Treatment of Candidal Cholangitis with Caspofungin Therapy in a Patient with a Liver Transplant: Documentation of Biliary Excretion of Caspofungin

SIR—Cholangitis due to candidiasis is a rare infection in patients without predisposing factors, but it has become an increasingly recognized complication in patients who have received a liver transplant [1]. After liver transplantation is performed, strictures may develop in the extrahepatic biliary tract and lead to secondary sludge formation, which can predispose a patient to recurrent cholangitis. Cases of biliary candidiasis in patients with liver transplants are further complicated by the potential for infection with azole-resistant isolates [2] and the potential for pharmacologic interactions between immunosuppressants and other drugs [3]. Here, we present a case of recurrent polymicrobial cholangitis due to infection with Candida albicans in a patient with a liver transplant whose case was conservatively managed with percutaneous drainage and systemic antimicrobial therapy. A 54-year-old man who had received a liver transplant 4 years earlier presented with fever and chills. The patient had been diagnosed 6 months earlier with recurrent cholangitis after imaging studies demonstrated markedly dilated hepatic ducts with numerous filling defects. Alkaline phosphatase levels were 5–10 times the normal level, and cultures of bile samples obtained from the patient were positive for Enterococcus species, Streptococci milleri, anaerobes, and C. albicans. Prior to admission, the patient had undergone multiple failed endoscopic procedures to relieve the biliary obstruction, and his case had been managed with external biliary drainage and chronic suppressive antimicrobial therapy with levofloxacin, metronidazole, and intrabiliary infusions of amphotericin and fluconazole. Microbiological testing of bile samples obtained from the patient at admission again yielded multiple organisms, including yeasts. Management of the patient's case was further complicated by elevated tacrolimus levels (which were 5 times greater than the target concentration) and chronic renal insufficiency.