International Journal of Infectious Diseases 70 (2018) 36–37

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International Journal of Infectious Diseases

journal homepage: www.elsevier.com/locate/ijid

Case Report

Persistent candidemia despite appropriate fungal therapy: First

case of Candida auris from the United Arab Emirates
Adnan Alatooma,* , Mohammad Sartawia , Karen Lawlora , Laila AbdelWaretha ,
Jens Thomsenb , Ahmad Nusairc , Imran Mirzaa
a
Pathology and Laboratory Medicine Institute, Clinical Microbiology Section, Cleveland Clinic Abu Dhabi, Al-Maryah Island, Abu Dhabi, United Arab Emirates
b
Division of Public Health, Environmental Health Section, Abu Dhabi Department of Health (DoH), Abu Dhabi, United Arab Emirates
c
Medical Subspecialties Institute, Department of Infectious Diseases, Cleveland Clinic Abu Dhabi, Al-Maryah Island, Abu Dhabi, United Arab Emirates

A R T I C L E I N F O A B S T R A C T

Article history:
Received 17 January 2018 In this case, we report an elderly patient with multiple chronic conditions and prolonged intensive care
Received in revised form 6 February 2018 unit (ICU) stays who had recurrent Candida auris (C. auris) in blood despite antifungal therapy. C. auris was
Accepted 7 February 2018 misidentified using conventional automated identification system as Candida haemulonii resulting in
Corresponding Editor: Eskild Petersen, Aar- delayed diagnosis. The isolate showed increasing minimum inhibitory concentrations (MICs) to different
hus, Denmark
antifungal drugs and persisted in the patient’s blood before the patient deceased. This is the first case of C.
auris reported from the United Arab Emirates (UAE); laboratories should be aware of this Candida species
Keywords: and should confirm suspected cases since it is an emerging multi-drug resistant and health-care
Candida auris
associated Candida.
Multidrug resistant
© 2018 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.
Healthcare- associated
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

Introduction due to methicillin-resistant Staphylococcus aureus (MRSA), coagu-

Candida auris (C. auris) is an emerging multi-drug resistant
yeast that causes healthcare- associated fungal infections (Sears
and Schwartz, 2017; Calvo et al., 2016). Due to the increasing
awareness of C. auris worldwide, we report a case of persistent
candidemia in a patient admitted to Cleveland Clinic Abu Dhabi
(CCAD) hospital, Abu Dhabi, United Arab Emirates (UAE). To our
knowledge, this is the first case of C. auris reported from the UAE.
Few other reports from the region have been published from Oman
and Kuwait (Al-Siyabi et al., 2017; Emara et al., 2015).
Case report
The patient is an 84-year old local female with chronic renal
failure on hemodialysis, severe psoriasis, chronic atrial fibrillation
and hypertension who was admitted to our hospital from an
outside facility for further follow up. At our facility, the patient had
a prolonged hospital stay (>1 year), recurrent intensive care unit
(ICU) admissions, and multiple infections (blood stream infections
* Corresponding author at: Pathology and Laboratory Medicine Institute, Clinical
Microbiology Section, Cleveland Clinic Abu Dhabi, Al-Falah Street, Al-Maryah Island,
Abu Dhabi, United Arab Emirates.
E-mail address: Alatooa@clevelandclinicabudhabi.ae (A. Alatoom).
lase-negative Staphylococci, Klebsiella pneumoniae, and Candida
parapsilosis; pneumonia due to Pseudomonas aeruginosa, Enter-
obacter aerogenes; and urinary tract infections (UTIs) due to
Candida albicans, Candida parapsilosis, Klebsiella pneumoniae, E. coli,
and Pseudomoas aeruginosa).
During the hospital stay, the patient complained of multiple
episodes of septic shock and fever, hypotension, leukocytosis, and
elevated procalcitonin and C-reactive protein (CRP). On 12/06/
2017, three months into her hospital stay, blood culture was
positive for C. haemulonii using the Vitek-2 automated identifica-
tion system (software version 7.1, BioMerieux, France). Timeline of
blood cultures and drug susceptibility performed in the reference
laboratory are shown in Table 1. The BioFire's Filmarray1 Blood
Culture Identification (BioMerieux, France) performed on the
positive blood culture bottle was negative since this test detects
only five common candida species (C. albicans, C. glabrata, C. krusei,
C. parapsilosis, and C. tropicalis). The patient was treated with
caspofungin on the same day the blood culture became positive
with a goal to continue treatment for two weeks after negative
blood culture. Blood culture was negative after two days. Since
then, the patient had multiple episodes of candidemia despite low
MICs to caspofungin and catheter replacement.
Due to the potential misidentification of C. auris as C. haemulonii
by the Vitek-2 system and persistent candidemia despite

https://doi.org/10.1016/j.ijid.2018.02.005
1201-9712/© 2018 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 A. Alatoom et al. / International Journal of Infectious Diseases 70 (2018) 36–37 37

