Invasive fungal infection presenting as early-onset neonatal sepsis: A case report from Northern Nigeria

Usman Abiola Sanni; Taslim Olatunde Lawal; Aliyu Mamman Na'uzo; Lamidi Isah Audu

doi:10.4103/jcn.jcn_98_22

CASE REPORT

Year : 2023 | Volume : 12 | Issue : 1 | Page : 38-41

Invasive fungal infection presenting as early-onset neonatal sepsis: A case report from Northern Nigeria

Usman Abiola Sanni¹, Taslim Olatunde Lawal¹, Aliyu Mamman Na'uzo¹, Lamidi Isah Audu²
¹ Department of Paediatrics, Federal Medical Centre, Birnin Kebbi, Nigeria
² Department of Paediatrics, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria

Date of Submission	21-Oct-2022
Date of Decision	04-Dec-2022
Date of Acceptance	08-Dec-2022
Date of Web Publication	03-Jan-2023

Correspondence Address:
Usman Abiola Sanni
Department of Paediatrics, Federal Medical Centre, Birnin Kebbi
Nigeria

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcn.jcn_98_22

Abstract

In neonatal intensive units, invasive fungal infection remains a significant cause of morbidity and mortality, although an unusual cause of early-onset neonatal sepsis. In this report, we present a case of Candida parapsilosis infection presenting as early-onset bacterial sepsis. The patient was a 6-day-old male preterm neonate (estimated gestational age of 32 weeks) admitted to our neonatal unit on account of fever, refusal to feed, and vomiting which started during the first 24 h of life. Initially, he was managed for early-onset neonatal sepsis. However, his clinical state deteriorated within the 1^st week of admission and his blood culture yielded C. parapsilosis. His clinical condition subsequently improved significantly following the administration of intravenous amphotericin. He spent a total of 25 days on admission before discharge. Our report reiterates the need to raise the index of suspicion for invasive fungal infection in cases of early-onset neonatal sepsis with poor response to appropriate and potent antibiotics.

Keywords: Congenital systemic candidiasis, early-onset neonatal sepsis, invasive fungal infection, Nigeria

How to cite this article:
Sanni UA, Lawal TO, Na'uzo AM, Audu LI. Invasive fungal infection presenting as early-onset neonatal sepsis: A case report from Northern Nigeria. J Clin Neonatol 2023;12:38-41

How to cite this URL:
Sanni UA, Lawal TO, Na'uzo AM, Audu LI. Invasive fungal infection presenting as early-onset neonatal sepsis: A case report from Northern Nigeria. J Clin Neonatol [serial online] 2023 [cited 2023 Mar 27];12:38-41. Available from: https://www.jcnonweb.com/text.asp?2023/12/1/38/366898

Introduction

Commonly, fungal infections are associated with late-onset sepsis and nosocomial infections in preterm neonates.^[1],[2] It is an uncommon etiology of early-onset neonatal sepsis, wherein it presents as congenital candidiasis.^[3] This may be localized (congenital cutaneous candidiasis), or generalized (congenital systemic candidiasis).^[4] Congenital systemic candidiasis is extremely rare with <50 published cases globally as of the year 2020.^[4]

Early diagnosis is challenging due to its subtle nonspecific clinical presentations and the difficulty with laboratory confirmation.^[5],[6] In spite of low yield, blood culture remains the main diagnostic method in newborn.^[7] In this report, we present a case of a systemic fungal infection in a 6-day-old preterm newborn who presented with vomiting, high-grade continuous fever, and poor feeding noticed during the first 24 h of life. He subsequently developed respiratory distress but responded to antifungal agents.

Case Report

The case was a 6-day-old male preterm (estimated gestational age of 31 weeks) brought to our neonatal unit with complaints of vomiting, high-grade continuous fever, and poor feeding noticed during the first 24 h of life. He was initially managed in another facility for 4 days as a case of congenital malaria (he was tested for malaria due to malaria in pregnancy, and the mother was managed for in the peripartum period), but represented at our facility, Federal Medical Centre, Birnin Kebbi, <48 h after discharge following worsening clinical condition. There was an initial marginal transient relief of symptoms at the first facility before discharge at the parents' request. His delivery was at a hospital through spontaneous vaginal mode and cried immediately after birth, although the Apgar scores were not provided. The mother had preterm prolonged rupture of membrane and peripartum pyrexia 3 days before delivery, for which she was treated for malaria in pregnancy. She also had a course of oral antibiotics. She had no history of thick whitish vaginal discharge or perineal pruritus and her examination by the obstetric team in our facility revealed no perineal lesion or evidence of superficial breast/ductal candidiasis.

The baby was the first child of his parents. The mother was a 23-year-old undergraduate student whose antenatal retroviral screening was negative. The family resided in a city and was of middle socioeconomic status.

