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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 35  |  Issue : 1  |  Page : 42-44

Candida parapsilosis: A rare cause of arthritis and its successful treatment with oral fluconazole


Department of Microbiology; Department of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Submission12-Jun-2021
Date of Acceptance17-Jun-2021
Date of Web Publication04-Aug-2021

Correspondence Address:
Khuraijam Ranjana Devi
Department of Microbiology, Regional Institute of Medical Sciences, Imphal, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_77_21

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  Abstract 


Fungal arthritis is a rare condition, often missed and underreported. Among all Candida species, Candida parapsilosis is a rare cause. A 66-year-old male with a history of arthritis on and off for the past 3 years and treated symptomatically presented with acute pain and swelling of the left knee joint for 1 week. Synovial fluid examination revealed yeast-like structures and fungal culture showed growth of Candida spp. VITEK 2 compact identified it as Candida famata but matrix-assisted laser desorption ionization–time of flight mass spectrometry assay confirmed it as C. parapsilosis. This is a rare case of nonalbicans candida arthritis, especially in this part of the country.

Keywords: Candida parapsilosis, Candidal arthritis, Fluconazole


How to cite this article:
Devi NP, Devi KR, Singh Akoijam K J, Devi PP, Singh LN. Candida parapsilosis: A rare cause of arthritis and its successful treatment with oral fluconazole. J Med Soc 2021;35:42-4

How to cite this URL:
Devi NP, Devi KR, Singh Akoijam K J, Devi PP, Singh LN. Candida parapsilosis: A rare cause of arthritis and its successful treatment with oral fluconazole. J Med Soc [serial online] 2021 [cited 2021 Dec 8];35:42-4. Available from: https://www.jmedsoc.org/text.asp?2021/35/1/42/323166




  Introduction Top


Candidiasis is the most common fungal disease found in humans. Infection ranges from mild mucocutaneous infections to invasive infections. Individuals at the highest risk of severe infection include neonates and patients in intensive care units. Candida parapsilosis has been surfacing as a major human pathogen that has dramatically increased in its significance and prevalence over the past 2 decades.

Candida arthritis is extremely rare and also represents a major challenge in diagnosis and treatment because the clinical manifestations, laboratory, and radiologic findings are not specific and ill defined. Among Candida species, Candida albicans contributes the highest incidence of cases, but often nonalbicans have been implicated to be the causative agent of Candida arthritis.[1]

Recent studies in reference laboratories have suggested that isolates initially identified as Candida famata by phenotypic methods were found to be strains of Candida guilliermondii, Candida lusitaniae, Candida fermentati, Candida intermedia, and Candida palmioleophila by molecular identification.[2] This suggests that C. famata is much less common. With this background, we investigated a case of candidal arthritis further up to ionization techniques by matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) before concluding and we found that the actual etiological agent to be C. parapsilosis rather than C. famata.


  Case Report Top


A 66-year-old male presented with pain, swelling, and restricted range of motion of the left knee joint for 1 week. He was afebrile at the time of presentation. He had been having symptoms of mild to moderate pain, occasionally accompanied by swelling of the knee joint (L) on and off for the past 3 years. He had been receiving supportive treatment with little improvement. There was no history of injury before the development of the condition. In the past 1 week, the pain and swelling were gradual in onset and progressive in nature. Radiological findings were inconclusive of the actual cause of the nonresolving symptoms. He gave no history of any intraarticular injections neither was an intravenous drug abuser. There was no history of tuberculosis, Type 2 diabetes mellitus, hypertension, human immunodeficiency virus infection, immunosuppressive therapy or conditions, and no history suggestive of bacteremia or candidemia before or during the course of arthritis. Laboratory investigations revealed the hemoglobin level of 11 gm% and total leukocyte count of 12,000/cu mm. Antinuclear antibody and dsDNA were found to be negative. Synovial fluid examination [Table 1] showed cell count of 200 cells/mm3 (lymphocytes – 60%, neutrophils – 10%, synovial cells – 30%) with red blood cells. Direct wet mount examination of the synovial fluid revealed scanty budding yeast cells and gram stain of sediments of the centrifuged sample showed budding yeast cells.
Table 1: Summary of the laboratory studies of the synovial fluid

