Virginia Research Day 2025

Medical Resident Research Case Reports

06 Candida in the Chest: A Case Report on Fungal Thoracis

Duncan A. McKinney, MD; Noah R. Kosnik, DO; Tiffany Jenkinson, DO, MPH; Anthony Weinstock, DO Corresponding author: duncan.mckinney@hcahealthcare.com

LewisGale Medical Center - Salem

was negative for evidence of malignant cells and instead only revealed inflammatory cells with cellular debris and a few yeast forms. Pleural fluid culture grew Candida glabrata , and fluconazole was started. Worsening respiratory status prompted repeat imaging, and CT chest demonstrated recurrent large left-sided loculated pleural effusion with septation. A small-caliber (pigtail) catheter was placed for ongoing drainage until definitive management could be performed. Cardiothoracic surgery performed video-assisted thoracoscopic surgery for pleural decortication of the left lung. Repeat pleural fluid culture returned positive for Candida glabrata while blood cultures remained negative, and additional testing was unremarkable. The infectious disease service recommended one month of micafungin and trimethoprim-sulfamethoxazole. Discussion: Common isolates in the literature of Candida are C. albicans and C. glabrata , both considered colonizers of the oral cavity, detected

in up to 55% of healthy individuals [2]. However, as we face increasing use of broad-spectrum antimycotic therapies, immunosuppressive drugs, or comorbidities such as diabetes mellitus, we must become more vigilant in our diagnosing of these once nonpathogenic saprophytes. Indeed, any pleural infection can be severe, however, little data exists regarding the standard of care for invasive candidiasis and IDSA guidelines per 2016 do not cite a standard of care for candida thoracis. Though patients with immunocompromised status are at higher risk, immunocompetent patients remain susceptible, with mortality rates as high as 70% [1,3]. Targeted therapy based on susceptibility remains the gold standard of treatment, especially in C. glabrata isolates as they are notoriously resistant to fluconazole and voriconazole due to efflux pumps. Literature suggests targeting the β-1,3-D-glucan component of fungal cell walls in addition to swift drainage [4].

Introduction: Fungal empyema, or fungal thoracis, is an exceedingly uncommon diagnosis most often described in immunocompromised or critically ill individuals. Where fungal pathogens isolated from pleural fluid were classically regarded as contaminants, there have been a number of reports over the past several decades documenting fungal species as a causal organism of empyema [1]. Case Presentation: A 39-year-old male presented for evaluation of acute hypoxic respiratory failure and left-sided chest pain. His medical history included esophageal adenocarcinoma s/p radiofrequency ablation, Barrett’s esophagus with high-grade dysplasia, esophageal stricture s/p numerous dilatations, and a history of heroin and tobacco abuse (in remission). Computed tomography (CT) of the chest demonstrated left pleural effusion and atelectasis (Figure 1), and thoracentesis removed 1 liter of pleural fluid. Pathologic analysis of the pleural fluid suggested an exudative effusion but,

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