At presentation, the baby was conscious but febrile (temperature of 39.9°C) and weighed 1.6 kg. He was lethargic with depressed primitive reflexes and global hypotonia. He had respiratory distress but no skin lesions. His respiratory and heart rates were 68 cycles/min and 150 beats/min, respectively. His oxygen saturation using pulse oximetry was 90%. There was no organomegaly. Our hospital, however, had no neonatal sphygmomanometer for blood pressure measurement. Urgent random blood sugar done was 2.0 mmol/L

An initial diagnosis of early-onset neonatal sepsis complicated by hypoglycemia was made and was treated with a combination of cefotaxime (75 mg/kg, 12 hourly) and ampicillin/sulbactam (75 mg/kg, 12 hourly), based on our unit protocol for babies admitted from the community or other facility. Investigations, including chest radiograph [Figure 1], blood culture, complete blood count, serum electrolytes and calcium, abdominopelvic ultrasound scan, and random blood sugar, were requested. The results of the investigations are shown in [Table 2].

Figure 1: Chest radiograph showing patchy opacities over the lung fields

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Table 2: Results of investigations

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Seven hours into admission, respiratory distress progressed (intercostal recessions, tachypnea, and respiratory rate = 80 cycles/min). Repeat oxygen saturation showed a value of 88%. Oxygen therapy was then initiated through the nasal cannula.

On day 5 of admission, he became more dyspneic necessitating the conversion of oxygen therapy to continuous positive airway pressure (CPAP) ventilation. Urgent hematocrit was 20% necessitating transfusion with fresh whole blood and intravenous fluconazole was commenced empirically. A repeat complete blood count showed thrombocytopenia of 59,000 counts per mm³ and mild anemia.

By the 8^th day of admission, respiratory distress persisted and the result of the blood culture sample taken at presentation using the BacT/Alert technique yielded Candida parapsilosis. This necessitated the change of fluconazole to intravenous amphotericin B at 0.8 mg/kg/day administered slowly in infusion over 2 h. Respiratory distress improved significantly after 72 h of commencement of the antifungal agent. The medication was, however, continued for another 2 weeks. The baby was then weaned off CPAP gradually. He did well and was discharged after 25 days of admission. The baby was seen three times at the follow-up clinic and was clinically stable. The chronology of the events is shown on [Table 1].

Table 1: Chronology of event

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Discussion

The risk of fungal infections is higher in very low and extremely low birth weight neonates and those receiving total parenteral nutrition.^[7] Even though our patient was a preterm baby, his risk of getting infected with a fungal agent was relatively low based on his weight. The manifestation of symptoms in the index patient started within the 1^st h of life, implying congenital systemic candidal disease. This is a very rare disease with only 44 cases reported globally over 54 years as of 2020.^[4] The index case manifested as pneumonia. This was in tandem with finding from earlier case reports in which pneumonia, and/or gastrointestinal manifestation, was the most common form of presentation in congenital systemic neonatal candidiasis.^[4],[5]

In this report, the baby had thrombocytopenia, in keeping with the finding by Tasneem et al.^[8] Thrombocytopenia could be a nonspecific marker of fungal sepsis in newborns.^[5],[8] In addition, leukocytosis and anemia reported in patients with neonatal candidiasis were also present in our patients.^[7] Therefore, the presence of thrombocytopenia, anemia, and leukocytosis in neonatal sepsis should raise the suspicion of possible fungal sepsis.

The blood culture of our patient yielded C. parapsilosis. Disseminated/systemic candidiasis is primarily caused by Candida albicans and C. parapsilosis in preterm infants.^[9] While C. albicans can be acquired perinatally as well as postnatally, perinatal acquisition of C. parapsilosis is rare.^[9],[10] In a meta-analysis by Georgescu et al.,^[4] only two out of the 44 cases of congenital systemic candidiasis reviewed were caused by C. parapsilosis. In this report, C. parapsilosis was congenitally acquired. The source of the infection could be the maternal genital tract. Perhaps, the mother had a subclinical genital fungal infection in addition to malaria in pregnancy.

The treatment of the index case was started with fluconazole. However, poor response necessitated a switch to amphotericin B following which a marked improvement was observed. Amphotericin B and fluconazole are the only therapeutic choice for candidiasis in neonates.^[11] Recently, the resistance of some Candida spp. against fluconazole was reported.^[11] Conversely, amphotericin B is shown to be highly effective in vitro against all Candida species.^[12] Our observation of the index patient was in consonance with these findings.

Conclusion

C. parapsilosis is a possible organism of neonatal infection in low birth weight preterm and can mimic early-onset neonatal sepsis. In the event of poor response to appropriate antibiotics for suspected bacterial sepsis in preterm infants, there should be a high index of suspicion for invasive candidiasis.

Declaration of patient

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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