Diagnostic Challenges in Non-albicans Candida Bloodstream Infection in an Immunocompromised Patient: A Case Report
Main Article Content
Keywords
bloodstream infection, non-albicans Candida, candidemia, immunocompromised
Abstract
Introduction: Candidemia has increased in recent years, leading to prolonged hospital stay, increased healthcare costs, and high mortality. Patients with underlying conditions such as malignancy and those requiring invasive medical devices are at higher risk of Candida bloodstream infection. Therefore, this study aims to describe a rare case of non-albicans Candida bloodstream infection in an immunocompromised patient, with emphasis on diagnostic challenges and clinical implications of discordant laboratory identification in guiding appropriate management.
Case Description: A 48-year-old female with cervical cancer undergoing chemotherapy and hemodialysis via a right-thigh double-lumen catheter presented to the emergency department with prolonged vaginal bleeding, oliguria, nausea, and significant weight loss. Laboratory findings revealed leukocytosis and renal impairment. She received a combination of ceftazidime, moxifloxacin, and metronidazole in the ICU. The patient had multiple invasive devices, including intravenous catheters, parenteral nutrition, and urinary catheters. Blood culture performed on day 15 of hospitalisation identified Candida lipolytica, which was sensitive to voriconazole, amphotericin B, and flucytosine. Moreover, PCR and phylogenetic sequencing were performed to ensure accurate species identification. Despite the final identification and clinical management efforts, the patient’s clinical condition continued to deteriorate, and she eventually succumbed after three weeks of hospitalisation.
Conclusion: This case highlights a rare non-albicans Candida bloodstream infection in an immunocompromised patient, emphasising the diagnostic challenges associated with accurate species identification. A stepwise diagnostic approach with culture, proteomic, and molecular confirmation, including PCR and phylogenetic analysis, is essential to ensure accurate identification and optimal clinical management.
References
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19. Dhiman N, Hall L, Wohlfiel SL, Buckwalter SP, Wengenack NL. Performance and Cost Analysis of Matrix-Assisted Laser Desorption Ionisation–Time of Flight Mass Spectrometry for Routine Identification of Yeast. J Clin Microbiol. 2011;49(4):1614–6. doi:10.1128/JCM.02381-10
20. Clark AE, Kaleta EJ, Arora A, Wolk DM. Matrix-Assisted Laser Desorption Ionisation–Time of Flight Mass Spectrometry: a Fundamental Shift in the Routine Practice of Clinical Microbiology. Clin Microbiol Rev. 2013;26(3):547–603. doi:10.1128/CMR.00072-12
21. Croxatto A, Prod’hom G, Greub G. Applications of MALDI-TOF mass spectrometry in clinical diagnostic microbiology. FEMS Microbiol Rev. 2012;36(2):380–407. doi:10.1111/j.1574-6976.2011.00298.x
22. Vrenna G, Fox V, Cortazzo V, Raimondi S, Cristiano M, Foglietta G, et al. When Conventional Methods Fail: First Detection of a Candida viswanathii Outbreak in Europe in a Paediatric Hospital Revealed by Whole Genome Sequencing and FT-IR Spectroscopy. MedRXiv [Internet]. 2025 [cited 2026 Jun 30]. Available from: https://doi.org/10.1101/2025.10.25.25337813 doi:10.1101/2025.10.25.25337813
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24. Maldonado N, Cano L, Zuluaga A, Arango Bustamante K, Caceres D, Sánchez Quitian Z, et al. Concordance analysis between different methodologies used for the identification of oral isolates of Candida species. Colomb Med. 2018;49(3):193–200. doi:10.25100/cm.v49i3.3774
