Trichosporon capitatum causing recurrent fungal endocarditis

Case report: Diagnostic and therapeutic challenges of fungal endocarditis by Trichosporon asahii in a child with congenital heart defects

Background

patients with congenital cardiopathies are the main group at risk for infective endocarditis (IE) in the pediatric population. Fungal etiology is responsible for 2%-4% of all IEs, and the Trichosporon genus is an increasingly prevalent cause of infections in human beings.

Case presentation

We describe a 9-year-old male with multiple surgical procedures to correct congenital cardiopathy defects, including insertion of RV-PA conduit, who was admitted due to suspicion of pneumonia and needed a surgical approach after being diagnosed with a mycotic pseudoaneurysm in the right ventricle's outflow tract, with dilation of the RV-PA conduit. The conduit was removed and antifungal treatment was started with Voriconazole after the agent was identified (T. asahii), with satisfactory therapeutic response. Approximately 4 years later, the patient was readmitted, presenting with intermittent fever, associated with nocturnal diaphoresis, dry cough, anxiety and chest pain. Vegetations consistent with T. asahii were evidenced in the RV-PA conduit, and a surgical approach was once again necessary.

Discussion

diagnostic methods and treatment of T. asahii endocarditis aren't yet standardized, and recurrent surgical approaches are needed due to the inefficacy of antifungal treatment.

Mycotic aneurysms due to Trichosporon asahii in a patient with ulcerative colitis under immunosuppression

Yeast fungi of the genus Trichosporon spp. can colonize the gastrointestinal tract in humans. In recent decades, the pathogenic role of Trichosporon asahii has been increasingly acknowledged especially in the setting of neutropenic patients with hematological malignancies. However, non-neutropenic patients who are immunosuppressed for other reasons are also at risk of developing invasive forms of this mycosis. We present the case of a 62-year-old male, with a history of ulcerative colitis under immunosuppressive treatment and previous exposure to antibiotics for various bacterial infections, who was admitted to the emergency department with a mycotic aneurysm of the abdominal aorta and left common iliac secondary to T. asahii infection. A multidisciplinary approach of the case (both early medical and surgical interventions) allowed the patient's favorable outcome. The patient was followed for more than two years with no evidence of relapse. We postulate that the diagnosis of invasive Trichosporonosis should be considered in patients with inflammatory bowel disease (IBD) under immunosuppressive treatment and with prior exposure to antibiotics.

Fatal course of Saprochaete capitata fungemia in children with acute lymphoblastic leukemia

Saprochaete capitata (S. capitata) is a very rare fungal pathogen that causes disseminated opportunistic infections in patients with hematologic malignancies. Fever resistant to broad-spectrum antibiotic and antifungal treatment is common in the presence of fungemia during the period of profound neutropenia. We describe three cases of leukemic children who died from S. capitata fungemia following a first febrile neutropenic episode after the induction of chemotherapy. S. capitata fungemia is an emergent infection associated with high mortality and low susceptibility to fluconazole and echinocandins. Awareness of this emergent infection is needed to ensure that it can be properly treated.

Genetic Variability among Blastoschizomyces Capitatus Isolates from Different Clinical Sources

Sixteen clinical isolates and nine ATCC reference strains of Blastoschizomyces capitatus were analysed genetically, examined for the cellobiose, arbutin and salicin assimilation and tested for the aspartyl-proteinase secretion. The restriction endonuclease analysis (REA) with HpaII and HinfI enzymes and the electrophoretic karyotype (EK) were investigated. Both the restriction enzymes revealed two groups (I, II) constituted by the same isolates: 17 isolates (68%) in group I and 8 (32%) in group II. The EK analysis revealed sixteen groups. These data prompts for a genetic variability of the isolates of Blastoschizomyces capitatus and their account in two distinct genetic groups as suggested by REA. This grouping was confirmed by examing the utilisation of cellobiose, arbutin and salicin. The tests for secretory aspartyl proteinase (Sap) were positive only for three isolates, suggesting a marginal role of this specific enzyme in pathogenesis for these isolates.

Geotrichum capitatum septicemia in patients with acute myeloid leukemia. Report of three cases

Geotrichum capitatum infection is uncommon, and has been exclusively reported in immunocompromised patients. The prognosis is poor with a mortality rate ranging from 50 to 90%. We report 3 cases of Geotrichum capitatum fungemia in neutropenic patients receiving chemotherapy for acute myeloblastic leukemia. The infection was successfully cured with voriconazole in 1 case and was fatal in the 2 remaining cases despite treatment with amphotericin B.

