A 3-year and 6-month-old girl presented in December 2019, with fever, cough, rhinorrhea, and watery stools (a few times) for four days. Two weeks before that, she had a brief hospital stay for acute viral gastroenteritis. She was healthy and had been immunized appropriately for her age, including with BCG. The parents were nonconsanguineous and healthy. She had a high temperature (40 C) and was tachypneic, with rales predominantly on the right lung field. In addition, she had moderate dehydration on admission. After initial stabilization, oral clarithromycin and intravenous co-amoxiclav were started empirically with a presumptive diagnosis of community-acquired pneumonia.
Laboratory evaluation indicated neutropenia and thrombocytopenia (white blood cells (WBCs) = 2.78 x 103/mm3, neutrophils = 0.83 x 103/mm3, and platelets = 76 x 103/mm3). The erythrocyte sedimentation rate and C-reactive protein (CRP) were 56 mm/1st h and 7.4 mg/dL. Liver enzyme levels were elevated (aspartate transaminase = 472 U/L; alanine transaminase = 194 U/L). Renal function test results were within the normal range. Antidengue IgM and IgG were negative. Chest radiography revealed peribronchial thickening, mainly in the right upper and middle zones. Polymerase chain reaction (PCR) of the nasopharyngeal aspirate was positive for adenovirus and negative for influenza and parainfluenza viruses.
Clinical improvement remained poor after 48 h of treatment. Tachypnea fluctuated between 48 and 60 breaths/min. The lowest oxygen saturation was 91%. Blood gas analysis revealed normal levels of carbon dioxide. Repeat investigations on day 8 of illness revealed reduced platelets (49 x 103/mm3) and neutrophils (0.65 x 103/mm3) and increased CRP levels (43 mg/dL). Repeat chest radiography revealed worsening lung condition, with interstitial infiltrates in both lung fields. No effusion was detected by ultrasound of the chest. The antibiotics were changed to intravenous cefotaxime and amikacin.
The blood culture (sampled on day 7 of illness) showed Candida infection. Two sputa (induced) cultures tested negative for bacteria and fungi. Cerebrospinal fluid (CSF) analysis revealed no cells and a protein concentration of 24.7 mg/dL. The CSF fungal culture was negative. Candida species were not isolated in urine and stool cultures. Mycobacterium tuberculosis was not detected in the induced sputum or gastric aspirate using the Xpert MTB/RIF assay. Echocardiography and eye assessments were normal. Abdominal ultrasound was normal.
Fluconazole was administered intravenously; however, blood cultures on illness days 9 and 11 remained positive for Candida. Fungal identification, which was performed using manual biochemical methods, revealed the presence of Candida famata. Molecular tests or gene sequencing for identification were not performed because of nonavailability of resources. With the sensitivity pattern, intravenous fluconazole was continued for an additional ten days after the first negative culture on day 13 of illness. Upon clinical recovery, complete blood count returned to normal (WBCs = 14.75 x 103/mm3, neutrophils = 5.16 x 103/mm3, and platelets = 896 x 103/mm3). The levels of liver enzymes had normalized, and chest radiography on day 18 indicated recovery. The subsequent immunological workup revealed parameters within the normal range (immunoglobulin levels, lymphocyte subsets, and neutrophil function tests). The serum tested negative for HIV antigen and antibody. The patient remained well, without signs of relapse during the subsequent follow-up.