25. Ceballos-Garzón A, Cortes G, Morio F, Zamora-Cruz EL, Linares MY, Ariza BE, et al. Comparison between MALDI-TOF MS and MicroScan in the identification of emerging and multidrug-resistant yeasts in a fourth-level hospital in Bogotá, Colombia. BMC Microbiol. 2019;19(1):106. doi:10.1186/s12866-019-1482-y
26. Lam LMT, Dufresne PJ, Longtin J, Sedman J, Ismail AA. Reagent-Free Identification of Clinical Yeasts by Use of Attenuated Total Reflectance Fourier Transform Infrared Spectroscopy. J Clin Microbiol. 2019;57(5). doi:10.1128/JCM.01739-18
27. Vallabhaneni S, Mody RK, Walker T, Chiller T. The Global Burden of Fungal Diseases. Infectious Disease Clinics of North America. 2016;30(1):1–11. doi:10.1016/j.idc.2015.10.004
28. Huang YS, Wang F Der, Chen YC, Huang YT, Hsieh MH, Hii IM. High rates of misidentification of uncommon Candida species causing bloodstream infections using conventional phenotypic methods. Journal of the Formosan Medical Association. 2021;120(5):1179–87. doi:10.1016/j.jfma.2020.11.002
29. Leaw SN, Chang HC, Sun HF, Barton R, Bouchara JP, Chang TC. Identification of medically important yeast species by sequence analysis of the internal transcribed spacer regions. Journal of Clinical Microbiology. 2006;44(3):693–9. doi:10.1128/JCM.44.3.693-699.2006.
30. Simonetti O, Zerbato V, Sincovich S, Cosimi L, Zorat F, Costantino V. Candida lipolytica Bloodstream Infection in an Adult Patient with COVID-19 and Alcohol Use Disorder: A Unique Case and a Systematic Review of the Literature. Antibiotics. 2023;12(4). doi:10.3390/antibiotics12040691
31. Agnelli C, Valerio M, Bouza E, Guinea J, Sukiennik T, Guimarães T, et al. Prognostic factors of Candida spp. bloodstream infection in adults: A nine-year retrospective cohort study across tertiary hospitals in Brazil and Spain. The Lancet Regional Health - Americas. 2022;6. doi:10.1016/j.lana.2021.100117
32. Morrell M, Fraser VJ, Kollef MH. Delaying the empiric treatment of Candida bloodstream infection until positive blood culture results are obtained: A potential risk factor for hospital mortality. Antimicrobial Agents and Chemotherapy. 2005;49(9):3640–5. doi:10.1128/AAC.49.9.3640-3645.2005
33. D’Antonio D, Romano F, Pontieri E, Fioritoni G, Caracciolo C, Bianchini S, et al. Catheter-related candidemia caused by Candida lipolytica in a patient receiving allogeneic bone marrow transplantation. Journal of Clinical Microbiology. 2002;40(4):1381–6. doi:10.1128/JCM.40.4.1381-1386.2002 PubMed PMID: 11923360.
34. Zhao Y, Chan JF Woo, Tsang C Ching, Wang H, Guo D, Pan Y. Antifungal Susceptibility of Yarrowia ( Candida ) lipolytica Isolates Causing Fungemia : a Multicenter, Prospective Surveillance Study. 2015;53(11):3639–45. doi:10.1128/JCM.01985-15
35. Walsh TJ, Salkin IF, Dixon DM, Hurd NJ. Clinical, microbiological, and experimental animal studies of Candida lipolytica. Journal of Clinical Microbiology. 1989;27(5):927–31. doi:10.1128/jcm.27.5.927-931.1989
36. Mazumder SA, Todd WA, Cleveland KO. Fatal Yarrowia lipolytica Intra-abdominal Abscess with Persistent Fungemia in a Liver Transplant Recipient. Infectious Diseases in Clinical Practice. 2015;23(5):273–5. doi:10.1097/IPC.0000000000000251
37. Tsai MH, Hsu JF, Yang LY, Pan Y Bin, Lai MY, Chu SM. Candidemia due to uncommon Candida species in children: new threat and impacts on outcomes. Scientific Reports. 2018;8(1):1–9. doi:10.1038/s41598-018-33662-x.
