Airway Necrosis and Fungal Plaque Causing Central Airway Obstruction Due to Candida auris: A Case Report

TL;DR

A rare case of Candida auris causing severe airway obstruction and necrosis in a critically ill patient is reported, highlighting the importance of early diagnosis and treatment.

Contribution

First reported case of C. auris causing obstructive tracheobronchial disease and airway necrosis in an immunocompromised patient.

Findings

C. auris infection led to extensive tracheal necrosis and narrowing confirmed by bronchoscopy and histopathology.

Antifungal therapy successfully resolved tracheal necrosis and stenosis.

The patient later succumbed to septic shock from Klebsiella pneumoniae bacteremia.

Abstract

Candida auris is an emerging multidrug-resistant fungal pathogen associated with high morbidity and mortality, particularly in critically ill and immunocompromised patients. To our knowledge, airway-obstructing tracheobronchial disease due to C. auris has not been previously reported.

An 80-year-old woman with multiple comorbidities, including myelofibrosis under erythropoietin therapy, presented with severe coronavirus disease 2019 (COVID-19) pneumonia. On admission, clinical findings included fever, cough, dyspnea, leukocytosis (20.3 K/µL), elevated C-reactive protein (23.9 mg/dL), and procalcitonin (2.12 ng/mL). Chest CT revealed diffuse consolidations and ground-glass opacities. Progressive hypoxemia necessitated intubation and mechanical ventilation. The clinical course was complicated by ventilator-associated pneumonia caused by multidrug-resistant Acinetobacter baumannii, treated according to antibiogram results. Severe neuromuscular weakness prevented extubation, leading to tracheostomy. Shortly thereafter, progressive respiratory failure developed. Bronchoscopy demonstrated extensive necrosis and narrowing of the trachea. Tissue biopsy and cultures confirmed C. auris infection. Histopathology demonstrated fungal spores and septate hyphae within necrotic tracheobronchial mucosa on periodic acid-Schiff/Grocott methenamine-silver (PAS/GMS) stains, consistent with tissue invasion rather than surface colonization. No angioinvasion was identified. The presence of organisms infiltrating the necrotic mucosal tissue, together with obstructing fungal plaques visualized bronchoscopically, supported invasive infection and excluded mere airway colonization. Antifungal therapy was administered, resulting in the complete resolution of tracheal necrosis and stenosis on follow-up bronchoscopy. Despite recovery from fungal infection, the patient subsequently developed septic shock secondary to Klebsiella pneumoniae bacteremia and died.

This case illustrates a rare presentation of C. auris tracheal infection leading to airway necrosis in an immunocompromised, mechanically ventilated patient. Early diagnosis through bronchoscopy, culture, and histopathology, combined with timely antifungal therapy, is critical for management. The case emphasizes the diagnostic and therapeutic challenges posed by multidrug-resistant fungal infections in critically ill patients with COVID-19.

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