Nosocomial outbreak of Blastoschizomyces capitatus associated with contaminated milk in a haematological unit

In July 2002, Blastoschizomyces capitatus was isolated from four neutropenic patients in a haematology unit. Two patients died due to disseminated infection while the other two had oropharyngeal colonisation. Nosocomial acquisition of the fungus was suspected and epidemiological and environmental studies were undertaken. To determine the potential source for the acquisition of the fungus, epidemiological relationships between the patients were investigated. We performed surveillance cultures on all patients and took environmental cultures of air, inanimate surfaces, food samples, blood products and chemotherapy drugs. No direct contact transmission between patients was found and B. capitatus was isolated only in vacuum flasks used for breakfast milk distribution. All isolates were compared by four independent molecular typing methods: pulsed-field gel electrophoresis, genomic DNA restriction endonuclease analysis, randomly amplified polymorphic DNA, and polymerase chain reaction fingerprinting using a single primer specific for one minisatellite or two microsatellite DNAs. Milk vacuum flasks and clinical strains were genetically indistinguishable by all typing techniques. Milk vacuum flasks were withdrawn from all hospital units and no further B. capitatus infection was detected. Our findings suggest that clonal dissemination of a single strain of B. capitatus from vacuum flasks used for milk distribution was responsible for this nosocomial outbreak in the haematological unit.

Spondylodiscitis due to an emergent fungal pathogen: Blastoschizomyces capitatus, a case report and review of the literature

The study includes a case report and a literature review. The main objective of this study is to present a case of spondylodiscitis due to a fungal pathogen, Blastoschizomyces capitatus and to review the published literature on this emergent fungus in etiology of spondylodiscitis, and osteomyelitis. Osteoarticular involvement due to B. capitatus has been reported in six cases, and vertebral involvement has been seen in five of them. All of these cases had underlying malignancy. Infection is usually advanced at presentation. Case notes and online databases were reviewed. Organism was isolated from bone material in all of the cases and antibiotic treatment by antifungal agents cured the infection. We present another case of infectious spondylodiscitis due to B. capitaus, which is reported first in Turkey and tried to attract attendance to this emergent fungal pathogen as an etiologic agent of spine infections in cancer patients.

Blastoschizomyces capitatus Pneumonia in an Immunocompetent Male

Blastoschizomyces capitatus is an emerging fungal pathogen. It has been well characterized as a cause of local and disseminated disease in immunocompromised hosts, especially in the setting of neutropenia. We describe a case of B. capitatus pneumonia in an otherwise healthy man and review the clinical presentation, microbiologic characteristics, and treatment strategies for B. capitatus infections.

Invasive infections caused by Blastoschizomyces capitatus and Scedosporium spp

Blastoschizomyces capitatus, Scedosporium prolificans and S. apiospermum are emerging fungal pathogens that may cause disseminated disease in neutropenic patients. They can present as fever resistant to antibiotics and to wide-spectrum antifungal agents, although they may involve almost every organ. The proportion of recovery from blood cultures is high and they are characteristically resistant to most antifungal agents. Prognosis is poor unless patients recover from neutropenia. Voriconazole has good in-vitro activity and is currently the drug of choice for these infections.

Case report. Disseminated infection of Blastoschizomyces capitatus in a patient with acute myelocytic leukaemia

Blastoschizomyces capitatus infection in a 48-year-old man with acute myelocytic leukaemia is reported. A multiorgan involvement and fulminant course of the fungal infection resulted in the patient's death despite fluconazole prophylaxis, therapy with amphotericin B and administration of granulocyte colony-stimulating factor. Predisposing factors to the infection, clinical relevance of surveillance strains and in vitro antifungal susceptibility testing are discussed.

[Geotrichum capitatum infection in a neutropenic patient. Apropos of a case and review of the literature]

INTRODUCTION

Geotrichum capitatum sepsis are rare, occurring exclusively in immunocompromised patients.

EXEGESIS

We report the case of a patient with acute leukemia, presenting with chemotherapy-induced neutropenia and hospitalized in an intensive care unit for a severe sepsis. In spite of an antibiotic and antifungal treatment, the patient died of cardiorespiratory failure. Later on, blood cultures proved to be positive for Geotrichum capitatum.

CONCLUSION

If fungal infections are common in neutropenic patients, Geotrichum capitatum sepsis remain exceptional. The portal of entry is digestive or respiratory, and the invasion is favored by immunodepression and suppression of the normal microbial flora. Induced lesions can be multiorganic. The treatment is not well established, and the association of either amphotericine B and 5-fluorocytosine or amphotericine B and itraconazole would lead to better results. Nevertheless, the prognosis is still unfavorable, with a mortality rate of approximately 75%.

