Management and treatment of Magnusiomyces capitatus (Geotrichum capitatum) pleural infection in a non-neutropenic patient with posaconazole. A new therapeutic opportunity?

Magnusiomyces capitatus may cause uncommon yet severe infections, especially in patients with haematologic disorders. Diagnosis may be difficult and time-consuming and newer approaches are required including the MALDI-TOF technique implemented with the detection of fungal antigens in the body fluids. The recommended treatment includes amphotericin B alone or in combination with flucytosine. We describe a case of a non-neutropenic patient with M. capitatus pleural infection, as identified by MALDI-TOF, positivity for galactomannan antigen in the BAL fluid, and successfully treated with oral posaconazole in single therapy.

Geotrichum capitatum septicemia in a hematological malignancy patient with positive galactomannan antigen: case report and review of the literature

Geotrichum capitatum, formerly known as Trichosporon capitatum, is an uncommon but frequently fatal invasive fungal infection in immunocompromised patients, especially in hematological malignancies. We report a seven-year-old patient with acute myeloid leukemia with Geotrichum septicemia with involvement of the lungs, liver, spleen, and kidneys, who had a favorable outcome after therapy. Alteration of antifungal treatment to liposomal amphotericin B resolved the fever with favorable clinical response.

[Investigation of in vitro activities of fluconazole, itraconazole and voriconazole against clinical isolates of Blastoschizomyces capitatus (Geotrichum capitatum) by two different methods]

Blastoschizomyces capitatus is an emerging opportunistic pathogen that may lead to invasive infections particularly in neutropenic patients. In this study, the in vitro activities of fluconazole, itraconazole and voriconazole against 15 clinical B. copitatus isolates were determined by microdilution method (MD) and Etest. The isolation and identification of the isolates were done by standard mycological methods. MD tests were done in accordance with CLSI microdilution method (M27A-2). Etest was performed according to the instructions of the manufacturer (AB Biodisk, Sweden) by using RPMI-2% glucose. Since susceptibility breakpoints were not yet established for B. copitatus, only the distribution of the MIC values obtained for the tested antifungals were given. MIC values were determined after 48 h incubation and by using MIC-2 value for all the drugs tested. At 48 h, MIC90 values obtained by MD and Etest were 16 and 32 microg/ml, 0.5 and 1 microg/ml, 0.5 and 1 microg/ml for fluconazole, itraconazole and voriconazole, respectively. These results suggested that voriconazole and itraconazole had favorable activity against B. capitatus isolates. However, the activity of fluconazole remained poor and limited at least for a significant number of isolates. Percent agreement of Etest with MD method within +/-1 dilution range and at 48 hour for fluconazole, itraconazole and voriconazole were 86.7%, 80% and 73.3%, respectively, suggesting a higher agreement of the two methods for fluconazole as compared to itraconazole and voriconazole. Etest tended to generate 1-2 fold higher MICs as compared to MD MICs for most of the isolates of this particular fungus. In conclusion, further studies are required for determination of the optimal susceptibility testing method and the MIC breakpoints for B. capitatus.

Invasive cutaneous infection withGeotrichum candidum– sequential treatment with amphotericin B and voriconazole

A rare case of an invasive cutaneous infection by Geotrichum candidum in an 80-year-old male patient with diabetes mellitus is reported. The primary site of infection manifested after trauma as an ulcerative lesion on the distal phalanx of the midfinger and extended throughout the right hand. Histological examination showed fungal invasion in the deep dermis without vascular involvement and G. candidum was grown in cultures from the biopsy material. Angiography revealed severe obstructive disease of the right brachial artery and its branches. Treatment, after susceptibility testing of the isolated strain, consisted of sequential administration of intravenous liposomal amphotericin B with oral voriconazole followed by liposomal amphotericin B, resulting in substantial improvement of the infection.

Effect of antifungal treatment in a murine model of blastoschizomycosis

Blastoschizomyces capitatus is an emerging pathogenic fungus that can cause deep invasive diseases in neutropenic patients. We developed a model of disseminated blastoschizomycosis in immunosuppressed mice to evaluate the effectiveness of amphotericin B, flucytosine, fluconazole and voriconazole. High-dose fluconazole was the most effective drug at prolonging the survival of mice and at reducing fungal burden in the kidneys, spleen and liver.

