronic sinusitis with polyps (CRSwP). Before surgery, the patient was repeatedly treated with antibiotics because of head-aches and purulent secretions from the nasal cavity. In August 2016, under general anaesthesia, the patient underwent bilater-al antroethmoidectomy and Draf I frontec-tomy on the left side. Polyps were removed from the left middle nasal meatus. After 2 weeks, because of persistent inflammation of the left eyelid, the postoperative cavity revision was performed, finding purulent content in the left maxillary sinus. A speci-men was taken for bacteriological exami-nation and 300 mg of Klindamycin was administered intravenously every 8 hours. After 3-day improvement, the patient’s con-dition gradually deteriorated, drowsiness, weakness and increased oedema of the left eyelid occurred.

Within the Department of Anaesthesiol-ogy and Intensive Therapy, intensive anti-biotic therapy was included: Ceftriaxone, vankomycin, Meropenem at doses relevant to the patient’s weight. After several hours, reduced consciousness and convulsions occurred. A CT scan of the head showed inflammatory lesions in the frontal sinuses, inflammatory infiltrate in the left frontal lobe and subdural empyema over the left hemi-sphere of the brain (Fig. 2).

The patient was transferred to the Department of Otolaryngology and Laryn-gological Oncology in Katowice, where the frontal sinuses (Draf IIB) were reoperated and trepanopuncture was performed, ob-taining plentiful pus from the subdural em-pyema (Fig. 3).

In bacteriological cultures, Candida tropicalis was identified. Within the De-partment of Anesthesiology and Intensive Therapy, intravenous antifungal therapy (50 mg of Caspofungin every 12 hours) was started, which resulted in an improve-ment in the patient’s condition.

We associate the dramatic postopera-tive course with the presence of fungal in-fection, which was not recognized in the first bacteriological examination. Intensive antibiotic treatment accelerated the devel-opment of a very rare but associated with mortality of 50% or more intracranial com-plications like meningeal empyema [4].

DiscussionCandida albicans is encountered most

frequently. Among non-albicans Candida, Candida glabrata is the most widespread in Europe and North America, while Candida tropicalis and Candida parapsilosis in Asia and South America [3]. The incidence of Candida glabrata is from 11.7% to 30.3%, depending on the source, and Candida tro-picalis from 9.8% to 20% [5,6].

One of the main causes of pathogeni-city of Candida spp. is the ability to form a biofilm on various surfaces, including surgical instruments, catheters and pro-stheses [7]. Some authors suggest that the increase in the density of cells in the biofilm is the cause of drug resistance [8]. Vila [3] demonstrated that C.tropicalis and C.glabrata obtained from the samples sho-wed greater resistance to Amphotericin B. The increase in cross-resistance of Candi-da glabrata to azoles was demonstrated by Yamada [9].

Microscopic fungi of the genus Candida produce endotoxin-like substances that are dangerous for the host organism. The best known is candida toxin, which exhibits toxic effects on the cells of the infected organism

Figure 1 Inflammatory infiltrate of the deep neck space.Naciek zapalny przestrzeni głębokich szyi.

Figure 2 Inflammatory infiltrate in the left frontal lobe and subdural empyema over the left hemisphere of the brain. Naciek zapalny i ropniak podoponowy lewej półkuli mózgu.

Figure 3 Trepanopuncture – pus from the subdural empyema.Trepanopunkcja – treść ropna z ropniaka podoponowego.

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and damages the immune system leading to increased spread of the infection [10].

There are descriptions of cases where steroids, used systemically and locally in the form of inhalation [11], and radiothera-py [12] contributed to fungal infections in the head and neck region.

The literature also describes a case of laryngeal aspergillosis in a patient after ra-diation therapy for cancer [13] and an AIDS positive patient, where lesions were super-ficial, included the right vestibular and vo-cal fold with the anterior commissure [14]. An abscess of the parotid gland caused by Candida albicans was identified within the deep tissues of the head in an elder-ly patient suffering from insulin-dependent diabetes [15]. Russo [16] presented disse-minated fungal infections within the organs of the head and neck caused by Candida albicans, Cryptococcus neoformans, Histo-plasma capsulatum or Blastomyces der-matitidis. The author suggests that fungal infections can simulate carcinoma or cause upper airway obstruction.

The patients described in the present paper did not have immunodeficiency, dia-betes or other chronic diseases, and they did not use systemic steroids. The patient who underwent gastrectomy had normal levels of Vitamins B 12 and no FE defi-ciency, and carcinoma was considered cu-red. In the case of the patient with chronic sinusitis, it was his first operation prece-ded by several antibiotic treatments and local steroid therapy. The patient did not report any previous fungal infections. The dramatic course of infection, especially in

the second case, led to intracranial com-plications that developed during several hours, causing a direct threat to the pa-tient’s life.

The risk of fungal infections within the organs of the head and neck must be taken into account in the course of conservative and surgical treatment.

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