James Thorpe, Irfan Ahmed, Richard E Hind.
Intestinal perforation with invasive candidiasis in an immunocompetent adult.
J Coll Physicians Surg Pak Jan ;14(3):187-8.

A 63 years old lady presented with a three weeks history of vomiting, abdominal pain and dysuria. The symptoms had significantly deteriorated two days prior to admission. Her past medical history included hypertension and anxiety. She had recently stopped smoking. Her usual medications were propranolol and chlorazepate. On examination she was obese and apyrexial. Her pulse rate was normal and blood pressure was 94/57 mmHg. Her abdomen was soft but tender in epigastric and suprapubic regions, although this was difficult to assess due to her habitus. Investigations showed a leucocytosis of 16.51 x10e9 /L due to neutrophilia with a C-reactive protein (CRP) concentration of 120 mg/dL. Urea was raised at 15.6 mmoles/L with a normal creatinine value. A urinary sample tested positive for only ketones and protein. The patient was initially treated with intravenous fluids for dehydration and oral trimethoprim was given for a possible urinary tract infection. Three days after admission, the patient`s condition began to deteriorate. She developed pyrexia at 38°C, tachycardia at 104 bpm and hypotension at 86/52 mmHg. There was continuous tenderness in suprapubic region and the left iliac fossa , the putative diagnosis being diverticulitis. However, on the eighth day, condition deteriorated with increasing abdominal pain, vomiting and shortness of breath. She developed tachycardia at 110 bpm with a normal blood pressure. Her chest revealed bilateral poor air-entry and oxygen saturations of 92% on 28% oxygen. At this stage she was transferred to the high dependency unit for treatment of her systemic sepsis and a central line was sited. Her condition failed to improve and the decision was taken to perform a laparotomy. At operation, three perforations were identified in the ileum with no identifiable cause. Histological examination of the resected bowel confirmed the presence of focal ulceration of the resected small bowel, which had perforated the wall in three places. Candidal hyphae were seen in the ulceration with the use of a PAS stain.

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