ENDOSCOPIC MANAGEMENT OF UNCONTROLLED FUNGAL INFECTION IN A CASE OF PERIPANCREATIC COLLECTION. ANTIFUNGAL INTRACAVITARY INFUSION AS AN ALTERNATIVE TREATMENT

Aims:

We present a case of peripancreatic collection with persistent fungal infection despite of drainage of the peripancreatic collection with the Hot-Axios® device. We describe a new successful treatment approach not previously reported so far for the management of the fungal infection.

Methods:

49-year-old woman was admitted for a second biliary acute pancreatitis, complicated with necrosis of 30 – 50% in pancreatic body which evolved to an extensive necrotic collection with clinical, systemic and radiologic data of superinfection. After 4 weeks of unsuccessful medical treatment and worsening of her clinical situation, the walled-off pancreatic necrosis was successfully drained by using the Hot-Axios device. despite of the fact of successive endoscopic debridement procedures, cavity irrigation through a nasocystic catheter and 3 weeks of systemic treatment with anidulafungin, the evolution was not good with fever, SIRS and persistent isolation of Candida Krusei in blood and collection. We decided to perform endoscopic instillation of liposomal amphotericin B (25 mg in 500 cc water for injection) within the peripancreatic cavity. In the next 48 hours the patient was without fever. she did not need new endoscopic instillations and was discharged after 10 days from the procedure with oral voriconazole for 2 weeks. 8 weeks later the lumen-apposing metal stent was pulled off without incidences.

Results:

After review of the literature, we found some treatments of local instillation of antifungeal for control of candidiasis in other medical situations and we decided to perform an endoscopic comparable procedure, according to Microbiology and Pharmacology departments, which turned out to be successful with only a single session of instillation of amphotericin B and also antifungal oral treatment, and the patient was free of fungal infection.

Conclusions:

Given the low cost and safety of the method described, this treatment deserves a more thoughtful evaluation in order to confirm this initial result.