Combined surgical and antifungal treatment of a subcutaneous infection due to Paecilomyces lilacinus

Purpureocillium lilacinum an emergent pathogen: antifungal susceptibility of environmental and clinical strains

Purpureocillium lilacinum is a filamentous and hyaline fungus cosmopolitan, saprophytic, largely used in the biological control of plant-parasitic nematodes and insects, also considered an emerging and opportunistic human pathogen. The standard treatment for hyalohyphomycosis caused by P. lilacinum is not yet defined, since this fungus is resistant to different antifungals, in vitro and in vivo. The aim of this study was to evaluate and compare in vitro antifungal activity against environmental and clinical P. lilacinum isolates and our results demonstrated that these isolates can be resistant to newer generation triazoles, such as voriconazole, and to caspofungin, a drug of the echinocandin class. In summary, we highlight the importance of knowing the different susceptibility profiles of P. lilacinum isolates, and besides that, the emergence of uncommon human and animal opportunistic fungi, such P. lilacinum, especially during COVID-19, highlight the need for antifungal susceptibility testing of isolates since empirical therapy with different treatment schedules failed in great number of patients.

Experimental Hyalohyphomycosis by Purpureocillium lilacinum: Outcome of the Infection in C57BL/6 Murine Models

Purpureocillium lilacinum is a filamentous, hyaline fungus considered an emerging pathogen in humans. The aim of our study was to evaluate the outcome of hyalohyphomycosis in C57BL/6 murine models inoculated with two clinical P. lilacinum isolates (S1 and S2). Each isolate was inoculated in mice randomly distributed in immunocompetent (CPT) and immunosuppressed (SPS) groups. Mice were evaluated at day 7, 21, and 45 after inoculation for histopathological analysis, recovery of fungal cells, and immunological studies. Histological analysis showed scarce conidia-like structures in lung tissue from CPT mice and a lot of fungal cells in SPS mice inoculated with S2 compared to mice inoculated with S1. The maximum recovery of fungal cells was seen in CPT mice inoculated with both isolates at day 7, but with mean significantly higher in those inoculated with S2 isolate. Phenotypical characterization of T cells showed TCD8⁺ lymphocytes predominance over TCD4⁺ in immunosuppressed mice infected and control groups. We also observed higher percentages of the central and effector memory/effector phenotype in CPT mice infected with S2 strain, especially in TCD8⁺ in the initial period of infection. Regulatory T cells showed higher percentages in immunosuppressed, predominantly after the acute phase. Our results showed that the P. lilacinum is a fungus capable to cause damages in competent and immunosuppressed experimental hosts. Furthermore, S2 isolate seems to cause more damage to the experimental host and it was possible to identify different cellular subsets involved in the mice immune response.

Characteristics of Paecilomyces lilacinus infection comparing immunocompetent with immunosuppressed murine model

The characteristics of Paecilomyces lilacinus infection were evaluated using two murine experimental models: immunocompetent and immunosuppressed. The evaluation criteria for characteristics of infection were clinical signs, weight loss, survival rates, histopathological alterations and the number of viable fungal cells re-isolated from different organs; and those for immunological status were in vitro lymphoproliferative response, cell surface phenotyping and IFN-γ production. Morphological evaluation showed that P. lilacinus isolates presented morphological characteristics consistent with those described in the literature. The immunocompetent mice could be infected by the fungi, but they did not develop the disease, unlike the immunosuppressed mice, which showed clinical signs of mycosis in an environment of suppressed cellular immune response. The hypothesis of latent infection reactivation in mice was not confirmed. The difference observed in the infection rate of the two fungi isolates points to an intrinsic variation between strains of P. lilacinus and led us to hypothesise that even in the presence of immunosuppressed environment, the fungus virulence can play a role in the pathogenesis of hyalohyphomycosis.

Pulmonary Paecilomyces lilacinus Infection in a Cat

A 6-year-old, spayed female domestic shorthair cat was referred for an intermittent cough and wheezing of 3 to 4 months' duration. Thoracic radiography revealed atelectasis of the right middle and caudal lung lobes with hyperinflation of the accessory lobe, consistent with bronchial obstruction. Bronchoscopy confirmed a narrowing of the right mainstem bronchial lumen; however, positive-pressure ventilation resulted in a severe pneumothorax. A lateral thoracotomy and right caudal lung lobectomy resulted in complete resolution of the pneumothorax and respiratory signs. Histopathology and culture of the lung revealed Paecilomyces lilacinus. The cat was placed on itraconazole therapy for 6 months. Since dismissal from the hospital, the cat has not exhibited clinical evidence of wheezing, coughing, or dyspnea and is neurologically normal.

Clinical manifestations, treatment and outcome of Paecilomyces lilacinus infections

The fungus Paecilomyces lilacinus is an emerging pathogen that causes severe human infections, including devastating oculomycosis. Usually, it shows low susceptibility to conventional antifungal drugs in vitro, and variable susceptibility to novel triazoles. A review of the published literature identified 119 reported cases of human infection by P. lilacinus between 1964 and 2004. Most were cases of oculomycosis (51.3%), followed by cutaneous and sub-cutaneous infections (35.3%), and a smaller group of miscellaneous infections (13.4%). Lens implantation is the most frequent predisposing factor for oculomycosis. Cutaneous and sub-cutaneous infections occur mainly in solid organ and bone marrow transplant recipients, although surgery and primary or acquired immunodeficiency are also relevant predisposing factors. Infections in apparently immunocompetent patients have also been reported. Surgical debridement combined with antifungal drug therapy, or the correction of predisposing factors, such as neutropenia, are usually required to obtain improvement. Treatment with traditional antifungal drugs often fails. Voriconazole has demonstrated good activity in both cutaneous and ocular infections in the few cases in which this drug has been used. The new triazoles ravuconazole and posaconazole show good in-vitro activity against P. lilacinus and could be promising therapeutic alternatives.

Identification of Candida fabianii as a cause of lethal septicaemia

Infections caused by rare fungal species of low pathogenic potential become increasingly common in hospital settings. The identification of these species presents a major challenge for the clinical mycology laboratory. We describe a case of fatal septicaemia caused by Candida fabianii. The use of common biochemical approaches led to misidentification of the isolate as Candida utilis. Sequencing of the internal transcribed spacer regions (ITS1 and ITS2) allowed unequivocal species identification.