Geotrichum capitatum septicaemia in neutropenic patients: case report and review of the literature

We report a case of systemic infection with Geotrichum capitatum in a patient with acute myeloid leukaemia. Three days before death, the patient developed acute renal failure, probably caused by occlusion of glomerula with hyphae of G. capitatum. Up until now, prophylaxis and treatment of infections caused by Geotrichum capitatum have not been established. However, the prophylactic administration of high-dose itraconazole and the therapeutic use of liposomal amphotericin B are subjects of discussion.

Empirical liposomal amphotericin-B therapy in a neutropenic patient: breakthrough of disseminated Blastoschizomyces capitatus infection

Blastoschizomyces capitatus (Trichosporon capitatum) is an uncommon fungal pathogen. Infections have mostly been seen in immunocompromised patients and use of broad spectrum antibiotics was identified as a risk factor. Treatment has been extremely difficult. A report is presented about a case of fatal B. capitatum infection with clinical septicemia and multiorgan failure during intravenous liposomal amphotericin B therapy.

Geotrichosis of oral mucosa

A livid, sharply defined enanthema of the oral mucosa with ulcerations on the soft palate in a patient presenting with de novo acute myeloid leukaemia with prolonged, therapy-induced granulocytopenia (< 0.5 nl-1 for 113 days!) was diagnosed as geotrichosis. Geotrichum capitatum was identified both in vivo and in vitro. Pneumonic infiltrates in the upper lobes of both lungs were treated with amphotericin B infusions. Healing of the aforementioned enanthema was only achieved after addition of 5-fluorocytosine to therapy. Susceptibility determinations with several Geotrichum capitatum isolates led to the conclusion that amphotericin B was unsuitable as a therapeutic agent in this case. 5-Fluorocytosine and itraconazole exhibited superior antifungal and antimycotic activity.

Disseminated Blastoschizomyces capitatus infection in acute myeloblastic leukaemia. Report of three cases

Three new cases of Blastoschizomyces capitatus infection occurring in neutropenic patients with acute myeloblastic leukaemia are reported. B. capitatus was isolated from blood cultures in all patients. All three patients were treated with amphotericin B, but only one was cured from the infection. Our study confirms the emergence of B. capitatus as an opportunistic agent of disseminated fungal infection in leukaemic patients.

Comparative efficacies of amphotericin B, triazoles, and combination of both as experimental therapy for murine trichosporonosis

We assessed the activities of amphotericin B deoxycholate, liposomal amphotericin B, fluconazole, and SCH 39304 against 10 strains of Trichosporon beigelii in mice with hematogenous infections. Cyclophosphamide-immunosuppressed CF1 male mice were challenged intravenously with a lethal inoculum of T. beigelii (5 x 10(6) conidia per mouse) and were assigned to different treatment groups or were left untreated. Amphotericin B deoxycholate (1 mg/kg of body weight and liposomal amphotericin B (1, 5, and 10 mg/kg) were given parenterally once daily. Escalating doses (5, 10, and 20 mg/kg/day) of fluconazole and SCH 39304 were tested. We also compared the activity of amphotericin B deoxycholate plus fluconazole (1 and 10 mg/kg/day, respectively) with that of each agent alone. Fluconazole significantly prolonged the survival of mice infected with each of the 10 strains tested. Amphotericin B deoxycholate achieved various responses, improving the outcomes in mice infected with seven of the strains. Liposomal amphotericin B was not more effective than amphotericin B deoxycholate against the two strains tested. Both fluconazole and SCH 39304 reduced the kidney fungal counts in a dose-dependent pattern, with SCH 39304 being more active than fluconazole against one of the two strains tested. The activity of the combination of amphotericin B deoxycholate plus fluconazole appeared to be superior to that of either agent alone, especially in reducing the kidney fungal burden. Fluconazole is more active than amphotericin B deoxycholate against experimental murine trichosporonosis.

Osteomyelitis and intervertebral discitis caused by Blastoschizomyces capitatus in a patient with acute leukemia

We describe the first known case of vertebral osteomyelitis and discitis caused by Blastoschizomyces capitatus in a leukemic patient and the results of therapy. We also reconfirm the microbiological characteristics which differentiate this species from other yeastlike pathogens.

Endocarditis caused by Blastoschizomyces capitatus and taxonomic review of the genus

Blastoschizomyces capitatus Salkin, Gordon, Samsonoff et Rieder was found to be the etiologic agent of endocarditis in a patient with a prosthetic mitral valve. Cultures inoculated with peripheral blood and portions of the valve yielded B. capitatus. Examination of stained tissue sections revealed the presence of fungal filaments morphologically consistent with this organism. The salient characteristics of B. capitatus and the factors contributing to its recognition as a distinct taxon are described.

