ws

(Fig. 1B).The patient, a 91-year-old male, had a history of bladder

adenocarcinoma, stage T4N2M0, status postoperation and

white blood cell count, 17,330 cells/mL; and plateletcount, 214,000 cells/mL. Routine urine examination

76.1 mmHg; and HCO3 , 6.1 mmol/L. He was admitted tothe intensive care unit because of metabolic acidosis, acuterespiratory failure, and urosepsis. During hospitalization,he received multiple broad-spectrum antibiotic therapiesfor the urinary tract infection and ventilator-associatedpneumonia. Sixteen days later, chest X-ray imaging

sites of Candida infections are the urinary tract, blood-stream, and bronchopulmonary system.2 Fungal empyemathoracis is rare, but its crude mortality is high(61.9e73%).1e2 Lin et al1 and Ko et al2 report that the most

leural fluid isandida glab-hogenesis ofspreading or1e4 The most

common underlying disease of Candida empyema thoracisis a malignancy.1 Many patients acquire it in intensive care

2

tinal perforation, bronchopulmonary infections, chest sur-gery, and bloodstream infections. Our patients case mayhave resulted from pulmonary Candida infection and CVC-related candidemia.

Adequate drug penetration into the pleural cavity iscrucial for successful antifungal treatment. Only a few

+ MODEL

Available online at www.sciencedirect.com

ScienceDirect

e:

Journal of Microbiology, Immunology and Infection (2014) xx, 1e2

1684-1182/$36 Copyright 2014, Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC. All rights reserved.http://dx.doi.org/10.1016/j.jmii.2013.12.011revealed pyuria and bacteriuria. The arterial blood gasshowed a pH of 7.175; PaCO2, 17.0 mmHg; PaO2,

units. The reported major causes of fungal empyemathoracis include previous abdominal surgery, gastrointes-postradiotherapy. He also had chronic obstructive pulmo-nary disease, coronary artery disease postoperation, and anold stroke. He was admitted to the hospital because offever, dyspnea, and drowsy consciousness. On admission,laboratory data showed a hemoglobin level of 9.6 mg/dL;

common fungal isolates recovered from the pC. albicans, followed by Candida tropicalis, Crata, and Aspergillus species.1e2 The patCandida empyema thoracis is by contiguousnoncontiguous spreading to the pleural space.CORRESPONDENCE

Successful salvage therapyCandida empyema thoraci

Dear Editor,

We read with great interest the article by Lin et al1 in theJournal of Microbiology, Immunology and Infection inwhich they reported that Candida empyema thoracis is aserious complication of invasive candidiasis and has a highmortality. The success rate of fluconazole treatment re-mains uncertain. Candida albicans is the most commonetiology of fungal empyema thoracis. However, the goldenstandard treatment for it is controversial. In this paper, wereport a patient who was diagnosed as having nosocomialCandida empyema thoracis with acute respiratory failure.He initially received multiple thoracocenteses and flucon-azole therapy for 14 days, but fever and pleural effusionpersisted (Fig. 1A). He could not be weaned from theventilator smoothly. For salvage therapy, we changed fromfluconazole to micafungin (100 mg) intravenous (iv) dripevery 24 hours. Thereafter, he was successfully weanedfrom the ventilator. After a 21-day course of micafungintreatment, chest X-ray imaging revealed an improvement

journal homepagPlease cite this article in press as: Lin P-Y, et al., Successful salvage thMicrobiology, Immunology and Infection (2014), http://dx.doi.org/10.ith micafungin for

showed left-sided pleural effusion. Pleural fluid analysisrevealed a lactate dehydrogenase level of 163 U/L (serum,200 U/L) and a white blood count of 14800/mL with 87%neutrophils and 13% mononuclear cells. Cultures of thesputum, pleural fluid, blood, and the tip of the centralvenous catheter (CVC) all showed C. albicans. Therefore,the CVC was removed, and he received fluconazole (800 mgiv drip stat and 600 mg iv drip every 24 hours) for Candidaempyema thoracis and bloodstream infection. Concurrentwith this treatment, he received multiple thoracocentesesfor drainage. The antifungal agent was replaced by mica-fungin because of treatment failure with fluconazole. Aftera 21-day course of antifungal therapy, the patient wasweaned successfully from the ventilator and micafunginwas discontinued.

