LETTERS TO THE EDITOR Congenital Candidiasis Caused by Different Candida Species in a Dizygotic Pregnancy To the Editors: C andida infections are common in late- onset septicemia in preterm popula- tions cared for in neonatal intensive care units (NICUs). The mean chronologic age of onset of Candida infection is 30 days and the lower the birth weight (BW), the greater the risk of sepsis. 1 Rarely, the infection may become ap- parent within 48 hours of birth, in which case the infection occurred most likely in utero. 1 Congenital candidiasis in full- term infants is manifested with skin le- sions (vesicles, pustules or a macular rash). 2 Congenital Candida pneumonia with sepsis has been reported in a full- term infant with no identified maternal risk factors. 3 In preterm infants, the dis- ease exhibits a more fulminant course and is manifested, apart from the cuta- neous lesions, as invasive pulmonary disease. We report the case of twin pre- term infants of extremely low BW, both manifesting congenital Candida infec- tion but with different Candida species. The mother was 37-year-old and was admitted to the fetomaternal unit at the university hospital of Ioannina be- cause of intrauterine growth restriction diagnosed on ultrasonography at 25 1 weeks of gestational age (GA). She had had 10 trials for in vitro fertilization with 2 previous miscarriages at 5 weeks and 8 weeks GA. She was being treated with prednisolone, acetylsalicylic acid and low-dose heparin for suspected im- munologically mediated miscarriages and heterozygous Leiden factor muta- tion. 4 Ultrasonography at 16 weeks re- vealed 2 normal fetuses. Amniocentesis was performed, which showed no chro- mosomal abnormalities. Repeat ultra- sonography at 25 1 weeks GA showed intrauterine growth retardation for both fetuses (corresponding to 20 and 22 weeks GA) and reverse end diastolic flow in the umbilical artery. At this time, the mother developed clinical signs of preeclampsia. At 26 4 weeks, she went into labor spontaneously and delivered 2 babies. Twin A, a baby girl weighting 425 g, was intubated at birth and trans- ferred to the NICU, where she was supported with mechanical ventilation. Chest roentgenogram showed respira- tory distress syndrome and she received 3 doses of surfactant. Twin B, a baby boy weighting 535 g BW, had the clin- ical picture of infection (instability, ap- nea and poor perfusion). Twin B died at 22 hours of life and Candida albicans was isolated from the blood culture. The infant at that point had disseminated intravas- cular coagulation with platelet count 52,000/mm 3 , prolonged partial throm- boplastin time 47 seconds (control, 26 seconds), international normalized ratio 1.49 (normal values, 0.8 –1.2) and in- creased D-dimers (500 –1000; normal values, 250). The initial antibiotic treatment of both infants was ceftazi- dime, penicillin and netilmicin. Twin A died at 72 hours of life, although the antibiotic was changed to amphotericin B as soon as the result from the blood culture of twin B was received. Blood culture from twin A revealed Candida parapsilosis. Fatal fetal Candida sepsis can occur in the absence of identifiable risk factors such as prolonged rupture of the mem- branes, an intrauterine device or cervical cerclage. 5,6 The mother can transfer the infection to the fetus either through the ascending route or through the placental circulation. Earlier studies failed to demonstrate a significant association be- tween preterm birth and Candida infec- tion in the vagina during pregnancy. 7 Other studies that have connected the presence of vaginal Candida infection with preterm birth recommend treatment of genital infections caused by Candida in pregnant women to decrease the risk of preterm birth. 7,8 Chaim et al 9 ob- served a 28% incidence of positive Can- dida culture in women with preterm premature rupture of the membranes compared with 6.5% in women with intact membranes. There have been reports of twin pregnancies in which both fetuses were affected by C. albicans. 10,11 Corticoste- roid therapy is known to favor vaginal colonization with yeast, but there is no significant difference in the occurrence of neonatal complications after antenatal corticosteroid treatment of prevention of hyaline membrane disease. 12 In our cases, the mother received long-term steroid treatment, which could have pro- moted Candida overgrowth. Melville et al 13 presented 7 patients with Candida sepsis, all of whom were 26 weeks GA and less than 750 g BW. Four of the mothers of these infants had received steroids antenatally. Two of the infants in that report presented with C. albicans and Candida species in the gastric aspi- rate and both died. In cases of in vitro fertilization, Candida glabrata is thought to be intro- duced into the uterus by the cannula at the time of embryo transfer. 14 It is rec- ommended that investigation of the mi- crobial flora at the cervix should be undertaken and treatment be instituted before the embryo transfer. This mother had the in vitro fertilization procedure in a private clinic and no record exists for cervical culture before fetus implanta- tion. A diagnosis of Candida chorioam- nionitis after serial or therapeutic am- niocenteses has been reported. 15 This mother had one diagnostic amniocente- sis at 16 weeks GA, which could also have been the source of infection. Nikolaos Krallis, MD Neonatal Intensive Care Unit Child Health Department University Hospital of Ioannina Ioannina, Greece Spyridon Tzioras, MD Fetomaternal Unit Department of Obstetrics and Gynaecology University Hospital of Ioannina Ioannina, Greece Vasileios Giapros, MD Neonatal Intensive Care Unit Child Health Department University Hospital of Ioannina Ioannina, Greece Stamatina Leveidiotou, MD Department of Microbiology University Hospital of Ioannina Ioannina, Greece Minas Paschopoulos, MD Fetomaternal Unit Department of Obstetrics and Gynaecology University Hospital of Ioannina Ioannina, Greece Dimitrios Stefanou, MD Department of Pathology University Hospital of Ioannina Ioannina, Greece The Pediatric Infectious Disease Journal • Volume 25, Number 10, October 2006 958