Aspergillus galactomannan enzyme-linked immunosorbent assay cross-reactivity caused by invasive Geotrichum capitatum

We report three cases of invasive Geotrichum capitatum infection in patients with acute leukemia for which an enzyme-linked immunosorbent assay (ELISA) for Aspergillus galactomannan was positive, with no evidence of aspergillosis. Supernatants obtained from suspensions of 17 G. capitatum strains gave positive reactions with the Aspergillus galactomannan ELISA. These clinical and laboratory data seem to suggest that G. capitatum produces a soluble antigen that is cross-reactive with Aspergillus galactomannan.

Polymicrobial keratomycosis in a three-year-old child

PURPOSE

To describe a previously unreported case of polymicrobial mycotic keratitis caused by an association between Candida lusitaniae, C. parapsilosis, and Geotrichum candidum.

METHODS

A three-year-old child with an antecedent trauma with vegetable matter and a prolonged use of corticosteroid eyedrops developed fungal keratitis.

RESULTS

The isolates of the corneal scraping using Sabaraud dextrose agar grew C. lusitaniae, C. parapsilosis, and G. candidum. After topical 0.2% and systemic fluconazole treatment, the corneal lesion resolved with no recurrence.

CONCLUSIONS

Corneal trauma with vegetables and the indiscriminate use of corticosteroids are important risk factors for mycotic keratitis. A combination of topical 0.2% and systemic fluconazole therapy was effective in the treatment of this mycotic association. This is the first report of fungal keratitis caused by C. lusitaniae and G. candidum.

[Evaluation of species distribution of yeasts isolated from intensive care units during the four years period]

The aim of this study was to evaluate the distributions of yeast species according to the years and to detect the emerging pathogens in intensive care units (ICU). For this purpose, yeast isolation rates were detected retrospectively, in the following time periods: Period I: April-December 2001; period II: January-December 2002; period III: January-December 2003; period IV: January-December 2004. A total of 490 yeast isolates recovered from 462 clinical specimens obtained from 360 different ICU patients were investigated during these periods. Urine (62.1%), blood (13.6%) and tracheal aspirate (8.7%) samples were detected as the most common specimens. Of these isolates, 53.3% were identified as Candida albicans, 14.5% as C. tropicalis, 12.2% as C. glabrata, 6.5% as C. parapsilosis, 4.5% as Trichosporon spp., 3.9% as C. kefyr, 1.6% as C. krusei, 1.4% as Geotrichum candidum and 2.1% as other Candida species. The isolation rates of C. albicans in the periods of I to IV were found as 47.7%, 55.5%, 41.7% and 62.4%, respectively. The decrease between the second and third periods, and increase between third and fourth periods were statistically significant (chi2 = 4.15, p = 0.04 and chi2 = 8.32, p = 0.004). C. glabrata was the second most common species in the first and second periods (14.8% and 15.5%, respectively), followed by C. tropicalis (12.5% and 10.0%, respectively), however this array has changed in the third and fourth periods (C. tropicalis was the second with the rates of 16.7% and 16.8%, while C. glabrata placed in the third line with the rates of 14.8% and 7.6%, respectively). It was concluded that C. albicans has still been the most frequent species among yeast isolates of ICU's in our hospital; however, the incidence of non-albicans species like C. glabrata and C. tropicalis has increased.

Invasive infections caused by Trichosporon species and Geotrichum capitatum in patients with hematological malignancies: a retrospective multicenter study from Italy and review of the literature

Trichosporonosis is an uncommon but frequently fatal mycosis in immunocompromised patients. A multicenter retrospective study was conducted to characterize cases of proven or probable invasive trichosporonosis diagnosed over the past 20 years in Italian patients with hematological diseases. Of the 52 cases identified, 17 were classified as Trichosporon sp. infections and 35 were attributed to Geotrichum capitatum. Acute myeloid leukemia accounted for 65.4% of the cases. The incidence rates of Trichosporon sp. and G. capitatum infections in acute leukemia patients were 0.4 and 0.5%, respectively. Overall, 76.9% of cases had positive blood cultures. Pulmonary involvement was documented in 26.9% of cases. Death was reported for 57.1% of G. capitatum infections and for 64.7% of Trichosporon sp. infections. A literature review on trichosporonosis in patients with any underlying disease or condition reveals G. capitatum as a predominantly European pathogen, particularly in certain Mediterranean areas, while Trichosporon sp. infections are seen with similar frequencies on all continents. The majority of published Trichosporon sp. and G. capitatum infections occurred in patients with hematological diseases (62.8 and 91.7%, respectively). Well over half of these were suffering from acute leukemia (68 and 84% of patients with Trichosporon sp. and G. capitatum infections, respectively). Crude mortality rates were 77% for Trichosporon spp. and 55.7% for G. capitatum. The optimal therapy for trichosporonosis has yet to be identified; however, in vitro experiences are providing encouraging evidence of the potential role of the new triazoles, in particular, voriconazole.