Table 1
Timeline of positive blood cultures from the patient. Currently, there are no Clinical and Laboratory Standards Institute (CLSI) or European Committee for Antimicrobial
Susceptibility. Testing (EUCAST) defined breakpoints for C. auris.

Organism 12/06 18/06 20/07 22/07 23/07 01/09 16/09

C. haemulonii C. haemulonii C. K. C. haemulonii C. auris C. auris
haemulonii pneumoniae K.
pneumoniae
Amphotericin MIC 0.25 mg/ml 0.5 mg/ml 1 mg/ml
Caspofungin MIC 0.016 mg/ml 0.06 mg/ml 0.25 mg/ml
Voriconazole MIC 0.016 mg/ml 0.12 mg/ml 1 mg/ml
Duration of Became negative Became negative Became positive after 7 days with S. capitis Became negative
positive cultures in 2 days in 3 days but negative in 10 days in 2 days
Antifungal Caspofungin Caspofungin Caspofungin Caspofungin Caspofungin Amphotericin Amphotericin
Therapy

antifungal therapy, we sent the fungal isolate to our reference
laboratory in the United States for identification that confirmed it
as C. auris by Matrix Assisted Laser Desorption Ionization-Time of
Flight (MALDI-TOF). The patient was in a single room and standard
contact precautions were already implemented. Susceptibilities
showed increasing minimum inhibitory concentrations (MICs) to
amphotericin B, caspofungin, and voriconazole with subsequent
cultures (Table 1). Treatment was switched to Amphotericin B.
Unfortunately, the patient deteriorated over the next month and
developed seizures, brain ring-enhancing lesions, and multi-organ
failure, and subsequently died three months after the first isolation
of C. auris from blood. The differential diagnoses of the ring-
enhancing lesions, as suggested by brain MRI, included pyogenic,
fungal, or mycobacterial abscesses.
Discussion
Similar to other patients reported with C. auris infections, our
patient is an elderly individual with multiple co-morbid chronic
conditions, prolonged ICU stay and antimicrobial exposure (Sears
and Schwartz, 2017; Chowdhary et al., 2017). Strict infection
control practices are required to prevent the spread of C. auris
inside the hospitals (Sears and Schwartz, 2017; Chowdhary et al.,
2017). Once a case of C. auris is identified in the hospital, close
contacts including patients and caregivers should be screened for
C. auris to detect colonization and potential transmission as
recommended by the Centers for Disease Control and Prevention
(CDC). Screening can be achieved by culturing swabs from different
body sites including axilla and groin.
Multiple studies have reported resistance of C. auris to different
antifungal drugs. Fluconazole has been found to have high
minimum inhibitory concentrations (MICs) while Amphotericin
showed a wide range of MIC results (Sears and Schwartz, 2017).
Echinocandins are probably the most active drugs based on low
MICs (Sears and Schwartz, 2017). All C. auris species should be
tested for susceptibility to different antifungal drugs as recom-
mended by CDC that suggested MIC breakpoints for guidance on
therapy. Based on these breakpoints for caspofungin and
amphotericin (2, Resistant), our isolate was susceptible to both
drugs. However, C. auris was isolated from multiple blood cultures
despite therapy.
We encourage clinical microbiology laboratories to further
confirm candida species when the isolate is C. haemulonii or C.
duobushaemulonii using Vitek-2 system, the isolate is unidentified
regardless of the identification system used, the isolate is
multidrug-resistant or causing persistent infection despite thera-
py, and in cases of outbreak investigations. Available systems that
can differentiate C. auris from the rest of candida species include
Matrix Assisted Laser Desorption Ionization-Time of Flight
(MALDI-TOF) and molecular techniques (Sears and Schwartz,
2017; Chowdhary et al., 2017). Based on a document sent to our
laboratory from a BioMerieux representative, the new Vitek-2
software update (version 8.01) will be able to differentiate C. auris
from the rest of the species.
Conflict of interest
None.
Financial support
None.
Acknowledgement
None.
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