38. Agarwal S, Thakur K, Kanga A, Singh G, Gupta P. Catheter-related candidemia caused by Candida lipolytica in a child with tubercular meningitis. Indian Journal of Pathology and Microbiology. 2008.298–300.
2. Muñoz P, Giannella M, Fanciulli C, Guinea J, Valerio M, Rojas L, et al. Candida tropicalis fungaemia: Incidence, risk factors and mortality in a general hospital. Clinical Microbiology and Infection. 2011;17(10):1538–45. doi:10.1111/j.1469-0691.2010.03338.x
3. Fu J, Ding Y, Wei B, Wang L, Xu S, Qin P, et al. Epidemiology of Candida albicans and non-C.albicans of neonatal candidemia at a tertiary care hospital in Western China. BMC Infectious Diseases. 2017;17(1):1–6. doi:10.1186/s12879-017-2423-8 PubMed PMID: 28477628.
4. Kalista KF, Chen LK, Wahyuningsih R, Rumende CM. Karakteristik Klinis dan Prevalensi Pasien Kandidiasis Invasif di Rumah Sakit Cipto Mangunkusumo. Jurnal Penyakit Dalam Indonesia. 2017;4(2):56. doi:10.7454/jpdi.v4i2.104
5. Vijayakumar R, Giri S, Kindo AJ. Molecular Species Identification of Candida from Blood Samples of Intensive Care Unit Patients by Polymerase Chain Reaction – Restricted Fragment Length Polymorphism. Journal of Laboratory Physicians. 2012;4(01):001–4. doi:10.4103/0974-2727.98661
6. Antinori S, Milazzo L, Sollima S, Galli M, Corbellino M. Candidemia and invasive candidiasis in adults: A narrative review. European Journal of Internal Medicine. 2016;34:21–8. doi:10.1016/j.ejim.2016.06.029
7. Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2015;62(4):e1–50. doi:10.1093/cid/civ933
8. Chauhan N, Latge JP, Calderone R. Signalling and oxidant adaptation in Candida albicans and Aspergillus fumigatus. Nature Reviews Microbiology. 2006;4(6):435–44. doi:10.1038/nrmicro1426
9. Kordalewska M, Perlin DS. Identification of Drug-Resistant Candida auris. Front Microbiol. 2019;10. doi:10.3389/fmicb.2019.01918
10. Pinto A, Halliday C, Zahra M, van Hal S, Olma T, Maszewska K, et al. Matrix-Assisted Laser Desorption Ionisation-Time of Flight Mass Spectrometry Identification of Yeasts Is Contingent on Robust Reference Spectra. PLoS One. 2011;6(10):e25712. doi:10.1371/journal.pone.0025712
11. Chao QT, Lee TF, Teng SH, Peng LY, Chen PH, Teng LJ, et al. Comparison of the Accuracy of Two Conventional Phenotypic Methods and Two MALDI-TOF MS Systems with That of DNA Sequencing Analysis for Correctly Identifying Clinically Encountered Yeasts. PLoS One. 2014; 9(10):e109376. doi:10.1371/journal.pone.0109376
12. Alkharashi N, Aljohani S, Layqah L, Masuadi E, Baharoon W, Al-Jahdali H, et al. Candida Bloodstream Infection: Changing Pattern of Occurrence and Antifungal Susceptibility over 10 Years in a Tertiary Care Saudi Hospital. Canadian Journal of Infectious Diseases and Medical Microbiology. 2019;2019. doi:10.1155/2019/2015692
13. Clancy CJ, Nguyen MH. Non-culture diagnostics for invasive candidiasis: Promise and unintended consequences. Journal of Fungi. 2018;4(1):1–12. doi:10.3390/jof4010027
14. Zhang W, Song X, Wu H, Zheng R. Epidemiology, species distribution, and predictive factors for mortality of candidemia in adult surgical patients. BMC Infectious Diseases. 2020;20(1):1–11. doi:10.1186/s12879-020-05238-6
15. Taj-Aldeen SJ, Abdulwahab A, Kolecka A, Deshmukh A, Meis JF, Boekhout T. Uncommon opportunistic yeast bloodstream infections from Qatar. Medical Mycology. 2014;52(5):549–53. doi:10.1093/mmycol/myu016
16. Zieniuk B, Fabiszewska A. Yarrowia lipolytica: a beneficial yeast in biotechnology as a rare opportunistic fungal pathogen: a minireview. World Journal of Microbiology and Biotechnology. 2019;35(1). doi:10.1007/s11274-018-2583-8 PubMed PMID: 30578432.
