Candiduria, Coagulopathy and GI Bleeding in Sepsis . — Part 5

  PART 5 OF 8

    Candiduria, Coagulopathy and Gastrointestinal Bleeding in Critical Illness

 

Introduction

    Critical illness can become increasingly complex when infectious complications are accompanied by progressive haematological abnormalities and bleeding. In this case of multidrug-resistant (MDR) Escherichia coli urosepsis with multiorgan dysfunction, the subsequent clinical course included Candida albicans candiduria, worsening thrombocytopenia, abnormal coagulation parameters and gastrointestinal bleeding.

    This part of the case series examines the documented clinical findings and their significance in the broader context of critical illness. It highlights the importance of interpreting microbiological results carefully, following laboratory trends over time and distinguishing documented findings from clinical interpretations that require further confirmation.

Clinical Course: Key Findings

    During the admission, the patient developed candiduria alongside a marked decline in platelet count and increasingly abnormal coagulation measurements. Bleeding was documented at multiple sites, followed by melena.

    Laboratory values are presented with their documented time points. Findings from different days should not be interpreted as if they were measured simultaneously.

Candiduria: Interpreting the Microbiology

    Urine microscopy showed budding yeast, and the urinary catheter was changed aseptically. The Day 13 urine culture grew Candida albicans at approximately 10⁵ CFU/mL. The serum beta-D-glucan result was negative. The documented treatment course included discontinuation of voriconazole and addition of micafungin.

    Candida isolated from urine in a catheterised patient does not, by itself, establish invasive fungal infection. Interpretation depends on the clinical context, symptoms, risk factors and evidence of infection beyond the urinary tract. A negative beta-D-glucan result is one piece of evidence, but it cannot independently exclude invasive candidiasis in every clinical situation.

Progressive Thrombocytopenia and Coagulation Abnormalities

    The platelet count declined from a previously documented value of 218 × 10³/µL to approximately 49 × 10³/µL on Day 15, 47 × 10³/µL on Day 16 and 30 × 10³/µL on Day 17. The haemoglobin concentration was 6.1 g/dL on Day 16.

    Coagulation testing showed prolonged prothrombin time and activated partial thromboplastin time. By Day 17, the aPTT had reached 131.7 seconds, while fibrinogen had declined from 702 to 177 mg/dL. Thromboelastography showed a markedly prolonged R time of approximately 44.8 minutes and near-absent early clot formation.

    The treating assessment considered sepsis-associated consumptive coagulopathy or evolving disseminated intravascular coagulation (DIC). However, the available findings do not independently establish a definitive DIC diagnosis. The documented record also does not provide a D-dimer result for a complete overt-DIC score.

    The markedly prolonged aPTT warrants careful interpretation rather than automatic attribution to sepsis alone. In a patient receiving dialysis, potential heparin exposure from the circuit or catheter lock is relevant to the differential assessment. Other causes of abnormal coagulation testing may also need consideration by the treating team.

Bleeding and Documented Management

    Oral and nasal bleeding were documented, followed by melena. The record describes blood-product support and haemostatic measures at different stages, including fresh frozen plasma (FFP), packed red blood cells (PRBCs), platelet support, vitamin K and tranexamic acid. Pantoprazole infusion was continued, while endoscopy was deferred.

    These interventions are reported as documented in the source material; the record describes some measures as given and others as planned at different stages. The available information does not establish the precise contribution of each intervention to subsequent laboratory changes or clinical progression.

Key Learning Points

   

• Interpret candiduria in the context of catheter use, clinical features and evidence for invasive infection.

   

• Follow platelet count, haemoglobin, PT/INR, aPTT and fibrinogen as a time-linked series rather than relying on isolated values.

   

• Consider sepsis-associated consumptive coagulopathy or evolving DIC when clinically appropriate, but distinguish a working assessment from a confirmed diagnosis.

   

• Investigate markedly prolonged coagulation times in context, including possible anticoagulant exposure in patients receiving dialysis.

   

• Document bleeding manifestations, laboratory trends, treatment decisions and the limitations of the available record clearly.

 

Conclusion

    This phase of the case illustrates the complexity of critical illness when candiduria, progressive thrombocytopenia, abnormal coagulation parameters and gastrointestinal bleeding occur during MDR E. coli urosepsis with multiorgan dysfunction. The clinical findings support careful serial assessment, contextual interpretation of microbiology and coagulation results, and clear separation of documented events from diagnostic conclusions that require further confirmation.