Invasive candidiasis has increasingly emerged as animportant hospital-acquired infection, especially in criticaland immunocompromised patients.1e4 The most common

www.e- jmii .comerapy with micafungin for Candida empyema thoracis, Journal of1016/j.jmii.2013.12.011

leu

2 Correspondence

+ MODELstudies exist regarding the penetration of antifungal agentsinto the pleural effusion. Matsuda et al5 used high-performance liquid chromatography to measure the mica-fungin and voriconazole concentrations in the plasma and inthe pleural fluid of a patient with fungal empyema thoracis.They found that the penetration ratio of micafungin was57e68% and that of voriconazole was 45e95%. The pleuralsurface is thicker and more acidic in patients with empy-ema. Pleural diffusion of antimicrobial agents is highlyvariable.6 The concentration of micafungin is high and thatthe concentration of micafungin is at a proper therapeuticlevel. It also has a greater ability to penetrate the biofilm ofthe pleural cavity, compared to fluconazole.5 These two

Figure 1. (A) Chest X-ray reveals cardiomegaly and left side peffusion after thoracocentesis and micafungin therapy.advantages may contribute to its successful treatment offungal empyema.5 For treatment-refractory patients withCandida empyema thoracis, salvage therapy with mica-fungin may be an alternative treatment.

Ethics approval

Ethics approval was not required for this study.

Conflicts of interest

The authors have no competing interests to declare.

References

1. Lin KH, Liu YM, Lin PC, Ho CM, Chou CH, Wang JH, et al. Reportof a 63-case series of Candida empyema thoracis: 9-yearexperience of two medical centers in central Taiwan.J Microbiol Immunol Infect 2012, in press.

2. Ko SC, Chen KY, Hsueh PR, Luh KT, Yang PC. Fungal empyemathoracis: an emerging clinical entity. Chest 2000;117:1672e8.

Please cite this article in press as: Lin P-Y, et al., Successful salvage thMicrobiology, Immunology and Infection (2014), http://dx.doi.org/10.3. Bassetti M, Righi E, Costa A, Fasce R, Molinari MP, Rosso R,et al. Epidemiological trends in nosocomial candidemia inintensive care. BMC Infect Dis 2006;6:1e6.

4. Liu WC, Chan MC, Lin TY, Hsu CH, Chiu SK. Candida lipolyticacandidemia as a rare infectious complication of acutepancreatitis: a case report and literature review. J MicrobiolImmunol Infect 2013;46:393e6.

5. Matsuda T, Koreeda Y, Mataki H, Taira T, Noma S,Higashimoto I. A case of Aspergillus empyema successfullytreated with combination therapy of voriconazole and mica-fungin: excellent penetration of voriconazole and micafungininto pleural fluid. Intern Med 2010;49:1163e9.

6. Teixeria LR, Sasse SA, Villarino MA, Nguyan T, Muligan ME,Light RW. Antibiotic levels in empyemic pleural fluid. Chest

ral effusion. (B) Chest X-ray shows markedly decreased pleural2000;117:1734e9.

Pai-Yang LinDivision of Chest Medicine, Department of InternalMedicine, Wan Fang Medical Center, Taipei Medical

University, Taipei, Taiwan

Shio-Shin JeanTsong-Yih OuFu-Lun Chen

Wen-Sen Lee*Division of Infectious Diseases, Department of Internal

Medicine, Wan Fang Medical Center, Taipei MedicalUniversity, Taipei, Taiwan

*Corresponding author. Division of Infectious Diseases,Department of Internal Medicine, Wan Fang Medical Center,

Taipei Medical University, Number 111, Section 3,Hsing-Lung Road, Taipei 116, Taiwan.

E-mail address: 89425@wanfang.gov.tw (W.-S. Lee)

12 December 2013

erapy with micafungin for Candida empyema thoracis, Journal of1016/j.jmii.2013.12.011

Successful salvage therapy with micafungin for Candida empyema thoracisEthics approvalConflicts of interestReferences