A 7-month-old girl underwent resection of hepatoblastoma after pre-treatment with chemotherapy. She was receiving total parenteral nutrition including lipids through her broviac catheter. On post-operative day 6, she developed low grade fever but was otherwise clinically well. A peripheral blood smear on the same day revealed budding yeasts both within and outside the phagocytic cells (Fig. 1). There was no evidence of deep seeded fungal infection in the abdomen by CT scan. Echocardiogram and retinal examination were negative for involvement with any fungus. She was empirically started on a combination of liposomal amphotericin-B and fluconazole after blood cultures. Her broviac catheter was removed and she was taken off lipid infusions. Her blood culture grew multiple colonies of Candida parapsilosis, which became negative after 2 days of antifungal therapy. Antifungal agents were continued for a period of 2 weeks and the patient remained clinically stable.

Fig.1. Multiple yeast cells seen in a cluster of damaged monocytes.

Predisposing factors for systemic candidiasis include neutropenia, multiple antibiotic treatment, indwelling catheters, and intra-abdominal surgery. Candida parapsilosis has emerged as an important cause of fungemia in oncology patients especially those with indwelling catheters. This case illustrates that a careful examination of the peripheral blood smear can sometimes hasten the diagnosis of fungemia, and early start of antifungal therapy.

Sameer Bakshi,
Esteban Abella,
Divison of Hematology Oncology,
Department of Pediatrics,
Children’s Hospital of Michigan and
Barbara Ann Karmanos Cancer Institute,
Wayne State University and School of Medicine,
Detroit, MI 48201, USA.
E-mail: [email protected]