International Research Journal of Medical Sciences __________________________________________________ Vol. 1(1), 18-19, February (2013) Int. Res. J. Medical Sci. International Science Congress Association 18 Mini Review Paper Pneumonia caused by Candida kefyr in a Pediatric patient with Acute Lymphoblastic Leukaemia: Case Report Dinkar A. 1 , Bhattacharyya S. 1 , Kumar D. 1 , Kumar A. 2 , Gupta P. 1 , Banerjee G. 1 and Singh M. 1 1 Departments of Microbiology, King George’s Medical University (KGMU), Lucknow-226003, UP, INDIA 2 Departments of Pediatrics, King George’s Medical University (KGMU), Lucknow-226003, UP, INDIA Available online at: www.isca.in Received 10 th January 2013, revised 21 st January 2013, accepted 5 th February 2013 Abstract Acute lymphoblastic leukaemia (ALL)is one of the commonest malignancies in children. The disease per se and immunosuppressant cytotoxic drugs administered, together make the patients of ALL very prone to secondary infections. Yeasts recovered from pulmonary tissue are mostly treated as colonisers and left unreported, though they can also be rarely responsible for pneumonia, especially in settings of haematological malignancies. Here we report a case of lung infection due to Candida kefyr in a patient with ALL. Keywords: ALL, Candida kefyr, immunocompromised. Introduction Acute leukaemia, a tumour of the haematological progenitor cells of the Bone marrow, is the commonest paediatric malignancy 1 . Of this, Acute Lymphoblastic Leukaemia (ALL) comprises about 75% 1 . The disease commonly presents with neutropenia, which is a risk factor for secondary infections in this group of patients 2 . An absolute neutrophil count of <500/μl has been associated with significant risk of infection 2 . Infect, a patient with febrile neutropenia has a 60% likelihood of being infected 3 . Most of these are bloodstream infections (BSI), although other organs may also be affected 3 . Pulmonary infiltrates develop in about 60-80% such patients, according to scientific literature 4 . Such infiltrates can be due to infection, haemorrhage or leukemic involvement of lung parenchyma 5 . In a study, about 12% of all episodes of infectious pneumonia in ALL are caused by fungi, most commonly by Aspergillus spp. 6 . Candida spp. is also a known cause of pneumonia in these patients, although the incidence has decreased due to prophylactic antifungal therapy 7 . Case Report A 13 year-old male patient presented in the Paediatric outpatient Department of the Medical University with respiratory distress and hepatosplenomegaly. The patient was admitted and baseline haematological investigations were performed. Based on bone marrow analysis, a diagnosis of B cell ALL was achieved. The patient was suffering from cough and breathlessness since 3 months, and also had 2 episodes of haemoptysis. A chest roentgenogram (postero-anterior view) was carried out, which revealed cavitatory lesions in lingular lobe of left lung with patchy fibrosis, along with nodular infiltrates. The total leucocyte count of the patient was 8000/μl and absolute Neutrophil count was 5200/ μl. The patient was put on Tetracycline, Tramadol, Fluconazole, Vincristine, Methotrexate and L-Asparaginase. Sputum sample was collected from the patient and sent to the Department of Microbiology for fungal culture. A 10% KOH smear showed multiple budding yeasts as well as pus cells, with a Quality (Q) score of +3(plus three). Gram stain also showed similar findings. The sample was inoculated in 2 Saboraud’s Dextrose agar (SDA) slants and incubated at 37 0 C and 25 0 C separately. After 48 hours of incubation, opaque, smooth white colonies grew on both tubes. A Lactophenol Cotton blue (LCB) mount of the colonies showed budding yeast cells. A loopful of the growth was streaked onto Corn meal agar by slit inoculation (Dalmau technique) and incubated at 25 0 C for 48 hours. Germ tube test and Sugar fermentation and assimilation tests were also performed. The isolate was Germ tube negative and showed elongated budding yeasts and pseudohyphae arranged in irregular parallel bundles (logs in stream appearance) on high power (40X) microscopic examination of the streaked Corn meal agar plate. Glucose, lactose and sucrose were fermented but not maltose. Lactose, glucose and sucrose were assimilated but not maltose. Based on these phenotypic characteristics, the isolate was identified as Candida kefyr 8 . Antifungal susceptibility test was done by the disc diffusion technique on Mueller-Hinton agar with 2% glucose and 0.5 μg/ml of Methylene blue, as per CLSI protocol 9 . The yeast isolate was susceptible to fluconazole and voriconazole. The sample was sent on 2 more occasions, which yielded the same results. There was no bacterial growth in the sputum samples. Blood culture on biphasic media was sterile after 21 days of incubation. The patient’s breathlessness improved on fluconazole therapy and there were no further bouts of haemoptysis.