17. Moreira-Oliveira MS, Mikami Y, Miyaji M, Imai T, Schreiber AZ, Moretti ML. Diagnosis of candidemia by polymerase chain reaction and blood culture: Prospective study in a high-risk population and identification of variables associated with development of candidemia. European Journal of Clinical Microbiology and Infectious Diseases. 2005;24(11):721–6. doi:10.1007/s10096-005-0041-7
18. Won EJ, Shin JH, Lee K, Kim MN, Lee HS, Park YJ, et al. Accuracy of Species-Level Identification of Yeast Isolates from Blood Cultures from 10 University Hospitals in South Korea by Use of the Matrix-Assisted Laser Desorption Ionisation–Time of Flight Mass Spectrometry-Based Vitek MS System. J Clin Microbiol. 2013;51(9):3063–5. doi:10.1128/JCM.00945-13
19. Dhiman N, Hall L, Wohlfiel SL, Buckwalter SP, Wengenack NL. Performance and Cost Analysis of Matrix-Assisted Laser Desorption Ionisation–Time of Flight Mass Spectrometry for Routine Identification of Yeast. J Clin Microbiol. 2011;49(4):1614–6. doi:10.1128/JCM.02381-10
20. Clark AE, Kaleta EJ, Arora A, Wolk DM. Matrix-Assisted Laser Desorption Ionisation–Time of Flight Mass Spectrometry: a Fundamental Shift in the Routine Practice of Clinical Microbiology. Clin Microbiol Rev. 2013;26(3):547–603. doi:10.1128/CMR.00072-12
21. Croxatto A, Prod’hom G, Greub G. Applications of MALDI-TOF mass spectrometry in clinical diagnostic microbiology. FEMS Microbiol Rev. 2012;36(2):380–407. doi:10.1111/j.1574-6976.2011.00298.x
22. Vrenna G, Fox V, Cortazzo V, Raimondi S, Cristiano M, Foglietta G, et al. When Conventional Methods Fail: First Detection of a Candida viswanathii Outbreak in Europe in a Paediatric Hospital Revealed by Whole Genome Sequencing and FT-IR Spectroscopy. MedRXiv [Internet]. 2025 [cited 2026 Jun 30]. Available from: https://doi.org/10.1101/2025.10.25.25337813 doi:10.1101/2025.10.25.25337813
23. Lohmann C, Sabou M, Moussaoui W, Prévost G, Delarbre JM, Candolfi E, et al. Comparison between the Biflex III-Biotyper and the Axima-SARAMIS Systems for Yeast Identification by Matrix-Assisted Laser Desorption Ionisation–Time of Flight Mass Spectrometry. J Clin Microbiol. 2013;51(4):1231–6. doi:10.1128/JCM.03268-12
24. Maldonado N, Cano L, Zuluaga A, Arango Bustamante K, Caceres D, Sánchez Quitian Z, et al. Concordance analysis between different methodologies used for the identification of oral isolates of Candida species. Colomb Med. 2018;49(3):193–200. doi:10.25100/cm.v49i3.3774
25. Ceballos-Garzón A, Cortes G, Morio F, Zamora-Cruz EL, Linares MY, Ariza BE, et al. Comparison between MALDI-TOF MS and MicroScan in the identification of emerging and multidrug-resistant yeasts in a fourth-level hospital in Bogotá, Colombia. BMC Microbiol. 2019;19(1):106. doi:10.1186/s12866-019-1482-y
26. Lam LMT, Dufresne PJ, Longtin J, Sedman J, Ismail AA. Reagent-Free Identification of Clinical Yeasts by Use of Attenuated Total Reflectance Fourier Transform Infrared Spectroscopy. J Clin Microbiol. 2019;57(5). doi:10.1128/JCM.01739-18
27. Vallabhaneni S, Mody RK, Walker T, Chiller T. The Global Burden of Fungal Diseases. Infectious Disease Clinics of North America. 2016;30(1):1–11. doi:10.1016/j.idc.2015.10.004
28. Huang YS, Wang F Der, Chen YC, Huang YT, Hsieh MH, Hii IM. High rates of misidentification of uncommon Candida species causing bloodstream infections using conventional phenotypic methods. Journal of the Formosan Medical Association. 2021;120(5):1179–87. doi:10.1016/j.jfma.2020.11.002
29. Leaw SN, Chang HC, Sun HF, Barton R, Bouchara JP, Chang TC. Identification of medically important yeast species by sequence analysis of the internal transcribed spacer regions. Journal of Clinical Microbiology. 2006;44(3):693–9. doi:10.1128/JCM.44.3.693-699.2006.