Long-term survival of a patient with prosthetic valve endocarditis due to Trichosporon beigelii

A case is described of a 49-year-old man with rheumatic aortic valve disease who developed endocarditis seven years after valvular replacement. Trichosporon beigelii was isolated from the blood, a peripheral thrombus, and the removed prosthesis. After two valve prosthesis replacements and prolonged antifungal therapy, the patient survived for four years, but eventually died as a consequence of multiple septic complications due to the same organism. To the authors' knowledge, this is the longest survival time of any reported case of Trichosporon prosthetic valve endocarditis.

Urinary tract infection caused by Hansenula anomala

A case of urinary tract infection due to Hansenula anomala is reported. The infection occurred in a cadaver kidney transplant patient who was receiving immuno-suppression therapy. Survey of the literature revealed that human infections due to this organism are rare and its causal relationship in urinary tract infection has not been previously reported.

First report of subcutaneous phaeohyphomycosis of the foot caused by Phoma minutella

Phoma minutella, a dematiaceous hyphomycete, was isolated to the exclusion of all other fungi from a subcutaneous inflammatory process on the foot of a farmer undergoing corticosteroid therapy for myasthenia gravis. Isolation was achieved on several nutrient media. Examination of stained smears and sections revealed dematiaceous fungal elements consistent with the mold. This is the first reported association of P. minutella with a human infection and only the second reported case involving a Phoma sp. as the etiologic agent of a subcutaneous infection.

Uncommon yeastlike zoopathogens and commercial systems for their identification

Opportunistic infections caused by yeasts or yeastlike fungi have increased in incidence in recent years as a result of clinical and therapeutic factors. Several formerly uncommon yeastlike zoopathogens--Candida lusitaniae, Candida paratropicalis (sucrose-negative variant of Candida tropicalis), Trichosporon beigelii, Blastoschizomyces capitatus, and Rhodotorula species--have been isolated from patients with invasive infections. The increased isolation of such opportunistic pathogens from a variety of clinical specimens has created a demand for simple, rapid, reliable, and accurate commercial systems to assist laboratorians in identification. Here we summarize the manual and automated systems currently available and present detailed descriptions of three representative commercial products, i.e., API 20C, Abbott Quantum II, and API Yeast-Ident.

DNA relatedness, taxonomy, and medical significance of Geotrichum capitatum

Among the clinical isolates hitherto identified as Geotrichum capitatum, two groups were defined from DNA-DNA reassociation experiments. This confirms the existence of two closely related, human-pathogenic Geotrichum species, namely, G. capitatum and G. clavatum. A third group of strains from cactus rots, though morphologically identical to G. capitatum, has a lower moles percent G + C of DNA. The three groups can be recognized by a combination of morphological and physiological characters.

Immunoblot analysis of the serological response in invasive Trichosporon beigelii and Blastoschizomyces capitatus infections

The serological response to Trichosporon sp. was examined by the immunoblot technique. Antibodies to a range of antigens (200 to 16 kilodaltons) were detectable in three patients with invasive Trichosporon beigelii or Blastoschizomyces capitatus infections and 10 uninfected controls. High levels of preexisting antibodies may contribute to the rarity of systemic infections.

Trichosporon beigelii endocarditis as a complication of peritoneovenous shunt

Trichosporon is a common cause of superficial mycotic infection but has rarely been associated with endocarditis. The case of a patient who had a peritoneovenous shunt for chronic intractable ascites due to Laennec liver cirrhosis is described. The shunt was revised on several occasions, and the last procedure was complicated by a draining skin sinus wound. To the authors' knowledge, this is the first reported case of Trichosporon endocarditis complicating a peritoneovenous shunt.

Systemic infection with Trichosporon capitatum in two patients with acute leukaemia

Trichosporon capitatum was isolated from the blood of two patients with acute leukaemia who were undergoing induction chemotherapy. Both patients died of their infections, and the fungus was cultured from their tissues after death. Systemic infection was proved by demonstrating the same pattern of fluorescein-labelled lectin staining of fungal elements in the tissues as was shown by the fungal isolates.

Trichosporon capitatum: thrush-like oral infection, local invasion, fungaemia and metastatic abscess formation in a leukaemic patient

A thrush-like oral infection with subsequent alveolar abscess formation and a positive blood culture due to Trichosporon capitatum developed in a patient with acute myelogenous leukaemia. Later T. capitatum was identified by indirect immunofluorescence in multiple splenic abscesses. The infection was controlled by immediate aggressive treatment with amphotericin B, flucytosine and rifampicin and by splenectomy. This case of systemic T. capitatum infection resembles somewhat the invasive mycosis due to candida.