B72-47 Unmasking the Unlikely Pathogen: Candida Albicans Empyema in a Critically Ill Patient

Abstract Candida albicans is a common commensal fungus colonizing approximately half of the population. It resides in the oral cavity, gastrointestinal tract, genital mucosa, and skin. In critically ill or immunocompromised patients, particularly those with prolonged antibiotic or steroid exposure, Candida overgrowth may occur in multiple body sites. Empyema, an infection of the pleural space, most often arises as a complication of bacterial pneumonia through inflammatory pleural permeability and parapneumonic effusion formation. Less common etiologies include malignancy, esophageal rupture, trauma, or infection extending from adjacent structures. Candida empyema is exceedingly rare and typically associated with severe immunosuppression or recent thoracic procedures. A 67-year-old woman with a history of chronic kidney disease stage IIIb, COPD, hypertension, mitral valve prolapse, seizures, scoliosis, and a 40-pack-year smoking history presented with progressive dyspnea and cough for two weeks. She had completed outpatient courses of azithromycin and doxycycline without improvement. Her husband brought her to the hospital after noting confusion and lethargy. On arrival, she met sepsis criteria and was treated with broad-spectrum antibiotics and fluids. Despite initial management, she developed severe hypoxic respiratory failure (SpO2 85%) requiring intubation. Chest CT revealed a moderate left hydropneumothorax occupying 30-40% of the hemithorax, diffuse bilateral consolidations with tree-in-bud nodularity, and left lower lobe bronchial obstruction. A 24-Fr chest tube was placed but failed to adequately drain the collection due to apical positioning. Interventional radiology subsequently placed 12- and 8-Fr tubes, draining serous exudative fluid. Pleural fluid culture later grew Candida albicans (hospital day 11). Despite maximal supportive care, the patient’s respiratory status and hemodynamics progressively declined. Blood cultures remained negative. Given poor prognosis and ongoing deterioration, her family opted for comfort-focused measures on hospital day 12. She was extubated and passed away the following day. This case illustrates a rare instance of Candida albicans empyema in a patient without recent thoracic surgery or known immunosuppression. The delayed culture positivity and absence of bacteremia likely contributed to late antifungal initiation and poor outcome. Clinicians should maintain suspicion for fungal pathogens in patients with persistent sepsis or empyema unresponsive to broad antibiotics. Early pleural drainage and timely antifungal therapy may improve outcomes in this often-fatal presentation. This abstract is funded by: None