Percutaneous diagnosis and treatment of biliary candidiasis

Biliary co-infection by multidrug-resistant Candida glabrata and Candida albicans in a case of pancreatic cancer with cholangitis: A case report and review of literature

Herein, we report a case of pancreatic cancer with acute cholangitis secondary to biliary obstruction. Empirical antibiotic therapy did not change the clinical presentation. Blood cultures were sterile; however, bile culture was positive for yeasts. Our laboratory analysis revealed a biliary coinfection by multidrug-resistant C. glabrata and C. albicans. The patient was successfully treated with endoscopic biliary drainage.

Obstructing fungal cholangitis complicating metal biliary stent placement in pancreatic cancer

Biliary obstructions can lead to infections of the biliary system, particularly in patients with occluded biliary stents. Fungal organisms are frequently found in biliary aspirates of patients who have been on antibiotics and have stents; however, fungal masses, or “balls”, that fully obstruct the biliary system are uncommon and exceedingly difficult to eradicate. We present 4 cases of obstructing fungal cholangitis in patients who had metal biliary stents placed for pancreatic malignancies, and subsequently required aggressive antifungal administration along with endoscopic and radiologic interventions. This report also reviews approaches previously undertaken to manage severe obstructing fungal cholangitis.

Prevalence, associations, and trends of biliary-tract candidiasis: a prospective observational study

BACKGROUND

Biliary obstruction and cholangitis are common problems in gastroenterology. Infections of the biliary tract with Candida and other fungal species have increasingly been seen in the last few years.

OBJECTIVE

To investigate the prevalence, associations, and trends of biliary-tract candidiasis.

DESIGN

A prospective, observational, diagnostic study.

SETTING

University Hospital, Muenster, Germany.

PATIENTS

Consecutive patients undergoing ERCP for various indications.

RESULTS

In 54 of 123 patients, we found Candida species in bile samples (44%). In only 7 patients, candidiasis was suspected on endoscopy before mycologic proof. Only 4 of these 7 patients were correctly diagnosed with biliary candidiasis by simple morphologic aspects. The fungus was mainly differentiated as Candida albicans or Candida glabrata and rarely as Candida parapsilosis, Candida tropicalis, or other subspecies. Immunosuppression for various reasons was significantly associated with bile-duct candidiasis (P < .02). No significant association was found between positive fungal cultures and prior endoscopic sphincterotomy (P = .0824) or prior ERCP (P = .1152). Biliary candidiasis was neither associated with positive fungal cultures of buccal smears (P = .0722) nor with positive findings in stool samples (P = .0860).

LIMITATIONS

Highly selected patient population. Buccal smears and stool samples were not obtained from all patients. Contamination artifacts cannot totally be excluded with the ERCP procedure.

CONCLUSIONS

Candida species very frequently can be detected in the bile. Positive fungal cultures of bile samples are not just contamination artifacts. This has to be taken into account when designing an anti-infectious treatment for recurrent cholangitis or even more cholangiosepsis. Especially in immunosuppressed patients or recipients of long-term antibiotic therapy, physicians should screen for biliary-tract candidiasis during endoscopic examination.