Case 1100 - Evaluation of a suspected seizure

Contributed by Matthew T. Chambers, MD, PhD and Bryan A. Stevens, MD


A man in his 30's presents to the emergency department for evaluation of suspected seizure. The patient has a history of anoxic brain injury in the setting of cardiac arrest, followed by several months of inpatient hospitalization. At baseline, the patient is ventilator-dependent and has severe dysautonomia. He was recently transferred to a local skilled nursing facility. A caregiver noticed a facial tic, was concerned for potential seizure activity, and had the patient brought to the ED for evaluation. Upon evaluation in the ED labs were drawn, revealing an elevated lactate of 1.9 mmol/L in the setting of an elevated WBC count of 12.5x10^6 cells/mL. Other significant labs included a mild hyponatremia of 134 mmol/L, and mild anemia of 12.2 g/dL. The patient was hospitalized in a critical care unit for management and further evaluation.

Lab Value Reference Range
Na 134 (L) 136 - 146 mmol/L
K 4.4 3.5 - 5.0 mmol/L
Cl 98 98 - 107 mmol/L
BUN 14 8 - 26 mg/dL
Creatinine 0.3 (L) 0.5 - 1.4 mg/dL
Glucose 102 (H) 70 - 99 mg/dL
Ca 9.4 8.4 - 10.2 mg/dL
Lactate 1.9 (H) 0.5 - 1.6 mmol/L

Lab Value Reference Range
WBC 12.5 (H) 3.8 - 10.6 X10E+09/L
RBC 4.18 4.13 - 5.57 X10E+12/L
Hgb 12.2 (L) 12.9 - 16.9 g/dL
HCT 36.9 (L) 38.0 - 48.8 %
MCV 88.3 82.6 - 97.4 fL
MCH 29.2 27.8 - 33.4 pg

Several days after admission, a repeat radiograph of the chest demonstrated a new left lower lung opacity/consolidation, concerning for pneumonia.

Blood cultures and sputum cultures were drawn. During this time, the patient experienced episodes of fever to 38.9 C, tachycardia, and hypotension to 90/60). Lab results showed a sputum culture positive for growth of Klebsiella, E. coli, and Enterobacter; a blood culture was positive for growth of an unknown yeast. Further identification of the yeast was determined to be Candida auris.

In the setting of a prolonged ICU stay and candidemia, which Candida species are commonly associated with invasive Candidiasis? What methods are available to identify the Candida species, and what are their limitations? Standard empiric therapy for invasive candidiasis is initial treatment with an IV echinocandin followed by stepdown to an oral azole following species identification. Is oral therapy with an azole appropriate in this case?


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