Candida Albicans Purulent Pericarditis Complicated by Cardiac Tamponade in a Critically Ill Burn Patient: A Case Report

Abstract

Candida pericarditis is a rare, life-threatening complication of invasive candidiasis, associated with high mortality. We report this case of a young woman with 60% body surface area burn, multidrug-resistant polymicrobial sepsis, and multiorgan failure who developed Candida albicans pericarditis complicated by cardiac tamponade. Despite urgent pericardiocentesis and escalation of antifungal therapy, she ultimately progressed to refractory shock and multiorgan failure.

This case illustrates the diagnostic challenge and therapeutic limitations of fungal pericarditis in critically ill host, and underscores the importance of maintaining a high index of suspicion in burn patients with multisite Candida colonization and prolonged antibiotic exposure.

1. Introduction

Candida pericarditis is an exceedingly rare but life-threatening complication of invasive candidiasis, accounting for only 1% of purulent pericarditis cases and fewer than 50 documented cases since its first description in 1967.1,2 It occurs predominantly in immunocompromised patients with prolonged antibiotic exposure, prior cardiothoracic surgery, or established multi-site fungal colonisation, with burn patients representing a uniquely high-risk group in whom only two prior cases have been reported.1 Clinical presentation is non-specific and frequently delayed, blood cultures are often negative, and cardiac tamponade may be the index manifestation, necessitating a high index of suspicion, early diagnostic pericardiocentesis with fungal cultures, and prompt combined antifungal and surgical drainage therapy.1,7 We report a case of Candida albicans purulent pericarditis with cardiac tamponade in a critically ill burn patient with multidrug-resistant polymicrobial sepsis.

2. History of presentation

A 31-year-old woman was transferred to a tertiary centre with 60% TBSA flame burns and septic shock after 2 months at a peripheral hospital. On arrival she was intubated, febrile, tachycardic, and profoundly hypotensive requiring high-dose vasopressor support. Despite resuscitation and antibiotic optimisation, she developed progressive acute kidney injury necessitating haemodialysis and remained haemodynamically unstable. An early echocardiogram showed a small pericardial effusion. She subsequently deteriorated with worsening haemodynamic instability, and repeat echocardiography demonstrated a large circumferential pericardial effusion with right ventricular diastolic collapse, dilated non-collapsible inferior vena cava, and respiratory variation in tricuspid inflow, consistent with cardiac tamponade (Fig. 1). Urgent pericardiocentesis drained 456 mL of purulent fluid, with a pigtail catheter left in situ (Fig. 2).

Fig. 1.

Transthoracic echocardiographic findings demonstrating cardiac tamponade secondary to Candida albicans purulent pericarditis in different views. LV: Left ventricle, RV: Right ventricle, RA: Right atrium, LA: Left atrium, IVC: Inferior vena cava, AO: Aorta,: Pericardial effusion

Fig. 2.

Pericardial Fluid Characteristics during Fungal Tamponade. Gross Appearance: Large-volume pericardial drainage exhibiting a distinct salmon-colored, opaque, and purulent appearance.

3. Past medical history

She had a background of asthma on as-needed inhalers and depression managed with mirtazapine.

4. Differential diagnosis

The differential included bacterial pericarditis from the documented MDR organisms, Candida pericarditis given her multisite fungal colonisation and antibiotic exposure, uraemic pericarditis in the setting of acute kidney injury, haemopericardium from coagulopathy, pulmonary embolism, and distributive shock from ongoing polymicrobial sepsis.

5. Investigations

Investigations revealed anaemia, thrombocytopenia, leukocytosis, progressive coagulopathy evolving to disseminated intravascular coagulation, elevated inflammatory markers, lactic acidosis, and acute kidney injury. Wound and respiratory cultures grew MDR Acinetobacter baumannii, carbapenem-resistant Klebsiella pneumoniae, and MDR Pseudomonas aeruginosa. Blood cultures were negative for Candida. Serial pericardial fluid cultures repeatedly grew Candida albicans, with a markedly elevated nucleated cell co unt, very high lactate dehydrogenase, and near-zero glucose. CT imaging excluded pulmonary embolism and intraabdominal collections.

6. Management

Management included urgent pericardiocentesis with pigtail catheter drainage, escalation of antifungal therapy to liposomal amphotericin B following echinocandin use, tailored broad-spectrum antibacterial therapy, high-dose vasopressor support, continuous haemodialysis, repeated blood product transfusions, and staged burn wound debridements. Surgical pericardiectomy was precluded by refractory coagulopathy and multiorgan failure. Despite maximal support, she progressed to refractory shock, severe disseminated intravascular coagulation, and multiorgan failure. A shared decision for comfort focused care was reached, and she died with progressive haemodynamic collapse.

