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| CASE REPORT |
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| Year : 2021 | Volume
: 1
| Issue : 4 | Page : 164-166 |
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Pancreatic pseudocyst with Candida glabrata infection
Dinu Abirami Premkumar, Joy Varghese
Department of Hepatology and Transplant Hepatology, Institute of Liver Disease and Transplantation, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| Date of Submission | 15-Apr-2020 |
| Date of Decision | 09-Jun-2021 |
| Date of Acceptance | 12-Aug-2021 |
| Date of Web Publication | 24-Sep-2021 |
Correspondence Address:
Joy Varghese
Institute of Hepatology and Transplant Hepatology, Gleneagles Global Health City, Perumbakkam, Chennai - 600 100, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ghep.ghep_16_21
The incidence of infection in pancreatic pseudocysts is estimated to be about 8.5%, commonly being bacterial. Fungal infection may occur and is usually secondary to intervention. We report here the case of a 51-year-old male with pancreatitis – not previously subjected to endoscopic, radiological, or surgical intervention – who presented with fever and mass and was found to have a pancreatic pseudocyst with Candida glabrata infection.
Keywords: Candida glabrata, cystogastrostomy, fungal infection, pancreatic pseudocyst
How to cite this article:
Premkumar DA, Varghese J. Pancreatic pseudocyst with Candida glabrata infection. Gastroenterol Hepatol Endosc Pract 2021;1:164-6 |
| Introduction | |  |
Pancreatic pseudocysts are the most common cystic lesions of the pancreas, constituting 75–80% of cystic lesions.[1] Pancreatic pseudocyst usually results from either acute or chronic pancreatitis, with an incidence of about 10%–15% in acute and 20%–40% in chronic pancreatitis.[1] The incidence of infection in pseudocyst of the pancreas is about 8.5%, the most common being bacterial, including Escherichia coli, Klebsiella, Enterococcus, Staphylococcus aureus, and Pseudomonas.[2] Fungal infection of the pseudocyst is uncommon accounting to <1% and is more life-threatening than bacterial infections.
| Case Report | | |
A 51-year- old male, who had been consuming alcohol regularly for the past 10 years, with no other comorbidities, developed acute-onset upper abdominal pain radiating to the back, typical of pancreatitis in December 2019. He was evaluated for the same at his hometown and was diagnosed to have acute pancreatitis and was treated conservatively and recovered without further complications. He continued to consume alcohol as he was asymptomatic for 1 year following the episode.
In December 2020, the patient developed another similar episode of abdominal pain, typical of acute pancreatitis and was treated at his hometown after complete evaluation. The patient had slight improvement in symptoms initially but developed low grade fever with persistent epigastric pain, radiating to back, and aggravated on food intake and hence was referred to us for further management.
The patient presented to us nearly after 20 days of diagnosis of acute pancreatitis. On admission in our center in January 2021, he had a history of abdominal pain for nearly 1 month, localized to the epigastric region and radiating to back. The patient also had fever spikes and vomiting within 30 min to 1 h of food ingestion. There was no history of significant weight loss or steatorrhea.
General examination was normal. Epigastric fullness was noted on inspection of the abdomen and on palpation, it was confined to epigastric and left hypochondrial region, tender, and cystic in consistency.
Initial ultrasound (USG) screening showed a large ~146 mm × 93 mm × 122 mm collection in the epigastric region, almost abutting the surrounding structures and predominantly anechoiec with few mobile internal echoes. No solid component was seen.
Computed tomography (CT) of the abdomen with contrast showed a large, well-circumscribed pseudocyst collection with homogenous hypodensity of size 8 cm × 11 cm × 7.8 cm to 7.3 mm × 7.6 cm × 6.2 cm, in close proximity to the liver. Minimal ascites and bilateral pleural effusion were noted [Figure 1]a and [Figure 1]b. | Figure 1: (a and b) Contrast-enhanced computed tomography abdomen showing large peripancreatic collection (infected pseudocyst) 8 cm × 11 cm × 7.8 cm to 7.3 cm × 7.6 cm × 6.2 cm in close proximity to liver
Click here to view |
His blood investigations are listed in [Table 1].
