S3528 Mycotic Cholangitis in Immunocompetent Adult: A Case Report

Introduction: Cholangitis is a severe infection often resulting from biliary obstruction, typically due to choledocholithiasis or strictures. Gram-negative enteric bacteria are the most common pathogens. Fungal cholangitis is a rare condition that affects typically individuals who are immunocompromised or those with indwelling biliary stents. We report a rare case of Candida albicans cholangitis in an immunocompetent individual presenting with acute pancreatitis and septic shock. Case Description/Methods: A 52-year-old previously healthy man presented with 3 days of severe epigastric pain, nausea, vomiting, and intolerance to oral intake. He had no past medical history or immunosuppressive risk factors. At presentation, he was hypoxic (SpO₂ 88% on NRB), tachypneic, and in respiratory distress, requiring intubation. Labs showed leukopenia, elevated liver enzymes, and high lipase. Computed tomography abdomen revealed Balthazar grade C pancreatitis, CBD dilatation (10 mm), and possible distal obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a distal CBD cut-off with purulent drainage; a 7 Fr stent was placed. Blood and bile cultures grew Candida albicans sensitive to fluconazole, echinocandins, and amphotericin B. Intravenous caspofungin was initiated. Over the course of 1 week, clinical and biochemical improvements occurred, allowing for extubation and cessation of vasopressors. The patient was discharged, and stent removal was performed 2 weeks later. He remained asymptomatic during 6-month follow-up. Discussion: Fungal cholangitis is an uncommon but serious infection typically seen in immunosuppressed individuals or those with prolonged antibiotic use, biliary stents, or intensive care unit (intensive care unit) stays. Candida albicans is the most frequently isolated fungal organism. While colonization can occur, actual infection is suggested by clinical deterioration and the presence of candidemia. This case is unique due to the absence of classical risk factors. Notably, the patient was not evaluated for rare immunodeficiency syndromes but lacked suggestive clinical features. In conclusion, Candidal cholangitis should be considered in critically ill patients with cholangitis, even in the absence of traditional risk factors for candidal infections. Prompt diagnosis, source control, and antifungal therapy are critical. This case highlights the evolving spectrum of biliary infections and underscores the importance of heightened awareness of fungal pathogens in atypical settings.