A 55-year-old man with a 10-year history of DM was admitted to our hospital with a 2 months history of dyspnea and cough. The patient was alert and afebrile and complained of chronic nonproductive cough. The patient had no history of immunosuppressive treatment or disease except the history of DM. The patient denied alcohol abuse and smoking. His vital sign was stable. Physical examination was not notable. Cell blood count (CBC) showed hemoglobin (Hgb) 9.9g/dl, white blood cell count (WBC) 6500, with polymorphonuclear dominant (56%). The level of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were 50mg/dl and 105 mm/hour respectively. HIV test was negative. In chest X-ray, nodular pattern was seen. This pattern also was showed in thorax computed tomography (CT) scan [Figure 1].
Considering the course of the disease, clinical manifestations and stable vital signs, the antibiotic was not started.
3 sets of blood cultures and echocardiogram were negative for endocarditis. Examination of the sputum specimen showed C.albicans. As the patient complained of a chronic cough and according to pulmonary lesions, bronchoscopy and bronchoalveolar lavage (BAL) was performed. The specimens evaluated for bacteria, nocardia, actinomyces, fungi and mycobacterium tuberculosis (TB) smear and culture, polymerase chain reaction for TB and also cytology for malignancies. The results were all negative except the culture of BAL fluid which revealed C. albicans. The serum and BAL fluid galactomannan were negative.
Hence, CT-guided percutaneous biopsy of the lesion of the lung was performed. The result showed yeast and pseudohyphae that was compatible with the diagnosis of Candida. The tissue culture yielded C. albicans as well. Furthermore, microscopic studies for other microorganism such as acid-fast staining were negative. On special sectioning, no evidence of granuloma or malignancy was reported. Considering diagnosis, antifungal regimen (intravenous fluconazole) was started. Parenteral antifungal therapy continued for 2 weeks and then followed with oral fluconazole. Control chest CT scan was done 5 weeks later, which showed significant regression of pulmonary lesions [Figure 2]. At the completion of treatment, the level of CRP and ESR decrease to 6 mg/dl and 17mm/hr, respectively.