# Fungal Infections in Severe Acute Pancreatitis: Insights from a Case Series

## TL;DR

Fungal infections in pancreatic fluid collections during severe acute pancreatitis are rare but serious, requiring early detection and targeted antifungal treatment to avoid poor outcomes.

## Contribution

This case series highlights the under-recognized clinical significance of fungal infections in severe acute pancreatitis and emphasizes the need for early microbiological sampling and species-specific antifungal therapy.

## Key findings

- Fungal infections in pancreatic fluid collections are associated with severe disease and poor outcomes in patients with acute pancreatitis.
- Non-albicans Candida species show reduced susceptibility to standard antifungal agents, requiring individualized treatment adjustments.
- Early microbiological sampling and species-level identification improve prognosis in fungal infections of pancreatic fluid collections.

## Abstract

Background: Fungal infection of pancreatic fluid collections (PFCs) in severe acute pancreatitis (SAP) is under-recognized and associated with poor outcomes. Overlap with bacterial infections and the need for invasive sampling often delay diagnosis, leading to prolonged antibiotic use without the use of antifungal agents. Methods: We report three cases of SAP complicated by fungal infection of PFCs. Two patients, one with alcohol-related pancreatitis and the other with biliary pancreatitis, developed symptomatic encapsulated necrosis. Both were successfully managed with endoscopic drainage and targeted antifungal therapy against Candida albicans, achieving full resolution. The third patient, with necrotizing biliary pancreatitis, underwent multiple surgical and endoscopic interventions and developed an infection with a non-albicans Candida species. Reduced susceptibility requires individualized antifungal adjustment guided by susceptibility testing. Despite aggressive multimodal therapy, the patient progressed to multiorgan failure and died subsequently. Results: These cases emphasize the clinical impact of fungal infections in patients with SAP, particularly their association with severe disease, prolonged hospitalization, and prior antibiotic exposure. These findings highlight the prognostic value of early microbiological sampling, species-level identification, and prompt initiation of antifungal therapy. Infections caused by non-albicans species pose additional challenges due to their reduced sensitivity to standard antifungal agents. Conclusions: Fungal infection of PFCs is a clinically significant and frequently underestimated complication of SAP. Early recognition and species-directed antifungal therapy are critical for improving outcomes in high-risk patients.