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Fungal culture on neutral Sabouraud dextrose agar (SDA) (Emmon's modification) with antibiotic (gentamicin, 0.04%) subsequently showed growth of budding yeast cells suggestive of Candida spp. Automated phenotypical identification with VITEK 2 compact system (Biomerieux, France) identified the growth as C. famata (92% probability). The patient was started on fluconazole 150 mg twice daily dose, and no surgical procedure was planned. The strain was sent to WHO Collaborating Centre, Centre of Advanced Research in Medical Mycology, Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, for confirmation by MALDI-TOF MS assay. MALDI-TOF MS assay confirmed the isolate as C. parapsilosis. The isolate when tested for antifungal susceptibility testing using VITEK® YST card in VITEK 2 was found to be sensitive to fluconazole, caspofungin, micafungin amphotericin B, and flucytosine with and minimum inhibitory concentration of fluconazole, and amphotericin B and flucytosine are ≤0.5, 1 and ≤1, respectively.

At 3-month follow-up, there was clinical improvement and no surgical intervention was required. Mycological examination of the synovial fluid revealed no fungal elements on direct microscopic examination and there was no growth on SDA media. He was asked to continue the same treatment for another 2 months. At 6 months, there was clinical improvement with no mycological findings on direct microscopy and culture of synovial fluid.


  Discussion Top


Fungal arthritis, though rare, occurs most often in persons with predisposing conditions such as immunosuppression, type 2 diabetes, use of hyperalimentation solutions. Prosthetic or rheumatic joints are similarly predisposed to infection by Candida species by hematogenous route or direct inoculation during joint surgery or intra-articular steroid injection and acupuncture therapies, which can be due to contamination nosocomially through the hands of health-care workers. Of the various species, C. albicans, Candida tropicalis, and C. parapsilosis were found to be the most common causes of Candida arthritis.

Nonalbicans candida species are arising as frequent fungal pathogens, one of which is C. parapsilosis. It has become one of the leading causes of invasive candidiasis. Factors responsible for pathogenesis include secretion of hydrolytic enzymes, adhesion to prosthetics, and indwelling devices and ability to form biofilm.

When compared with molecular methods of identification, VITEK 2 compact (Biomerieux, France) has a sensitivity and specificity >95% for commonly isolated yeasts. However, difficulties in differentiating various species with similar metabolic characteristics are known to occur. In our study, we observed that C. parapsilosis was misidentified as C. famata and confirmation by MALDI-TOF MS was required. An update of the databases is mandated by further studies into the minute differences in culture characteristics of various Candida species. Apart from this study, misidentification of C. parapsilosis as C. famata had been reported in studies conducted by Kim et al.[3] Most of the C. parapsilosis arthritis occurs in immune impaired individuals as observed in various literatures.[1] Fang et al. reported a patient who had invasive procedure in the form of small needle-knife acupuncture and corticosteroid injection of the joint, before the development of Candida arthritis, and the particular patient had associated comorbidities such as type 2 diabetes mellitus.[1] This is contradictory to our case where the patient had no history of immunosuppressive condition nor any intraarticular injections except for the advancing age. The probable cause of the spontaneous arthritis in this particular case remains unknown. Although it may be speculated that the cause to be due to the hematogenous spread of the fungal pathogen, this needs to be supported by simultaneous blood culture, which was not conducted.

