Case Report: Facial mixed fungal infection in a poorly responding non-Hodgkin’s lymphoma patient with suspected immunodeficiency

A male child presented with left lacrimal gland and right submandibular masses that were diagnosed as high grade B-cell non-Hodgkin's Lymphoma. Immunodeficiency was suspected, mostly due to secondary to Epstein Barr virus infection. Chemotherapy was started and gradual regression was observed in the size of the lesions forming a central necrosis and facial wound. Cultures from this wound showed mixed gram negative growth of Pseudomonas aeruginosa , and Escherichia coli . Two days later, a follow up swab of the wound was taken and showed fungal growth of mixed Candida tropicalis and Cryptococcus laurentii which was treated with two antifungals (fluconazole and liposomal amphotericin B). After a second chemotherapy cycle, the facial necrotic lesion increased in size and the patient's general condition markedly deteriorated with multi-organ system failure secondary to septic shock by candidemia. Candida glabrata , which is non- Candida albicans fungus was the fungus that appeared in the patient's blood culture. Caspofungin was prescribed in addition to liposomal amphotericin B. two days later, the follow up blood culture revealed growth of methicillin resistant Staphylococcus aureus and the pulmonary condition of the patient then deteriorated gradually. Six days later, the patient developed multi-organ dysfunction syndrome secondary to sepsis. We conclude that we mixed fungal infection in not uncommon among immunocompromised patients, candidemia is fatal even if treated with the correct antifungals.