John Paul B.

Garrido Clinical Pharmacy

Fungal Infection Case Studies
1. BGKC is a 21-year-old college student who presents to the pharmacy at her
school’s student health center. She reports a 2-day history of pain on
urination, vaginal itching, and a thick, white discharge. She denies having any
allergies to medications or other medical conditions. She reports she is
sexually active with 1 partner and uses latex condoms for birth control. She
recalls having a yeast infection once before a few years ago, which she
remembers taking a prescription to treat. To avoid another doctor’s office
visit, she reports purchasing the Vagisil Screening Kit the night before and
that the results indicated a vaginal pH of 4.0. Based on the results of the test
and her current symptoms, identify what condition she is likely suffering from.
Consider which OTC product you would recommend and what counselling
points you would want to reinforce to assure correct use.
2. SC, a 55-year-old man presents to the emergency department with a 2-week
history of an expanding ulcer on his left lower leg. He has a history of chronic
neutropenia and transfusiondependent anemia secondary to myelodysplastic
syndrome requiring chronic therapy with deferoxamine for hepatic iron
overload. He first noticed a red bump on his leg while fishing at his cabin in
the woods and thought it was a bug bite. It rapidly enlarged, first as a red
swollen area, and then began to ulcerate. He was given dicloxacillin orally,
but with no improvement. In the emergency department he is febrile to 39°C
(102.2°F), and looks unwell. On his left leg he has a 6 by 12 cm black ulcer
with surrounding swelling and erythema that is quite tender. His complete
blood count demonstrates an absolute neutrophil count of 300 and a total
white blood cell count of 1000. An immediate operative debridement yields
pathologic specimens demonstrating broad club-like nonseptate hyphae and
extensive tissue necrosis. What initial medical therapy would be most
3. JPG is a 67-year-old male complaining of painful white lesions in his mouth
and on his tongue that occasionally bleed when he pokes or scrapes them
with his toothbrush. He first noticed symptoms several days after starting a
new inhaler medication to control his chronic obstructive pulmonary disease
(COPD). He has never experienced symptoms like this in the past and would
like a recommendation for an OTC product to get rid of them. He has a history
of diabetes, hypertension, chronic kidney disease, and COPD, for which he
takes aspirin 81 mg, atorvastatin 20 mg, lisinopril 20 mg daily, amlodipine 5
mg daily, glipizide XL 10 mg once daily, tiotropium 18 mcg once daily,
fluticasone/salmeterol 250/50 mcg twice a day, and albuterol 2 puffs every 4
hours as needed for shortness of breath; he has no known medication
allergies. Is JPG a candidate for self-care? What treatment options can you
4. SMK, a 56-year-old diabetic male with carcinoma of the oesophagus
undergoes sub-total oesophagectomy. He spends the early post-operative
period on surgical ITU and is sent to the surgical ward for further
management. On day 6, post-op, he begins to show signs of sepsis for which
antibiotics are commenced. However, 48 h later, he has difficulty in
breathing, takes a turn for the worse and is transferred to ITU. Imaging the

The patient has suffered a moderate degree of renal failure. upper body and right arm at a family barbecue. How should this patient's infection be managed? 5. He had recently left hospital after successful antibiotic treatment for a febrile neutropenic episode post-chemotherapy. Two weeks after admission to ITU for management of burns. another blood culture is taken through an arterial line and shows yeast cells on Gram stain. How should the patient be managed? . His peripheral blood count is 3 × 109/L and he has a markedly raised C-reactive protein (CRP). Garrido Clinical Pharmacy 4BSPh chest revealed a leak from the oesophagectomy site and fluid collection in the pleural space. Two days later. Intravenous fluconazole is added to his treatment. The arterial blood culture grows Candida krusei. He is commenced on broad-spectrum antibiotics. he undergoes a septic episode with septic shock.John Paul B. Antifungal sensitivities are awaited. A blood culture taken through a central line shows Gram- negative bacilli. Gram stain of aspirated pleural fluid revealed budding yeast cells and sputum culture taken 2 days previously has grown Aspergillus. Culture growth from the central line blood culture reveals Pseudomonas aeruginosa and Candida albicans. A 18-year-old boy with acute myeloblastic leukaemia sustained 20% accidental burns injury on face.

