S5525 Hepatic Candidiasis in a Patient With ANCA-Associated Vasculitis Following Immunosuppressant-Induced Neutropenia

Introduction: Chronic disseminated candidiasis (CDC), or hepatosplenic candidiasis, is a rare but serious fungal infection that typically arises in patients with hematologic malignancies during recovery from prolonged neutropenia. It is often linked to translocation of Candida species through damaged gastrointestinal mucosa during neutropenia, with seeding of organs like the liver and spleen once immune recovery begins. Although most common in cancer patients, it may also occur in those with autoimmune diseases receiving immunosuppressive therapy. Case Description/Methods: An 82-year-old woman with anti-neutrophil cytoplasmic antibodies-associated vasculitis presented with 5 days of right upper quadrant pain, nausea, and vomiting. Her history included ILD, pauci-immune glomerulonephritis, COVID-related ARDS, cytomegalovirus pneumonitis, and hemorrhagic cholecystitis with prior cholecystostomy. Azathioprine had been discontinued 5 months earlier due to neutropenic fever; she remained on prednisone. Neutrophils had since recovered. Labs: white blood count 34.14 /nL, Cr 2.0 mg/dL, alkaline phosphatase 2296 U/L, aspartate aminotransferase 107, alanine aminotransferase 45, TBili 4.3. Magnetic resonance cholangiopancreatography showed biliary dilation with an obstructive lesion. Endoscopic retrograde cholangiopancreatography retrieved 3 stones and a clot; cholangiogram confirmed clearance. However, liver enzymes remained elevated. Computed tomography revealed a 16.4 × 12.0 cm multiloculated subcapsular perihepatic collection. Interventional radiology drained 360 cc of dark brown fluid. Blood cultures were negative, but aspirate grew Candida albicans. Oral fluconazole was started, with rapid clinical and biochemical improvement. Residual fluid was treated with intralesional dornase and alteplase. Follow-up imaging showed near-complete resolution, and the patient remained asymptomatic. Discussion: Hepatic candidiasis in immunocompetent or autoimmune patients is rare and often presents with nonspecific symptoms and abnormal liver tests. It frequently occurs without candidemia, and blood cultures lack sensitivity. Diagnosis depends on clinical suspicion, imaging, and aspirate culture or histology. Targeted antifungal therapy is the cornerstone of treatment, and fluconazole is often effective in susceptible cases. In our patient, prompt oral fluconazole and adjunctive intralesional fibrinolytics led to full recovery. This case highlights the importance of early recognition, appropriate antifungal therapy, and multidisciplinary management for optimal outcomes.