7. Discussion

The present case of a young patient with burns, critical illness, and polymicrobial sepsis, a constellation that created compounding susceptibility to fungal infection. While Candida pericarditis is an uncommon diagnosis, this case is further distinguished by the coexistence of multidrug-resistant sepsis, renal replacement therapy, and recurrent coagulopathy, all of which constrained therapeutic options and contributed to a fatal outcome.

Candida pericarditis remains rare, with few cases documented in the literature since its first description in 1967 and reported to represent only 1% of purulent pericarditis [1,2]. It has been reported in patients who are immunocompromised, on prolonged antibiotic therapy, or who have undergone pericardiotomy [1]. More recently, cases have been described in the context of esophageal surgery, total parenteral nutrition, malignant fistulae, and intensive care patients with multiple organ dysfunction, reflecting the broadening spectrum of predisposing conditions [3–6]. Our patient with her extensive burns giving a state of profound immunosuppression through loss of skin-associated immune barriers, systemic inflammation, multiple prolonged courses of broad-spectrum antibacterials; and multisite Candida colonization placed her at an even higher risk. Burns are recognized predisposing condition for Candida pericarditis, with at least two prior cases occurring in burn patients [1,7]. Additionally, risk factors such as renal replacement therapy, mechanical ventilation, and central vascular catheter use, have been associated with invasive candidiasis [8].

The route by which Candida gained access to the pericardium is most consistent with hematogenous dissemination. Prolonged broad-spectrum antibiotic therapy is believed to facilitate systemic fungal colonization and overgrowth across skin, airways, and mucosal surfaces [1]. Once hematogenous candidemia is established, the pericardium becomes a target for seeding [3]. A pre-existing small pericardial effusion may have provided an anatomical niche for fungal growth [3]. Once established in the pericardium, progressive exudation, purulent transformation, and tamponade physiology ensued as previously reported.

The diagnosis is difficult to establish promptly because the clinical presentation is overlapping with other causes of hemodynamic deterioration in critically ill patients [1,9]. In our patient, the initial small pericardial effusion was noted early in the admission but did not prompt antifungal investigation at that stage, as it was attributed to the broader inflammatory state of sepsis. It was only after hemodynamic deterioration and clinical signs of tamponade that repeat echocardiography revealed cardiac tamponade. Serial cultures from the pericardial fluid grew C. albicans repeatedly, confirming the diagnosis. Blood cultures, however, may be negative as has been observed in reported cases and should not be relied upon to exclude the diagnosis [7].

The established therapeutic approach combines systemic antifungal therapy with pericardial drainage [1,9]. Urgent pericardiocentesis was performed in our patient as a temporizing measure for tamponade. Systemic antifungal therapy was escalated to liposomal amphotericin B, which remains among the most employed antifungals in the documented literature and is recommended for invasive candidiasis involving deep-seated infection [1,7,10]. Echinocandins have also emerged as effective agents in Candida pericarditis [9].

Several authors have argued that percutaneous drainage alone is insufficient for Candida pericarditis, given the high rate of re-accumulation and the propensity for fibrinous septation [3,11]. In our patient, the degree of systemic illness with ongoing septic shock, DIC, thrombocytopenia, and multiorgan failure, precluded surgical escalation beyond the pigtail catheter, a limitation that likely contributed to persistent infection and progressive deterioration.

The mortality of Candida pericarditis, even with prompt diagnosis and treatment, remains very high. Early reviews reported 100% mortality in untreated cases, while those diagnosed and treated promptly had meaningful rates of cure [1,2]. In our patient, despite prompt pericardiocentesis and targeted antifungal therapy, pericarditis compounded by polymicrobial sepsis and ultimately refractory multiorgan failure resulted in death. This outcome underscores that Candida pericarditis in the context of massively burned patients with co-existing sepsis represents a uniquely lethal convergence in which no single intervention is likely to be curative without addressing the totality of the host’s immunological and physiological collapse.

8. Conclusion

This case adds to the limited literature on Candida pericarditis in burn patients. It highlights that blood cultures alone cannot exclude fungal pericarditis, and that early diagnostic pericardiocentesis with fungal cultures is essential in suspected cases.

9. Learning objectives

Recognize Candida pericarditis early in burn patients with fungal colonisation and evolving pericardial effusions.

Pursue diagnostic pericardiocentesis promptly, escalate to liposomal amphotericin B, and prioritise surgical drainage whenever feasible.

Abbreviations

AKI

acute kidney injury

CRP

C-reactive protein

CRKP

carbapenem-resistant Klebsiella pneumoniae

CRRT

continuous renal replacement therapy

CT

computed tomography

DIC

disseminated intravascular coagulation

ICU

intensive care unit

IVC

inferior vena cava

LDH

lactate dehydrogenase

LVEF

left ventricular ejection fraction

TBSA

total body surface area

TTE

transthoracic echocardiography