which is characterized by overgrowth of Candida albicans fungal species in the mouth. It is important to counsel BGKC on appropriate application technique —ie. dysuria. 3. minimal bleeding with irritation. This patient should be treated with an initial. dyspareunia (painful intercourse). prolonged course of therapy with liposomal amphotericin B and caspofungin and subsequent chronic suppressive therapy with posaconazole. it is important to realize that symptoms alone may mimic other vaginal conditions and are often nonspecific. including odor and discolored or frothy discharge. clotrimazole. Vaginal disorders are common ailments that send women into pharmacies seeking self-treatment. and an absence of a malodor are other symptoms that may occur with VVC. OTC imidazole antifungal products. Combination products are available for both internal and external application. taste disturbances. which typically does not cause elevations in vaginal pH. Rates of cure are similar among all products.5. are appropriate for the self-treatment of VVC. In a young. oral pain. or a yeast infection. miconazole. wear dentures. Her symptoms that are characteristic of VVC include vulvar itching.Answers: 1. the pharmacist can be confident in recommending self-treatment with an antifungal preparation. This condition is likely to affect individuals who are immunocompromised. In this case. Although these symptoms are consistent with a diagnosis of VVC. The club-like nonseptate hyphae observed in cultures of intraoperative specimens from this patient are characteristic of Rhizopus .1 Symptoms of thrush can include cottage cheese–like.John Paul B. 2. sexually active woman. or use inhaled corticosteroids. apply at bedtime to avoid product leakage and follow directions for filling applicators and inserting vaginal creams and suppositories—and also remind her that these products can affect the integrity of latex condoms. regardless of duration of therapy. one of the agents of mucormycosis. white vaginal discharge. BL is likely suffering from vulvovaginal candidiasis (VVC). Garrido Clinical Pharmacy 4BSPh Fungal Infection . including butoconazole. These conditions are usually associated with different symptoms. Considering she also reports having a medically-diagnosed yeast infection previously. or tioconazole. Vulvar edema. or . Our patient reports utilizing a home vaginal pH test and obtaining a reading that is consistent with a fungal infection. white discolorations or plaques on the mouth structures. and tend to cause elevations in vaginal pH above 4. including trichomoniasis and bacterial vaginosis. and having an abnormal thick. JPG’s symptoms are consistent with the presentation of oral thrush. Product selection should be based on patient preference and symptoms. erythema. it is important to rule out symptoms of sexually transmitted infection.

4. antibiotics should be avoided in a patient who has an invasive fungal infection as it is believed that killing the bacterial flora helps fungi thrive in the absence of commensal competition. It is imperative that these lines are taken out. Salt water gargles are the safest remedy for providing some symptomatic relief while waiting to see his physician. Ideally.1 JPG’s risk factors for developing thrush may include recently starting a combination inhaled corticosteroid/long-acting beta2-agonist for the treatment of COPD and having diabetes. The source is very likely to be oral thrush as the patient is diabetic and the candida has travelled from the mouth/oropharynx through the leak in the oesophagectomy wound into the pleural space. and this case has an additional co-morbidity on top.John Paul B. to cure this condition. the patient has concomitant Gram-negative sepsis and lacks a strong bodily defence system because of his underlying disease condition. . as JM will likely need a topical oral antifungal agent. such as clotrimazole troches. The duration of antifungal agent would be normally be 14–21 days. New lines are very likely to get colonised with the same microorganisms if inserted too early. Treatment of infections in burns patients can be challenging as the loss in skin integrity increases the risk of being colonised with various endogenous and hospital-acquired bacteria and fungi. Choice of antifungals can be reviewed after antifungal sensitivity is made available and amphotericin can be switched to caspofungin if necessary. In this case. The duration of treatment can be decided based on daily clinical follow-up that includes imaging and echo cardiograms for up to 2 weeks to look for seeding of Candida in other organs. including the importance of rinsing the mouth after each use. Urgent review is indicated for surgical intervention to close the leak. available by prescription only. Patients with haematological malignancies and chemotherapy treatment are more vulnerable to opportunistic infections. Both Candida albicans and Candida krusei can be treated with a lipid formulation of amphotericin (use of non-lipid conventional formulations of amphotericin should be avoided as the patient has a moderate degree of renal failure and his present condition could deteriorate). Candida krusei is known to be resistant to fluconazole. Garrido Clinical Pharmacy 4BSPh difficulty swallowing if the lesions have spread and have affected the esophagus. The immediate management of this patient would involve drainage of pleural fluid through an intercostal drain and systemic antifungal therapy. poor control of which may result in this infection. Counsel JPG to avoid self-care at this time and to follow up with his primary care provider. It is difficult to treat intravenous catheter and other line infections with systemic antibiotics and antifugals alone. 5. Fluconazole at 400 mg twice daily should be commenced awaiting full culture identification of the yeast and antifungal sensitivities. Take this opportunity to reinforce proper inhaler technique. and treatment given through temporary peripheral lines for at least 48 h before a new central line is inserted.