Our case responded well to oral fluconazole without the need for surgical intervention. In most of the candidal arthritis, surgical resection along with antifungal drugs was the mainstay of treatment protocol. Gamaletso et al. in their study of Candida arthritis analyzed 112 patients of which 25% needed surgical debridement, irrigation in 10%, and drainage in 12%. Moreover, among these 112 cases, complete or partial cure was achieved in 96% and relapse in 16%. Fluconazole is a triazole antifungal drug with broad-spectrum activity and good tissue penetration after oral administration. Fluconazole levels in the synovial fluid have been documented to be between 90 and 100 of those in plasma. In a study, Weers-Pothoff et al. in 1997 have reported successful use of oral fluconazole in the treatment of septic arthritis due to C. tropicalis. In their patient, synovial fluid became culture negative after 1 month of antifungal therapy and fluconazole concentration in the synovial fluid and serum were 20 mg/l and 19.4 mg/l, respectively. The patient was treated for a total of 7 months and made a full recovery.[4]

In an Italian University hospital, a significant higher mortality rate was observed with biofilm-forming C. albicans, C. parapsilosis, C. tropicalis, and C. glabrata isolates as compared to nonbiofilm-forming isolates. For C. parapsilosis, mortality rate for biofilm-forming isolates was 71.4% as opposed to 28% for biofilm-deficient isolates.[5] C. parapsilosis strains are known to produce quantitatively and structurally less complex biofilm as compared to C. albicans. It is not considered to be particularly prone to the development of antifungal resistance, but some recent studies suggested that it is starting to have decreased susceptibility to azoles and echinocandins and this might become a cause for clinical concern.[6]

Our patient responded well to oral fluconazole which may be because of apparently healthy nonimmunocompromised status of the patient and ready susceptibility of the species of Candida to fluconazole.

In conclusion, we report a case of monoarticular left knee septic arthritis with C. parapsilosis which was previously misidentified as C. famata by the VITEK 2 in a supposedly immune-competent individual. The misidentification caused delay in diagnosing the correct pathogen, leading to further delay in administration of appropriate therapy for the unresolving chronic condition. Misidentification of fungal species with the VITEK 2 is uncommon with commonly isolated clinical yeasts, but the possibility needs to be kept in mind. Timely diagnosis, accurate identification of the causative agent up to species level and prompt antifungal therapy will reduce tissue damage, joint destruction, and disability and will preserve function. Possibility of fungal arthritis in cases of chronic arthritis though remote needs to be noted and emphasized.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors are grateful to Professor A. Chakrabarti and his team in WHO Reference Centre, Department of Medical Microbiology, PGIMER, Chandigarh for confirmation of the strain.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fang H, Huang L, Zhang R, Xie D, Sun H, Zeng C, et al. Recurrent arthritis caused by Candida parapsilosis: A case report and literature review. BMC Infect Dis 2019;19:631.  Back to cited text no. 1
    
2.
Castanheira M, Woosley LN, Diekema DJ, Jones RN, Pfaller MA. Candida guilliermondii and other species of candida misidentified as Candida famata: Assessment by vitek 2, DNA sequencing analysis, and matrix-assisted laser desorption ionization-time of flight mass spectrometry in two global antifungal surveillance programs. J Clin Microbiol 2013;51:117-24.  Back to cited text no. 2
    
3.
Kim HY, Huh HJ, Choi R, Ki CS, Lee NY. Three cases of candidiasis misidentified as Candida famata by the Vitek 2 system. Ann Lab Med 2015;35:175-7.  Back to cited text no. 3
    
4.
Weers-Pothoff G, Havermans JF, Kamphuis J, Sinnige HA, Meis JF. Candida tropicalis arthritis in a patient with acute myeloid leukemia successfully treated with fluconazole: Case report and review of the literature. Infection 1997;25:109-11.  Back to cited text no. 4
    
5.
Tumbarello M, Posteraro B, Trecarichi EM, Fiori B, Rossi M, Porta R, et al. Biofilm production by Candida species and inadequate antifungal therapy as predictors of mortality for patients with candidemia. J Clin Microbiol 2007;45:1843-50.  Back to cited text no. 5
    
6.
Lotfali E, Kordbacheh P, Mirhendi H, Zaini F, Ghajari A, Mohammadi R, et al. Antifungal susceptibility analysis of clinical isolates of Candida parapsilosis in Iran. Iran J Public Health 2016;45:322-8.  Back to cited text no. 6
    



 
 
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