The patient underwent upper gastrointestinal endoscopy and gastric lumen was almost entirely collapsed with extraneous compression. Endoscopic USG was done and pseudocyst cavity was punctured with 21 Fr needle and cyst fluid was collected and sent for the analysis. Two double pigtail stents of size 10 Fr 5 cm were placed across the gastric lumen and cyst cavity [Figure 2]. | Figure 2: Endoscopic image showing cystogastrostomy stent draining into the stomach
Click here to view |
Pseudocyst fluid amylase was elevated. Gram stain showed no organisms and only pus cells. Pseudocyst fluid culture report revealed Candida glabrata growth sensitive to fluconazole. The patient was continued on fluconazole for 14 days and discharged after clinical improvement. Follow-up contrast-enhanced CT of the abdomen after 2 weeks showed complete collapse of the cyst cavity with stent in situ [Figure 3]. | Figure 3: Computed tomography abdomen showing complete collapse of the cyst cavity with stent in situ
Click here to view |
Subsequent endoscopic retrograde cholangiopancreatography (ERCP) and pancreatogram revealed a ductal leak at the proximal body. Pancreatic duct (PD) in the head region was dilated and irregular along with branch duct dilatation. Distal duct could not be cannulated nor visualized. Balloon sweep showed fragments of soft white stones suggestive of chronic pancreatitis. 7 Fr 7 cm plastic single pigtail stent was deployed in proximal PD (the leak could not be bridged). The distal duct could not be cannulated during ERCP, and hence, the patient was advised surgical management for disrupted PD.
| Discussion | | |
There are only a few case studies in the literature on isolated Candida infection in complicated pancreatitis, the most common being Candida albicans.[3] C. glabrata stands third among fungal infections caused by Candida in complicated pancreatitis according to foreign studies[4] but has not been reported previously in the Indian literature. In accordance with the literature, we emphasize the need for effective antifungal therapy in addition to antibiotics and drainage in treatment. C. glabrata, a common commensal and a rare fungal infection, usually occurs in the setting of either usage of broad spectrum antibiotics or prolonged intensive care unit stay or usage of total parenteral nutrition or following therapeutic drainage. We consider our case report as primary fungal infection as all the above factors have been ruled out and no intervention was performed before admission and initial cyst fluid collected under aseptic conditions revealed significant growth of C. glabrata. The patient has been screened adequately for immunosuppressed state and proved negative. Only very few case reports on isolated Candida infection in pancreatic pseudocyst secondary to broad spectrum antibiotic use were found in literature.[5] Mixed infection of Burkholderia cepaciae, C. glabrata, and Candida dubliniensis has been reported in pseudocyst pancreas.[2]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Habashi S, Draganov PV. Pancreatic pseudocyst. World J Gastroenterol 2009;15:38-47.  |
| 2. | Rawi S, Mago S: Multi-drug resistant Burkholderia cepacia infected pancreatic pseudocyst. Am J Gastroenterol 2019, 114:S727-8. |
| 3. | Janani J, Asif M, Patel D, Mir AS, Madison G, Khan M, Lichtenstein S. A case of chronic pancreatitis with pancreatic pseudocysts complicated by a rare Candida albicans infection. Am J Gastroenterol 2017;112:S732. |
| 4. | Trikudanathan G, Navaneethan U, Vege SS. Intra-abdominal fungal infections complicating acute pancreatitis: A review. Am J Gastroenterol 2011;106:1188-92. |
| 5. | Berzin TM, Rocha FG, Whang EE, Mortele KJ, Ashley SW, Banks PA. Prevalence of primary fungal infections in necrotizing pancreatitis. Pancreatology 2007;7:63-6. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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