An Atypical Source of Persistent Fungemia in the Intensive Care Unit

Patient: Female, 63-year-old Final Diagnosis: Deep vein thrombosis • septic shock Symptoms: Hematemesis • respiratory failure Medication: — Clinical Procedure: — Specialty: Critical Care Medicine • Infectious Diseases • General and Internal Medicine OBJECTIVE: Unknown etiology BACKGROUND: Candidemia is a common complication of critically ill and immunocompromised patients, with more than 50% associated mortality. Typical etiologies include valvular vegetations, intra-abdominal fluid collections, and central venous catheters. Treatment often entails surgical excision, but anticoagulation may be sufficient. CASE REPORT: Our case was a 63-year-old woman with diabetes mellitus, left hip osteoarthritis status after hemiarthroplasty, and alcohol use disorder, admitted to the Intensive Care Unit with diabetic ketoacidosis (DKA) and hemorrhagic shock from an upper gastrointestinal bleed. Complicating her course was the development of Candida species fungemia. An extensive workup including transthoracic echocardiography, computed tomography of the chest, abdomen, and pelvis, ocular examination, and hip aspiration was unrevealing in determining the etiology. Despite early line removal and appropriate antifungal therapy, the fungemia persisted. A broader evaluation revealed a venous thromboembolism, which ultimately was thought to be the source. Subsequent initiation of anticoagulation and continued antifungal therapy led to clearance of blood cultures with overall clinical improvement. CONCLUSIONS: In critically ill patients at higher risk for development of venous thromboembolism, septic thrombi should be considered in the differential diagnosis when evaluating for source control in a patient with fungemia.