Hepatosplenic (Chronic Disseminated) Candidiasis

Hepatosplenic candidiasis is a chronic disseminated form of invasive candidiasis that typically affects patients recovering from prolonged neutropenia following chemotherapy for hematologic malignancies, particularly acute leukemia and after stem cell transplantation. The condition is paradoxically diagnosed during neutrophil recovery when fungal organisms previously sequestered are exposed to immune cells, generating granulomatous inflammation. Incidence has decreased substantially with widespread antifungal prophylaxis but remains an important consideration in immunocompromised patients with persistent fever.

Pathogenesis involves Candida species (C. albicans, C. tropicalis, C. krusei, C. parapsilosis, and C. glabrata) seeding to hepatic and splenic microvasculature during initial neutropenic candidemia, with persistent infection in tissues during prolonged immunosuppression. Upon neutrophil recovery, granulomatous inflammation develops at infection sites producing characteristic bull's-eye or target lesions on imaging. Clinical features include persistent fever despite antibiotics, abdominal pain (right upper quadrant), hepatomegaly, splenomegaly, weight loss, anorexia, elevated alkaline phosphatase (most common laboratory abnormality), elevated transaminases, and elevated bilirubin in some cases. Skin lesions, eye involvement (chorioretinitis), and other organ dissemination may occur.

Diagnosis includes characteristic imaging findings (bull's-eye, target, or 'wheel within a wheel' lesions on ultrasound, CT, MRI), elevated alkaline phosphatase, blood cultures (often negative at this stage), beta-D-glucan (positive in invasive candidiasis), Candida-specific PCR, and histopathology with Candida elements (yeasts, pseudohyphae, hyphae) on biopsy. Treatment requires prolonged antifungal therapy: echinocandins (caspofungin, micafungin, anidulafungin) for initial therapy, followed by step-down to fluconazole 400 mg daily for sensitive species, voriconazole or posaconazole for resistant species, liposomal amphotericin B for severe cases or refractory disease, and addition of corticosteroids in selected cases to reduce inflammatory response. Treatment duration extends 3-6 months until lesion resolution on imaging.