A Preterm Infant of Congenital Cutaneous Candidiasis With Elevated Plasma (1, 3) β-D-glucan Level

To the Editors: Congenital cutaneous candidiasis (CCC) is considered a systemic fungal infection, and the risk of systemic dissemination varies with gestation. A male neonate weighing 2095 g at 32 weeks of gestation was born by vaginal delivery. As serum C-reactive protein level of his mother elevated just before delivery, the neonate was treated with ampicillin and gentamicin after collecting blood (1 sample), stool and nasal swab cultures. The day after delivery, he had multiple erythematous papulovesicular eruptions over the entire body (Fig. 1A). Three days after birth, Candida albicans were isolated from all cultures collected at birth. Peripheral white blood cell counts and serum C-reactive protein levels were 27.6 × 103/L and 1.2 mg/L, respectively. Plasma (1, 3)-β-D-glucan (BDG) level, measured using Fujifilm Wako β-glucan test (reference range <11 pg/mL, FUJIFILM Wako Pure Chemical Corporation, Osaka, Japan), was markedly high at 289 pg/mL. Intravenous fosfluconazole (first dose, 12 mg/kg; subsequent doses, 6 mg/kg every 72 hours until 14 days after birth and 6 mg/kg every 48 hours thereafter) was started 3 days after birth. The eruptions completely disappeared 14 days after birth. Fosfluconazole was discontinued 24 days after birth. The patient was diagnosed with CCC, based on the histopathologic findings (Fig. 1B–D). Plasma BDG levels serially decreased (93.5, 34.5 and 11.4 pg/mL at 16, 36 and 161 days after birth). C. albicans was not isolated from blood collected just before starting fosfluconazole, suggesting that the result of blood culture at birth might indicate contamination with C. albicans.FIGURE 1.: The findings of the skin lesion and microscopic examinations in the patient. A: Multiple erythematous papulovesicular eruptions on the trunk, which appeared on the day after birth. B: Histological finding of the umbilical cord tissue (hematoxylin and eosin staining, original magnification ×50). Various inflammatory cells, mainly neutrophils, infiltrate extensively from the umbilical artery wall to Walton's jelly. C: Histological finding of the umbilical cord tissue (hematoxylin and eosin staining, original magnification ×200). D: The finding of Grocott staining in the umbilical cord tissue (original magnification ×200). Many fungal spores and pseudohyphae were observed on the surface of the umbilical cord in the specimen.In preterm infants with CCC, Candida species invade the epidermis and dermis and might enter the bloodstream through an immature cutaneous barrier.1 Prompt systemic antifungal treatment is needed even if no fungal species were isolated from blood at the onset of CCC. However, CCC neonates born weighing >1000 g were not at greater risk for the development of systemic candidiasis.2 BDG is a sensitive diagnostic marker for invasive candidiasis,3 whereas the usefulness of BDG to predict progression to systemic infection in CCC neonates is unclear. The elevated plasma BDG level in our patient with only cutaneous symptoms suggested that it might be useful to predict the dissemination of Candida species in CCC. However, there were the following concerns. BDG might be transplacentally transferred from the patient's mother to the patient. The placental transportability of BDG is unknown. Due to their low renal function, the half-life in neonates may be slightly longer than the half-life in adults (20 hours).4 In our patient, the plasma BDG level likely reflected the patient's condition because the sample was collected 3 days after birth. Furthermore, the usefulness of the BDG assay used for our patient is unknown in neonates. In adults, the assay used for our patient showed a moderate correlation with the Fungitell assay previously used to diagnose neonatal invasive candidiasis.3,5 The result of our patient suggested that BDG might be useful for predicting systemic progression in CCC. Further large-scale study is desired to evaluate the usefulness of the Fujifilm Wako β-glucan test in neonatal CCC.