30. Simonetti O, Zerbato V, Sincovich S, Cosimi L, Zorat F, Costantino V. Candida lipolytica Bloodstream Infection in an Adult Patient with COVID-19 and Alcohol Use Disorder: A Unique Case and a Systematic Review of the Literature. Antibiotics. 2023;12(4). doi:10.3390/antibiotics12040691
31. Agnelli C, Valerio M, Bouza E, Guinea J, Sukiennik T, Guimarães T, et al. Prognostic factors of Candida spp. bloodstream infection in adults: A nine-year retrospective cohort study across tertiary hospitals in Brazil and Spain. The Lancet Regional Health - Americas. 2022;6. doi:10.1016/j.lana.2021.100117
32. Morrell M, Fraser VJ, Kollef MH. Delaying the empiric treatment of Candida bloodstream infection until positive blood culture results are obtained: A potential risk factor for hospital mortality. Antimicrobial Agents and Chemotherapy. 2005;49(9):3640–5. doi:10.1128/AAC.49.9.3640-3645.2005
33. D’Antonio D, Romano F, Pontieri E, Fioritoni G, Caracciolo C, Bianchini S, et al. Catheter-related candidemia caused by Candida lipolytica in a patient receiving allogeneic bone marrow transplantation. Journal of Clinical Microbiology. 2002;40(4):1381–6. doi:10.1128/JCM.40.4.1381-1386.2002 PubMed PMID: 11923360.
34. Zhao Y, Chan JF Woo, Tsang C Ching, Wang H, Guo D, Pan Y. Antifungal Susceptibility of Yarrowia ( Candida ) lipolytica Isolates Causing Fungemia : a Multicenter, Prospective Surveillance Study. 2015;53(11):3639–45. doi:10.1128/JCM.01985-15
35. Walsh TJ, Salkin IF, Dixon DM, Hurd NJ. Clinical, microbiological, and experimental animal studies of Candida lipolytica. Journal of Clinical Microbiology. 1989;27(5):927–31. doi:10.1128/jcm.27.5.927-931.1989
36. Mazumder SA, Todd WA, Cleveland KO. Fatal Yarrowia lipolytica Intra-abdominal Abscess with Persistent Fungemia in a Liver Transplant Recipient. Infectious Diseases in Clinical Practice. 2015;23(5):273–5. doi:10.1097/IPC.0000000000000251
37. Tsai MH, Hsu JF, Yang LY, Pan Y Bin, Lai MY, Chu SM. Candidemia due to uncommon Candida species in children: new threat and impacts on outcomes. Scientific Reports. 2018;8(1):1–9. doi:10.1038/s41598-018-33662-x.
38. Agarwal S, Thakur K, Kanga A, Singh G, Gupta P. Catheter-related candidemia caused by Candida lipolytica in a child with tubercular meningitis. Indian Journal of Pathology and Microbiology. 2008.298–300.