Candida nivariensis infection in South East Asia: Series of case reports from Selayang Hospital, Malaysia and South East Asia Region

Introduction: Candida nivariensis, first described from Spain in 2005 is an emerging fungal pathogen. Malaysia has cap-tured a total of 11 cases since its first reported here in 2014. Indonesia, Thailand, and Vietnam are among South East Asia countries that reported its occurrence too. Objective(s): The occurrence and characteristics of Candida nivariensis in South East Asia are studied. We would like to highlight two cases from Selayang Hospital, Malaysia that occurred during pandemic COVID-19 in 2020 and 2022. Case Description: In July 2020, a 60-year-old lady underlying poorly controlled diabetes mellitus, CKD stage V approach-ing ESRD, congestivecardiac failure, hypertension, and dyslipidemiawas diagnosed as complicated MSSAbacteremia secondary to right gluteal carbuncle.Appropriate antibiotics were commenced.Aggressive source control including incision and drainage, cauterization of right gluteal carbuncle, and multiple wound debridement for the infected gluteal wound was performed. She underwent a trephine sigmoid loop colostomy.Tracheostomy was done following prolong ventilation.Anidulafungin as empir-ical fungal coverage was commenced in ICU as she further deteriorated. Candida nivariensis was isolated later from her blood culture. In February 2022, a 74-year-old man underlying Diabetes mellitus, chronic kidney disease, hypertension, ischemic heart disease with two vessels disease stented, post-Whipple's procedure due to necrotizing pancreatitis in 2014 complicated with chronic abdominal pain with hyperalgesia admitted to the ward for acute right lacunar infarct with failed swallowing test and neurogenic bladder.His general condition deteriorated with worsening of biochemical and septic parameters.His blood culture grew C. nivariensis following which anidulafungin was started. No distant seeding and no signs of endophthalmitis. He then required mechanical ventilatory support complicated with multiorgan failure, leading to ICU admission. Method(s): For both cases, yeast isolates were subcultured on Sabouraud dextrose agar and CHROMagar. Matrix-assisted laser desorption ionization time of flight mass spectrometry (MALDI-T OF MS) with molecular testing was performed for confirmation of isolates.Phylogenetic tree among isolates from Malaysia was analyzed.Antifungal susceptibility test (AFST) to study the minimum inhibitory concentration (MIC) among treatment options was performed using the e-test method. Result(s): Wide use of MALDI-T OF MS with molecular testing increased the detection rate of the species. Isolation sites in Malaysia and South East Asia region include blood culture, peritoneal fluid, high vaginal swab, and oropharyngeal swab. Risk factors namely immunocompromised status, indwelling vascular catheter, abdominal surgeries, renal failure or on dialy-sis support, polymicrobial usage, and prolonged stay in ICU. AFST established susceptibility towards fluconazole, high MIC to itraconazole and low MIC against amphotericin B, anidulafungin and voriconazole for both patients who unfortunately succumbed to their illness. Conclusion(s): Diagnosing C. nivariensis is challenging due to its closely related phylogenetic with C. glabrata, and C. bracarensis, thus molecular testing is vital. Inadequate antifungal coverage or delay of treatment could be detrimental to pa-tient's outcome. Continuous epidemiological surveillance is crucial to address this potential invasive fungal pathogen and to observe emerging of drug resistance.

A CASE SERIES OF ACUTE SYMPTOMATIC HYPONATREMIA DUE TO SIADH: AN UNUSUAL PRESENTATION OF COVID-19 INFECTION

Introduction The Syndrome of Inappropriate ADH Secretion (SIADH) is one of the most common causes of hyponatremia among medical inpatients. The evolution of SARS-CoV-2 infection over recent years has led to atypical presentations, one being in the form of acute symptomatic hyponatremia secondary to isolated SIADH not associated with pneumonia. CASES We report a series of three unusual cases of Category 2 COVID-19 infection presenting with acute symptomatic hyponatremia secondary to SIADH. All three patients presented with symptoms of acute severe hyponatremia and coincidentally tested positive for SARSCoV- 2 virus without respiratory tract symptoms and normal chest imaging. All patients were fully vaccinated and boosted at least 3 months before the presentation. Clinical and biochemical workup confirmed SIADH in all three patients. They were treated with hypertonic saline in the initial phase, followed by fluid restriction as per recommendations. It was postulated that the inappropriate ADH secretion was mediated by increased inflammatory cytokines, especially interleukin 6 may be a direct effect of the SARS-CoV-2 infection itself. Conclusion In the context of the ongoing COVID-19 pandemic, acute symptomatic hyponatremia without an obvious cause could be an atypical, isolated manifestation of SARS-CoV-2 infection. Awareness of these uncommon presentations is important so that specific treatment protocols or recommendations can be created and instituted to address this likely reversible but potentially fatal presentation of COVID-19.