Fatal Blastoschizomyces capitatus sepsis in a neutropenic patient with acute myeloid leukemia: first documented case from Greece

Blastoschizomyces capitatus (formerly known as Geotrichum capitatum and Trichosporon capitatum) is a rare, yet an emerging, cause of invasive infections in immunosuppressed patients. Profound and prolonged neutropenia is the crucial predisposing factor for this yeast infection. Blastoschizomyces capitatus was isolated from peripheral blood cultures of a profoundly neutropenic patient with acute myeloid leukemia (M2 FAB). Despite administration of antifungal chemotherapy with liposomal amphotericin B at 4.5 mg kg(-1) daily, the patient succumbed 4 days after initiation of treatment. Infections attributed to B. capitatus have generally a poor prognosis, although the yeast shows in vitro susceptibility to antifungal agents. Low flucytosine, caspofungin acetate, voriconazole and amphotericin B minimum inhibitory concentration values were also recorded with our isolate. The clinical relevance of the in vitro susceptibility testing against the isolate and the current antifungal chemotherapy regimens against B. capitatus systemic infections are discussed.

Coinfection of Cryptosporidium and Geotrichum in a case of AIDS

A 32 year old male, positive for human immunodeficiency virus (mY) antibodies, was found to be positive for multiple opportunistic infections by a parasite and a fungi, which is a very rare occurrence. Cryptosporidium and Geotrichum were simultaneously detected from his stool and sputum respectively.

Duodenal colonization by Geotrichum candidum in a child with transient low serum levels of IgA and IgM

Fungal colonization was observed in the duodenal biopsy specimens of a nine-year-old girl who complained of anorexia and epigastric pain. Endoscopy revealed gastric redness and Geotrichum candidum was identified in the duodenum by histopathology and tissue culture. Immunologic work-up showed low serum levels of IgA and IgM. She was treated with ranitidine and antacids for gastritis. At follow-up, the levels of immunoglobulins had normalized, no fungal elements were detected, and clinical symptoms had disappeared. Duodenal invasion by G. candidum has not been described so far. Duodenal colonization by G. candidum may occur when mucosal immunity is disturbed and may be the source of dissemination in severe immunodeficiency states.

Isolation and identification of Geotrichum candidum as an etiologic agent of geotrichosis in Bulgaria

Geotrichosis affects mainly patients with systemic diseases like diabetes mellitus, leukoses, neoplasms etc. Clinically, it is similar to candidiasis and may occur as an oral, vaginal, skin, or systemic infection. Clinical specimens (98 sputa and 67 oral smears) were collected and studied using microscopic examination of Gram stained preparations and culture sampling between 1995 and 1997. Geotrichum candidum was isolated as a single pathogen in 8 sputum and 7 oral smear samples. Ten-day antifungal treatment with Nizoral was applied and resulted in relatively quick clinical improvement. The presented cases are the first cases of pulmonary and oral infections reported in our home practice in which Geotrichum candidum species was identified as a pathogen. The identification of Geotrichum candidum using combination of colonial and microscopic morphologic features increase the possibilities for diagnostic decision.

[Secondary active-evolutive cavitary pulmonary tuberculosis of the apicodorsal segment of the left upper lobe associated with bronchial tuberculosis and bronchial geotrichosis]

A case of active pulmonary secondary tuberculosis associated with bronchial tuberculosis and bronchial geotrichosis is presented. This association is infrequent. Favoring factors: local and general immunodepression (recurrent infection with pyogenic germs, rubella, neutropenia, aggressive antibiotherapy, iron deficiency). The diagnosis was based mainly on the bacteriological sputum examination for bK (smear and culture) and the mycologic examination (smear and culture) of the bronchial aspiration, identifying Geotrichum candidum. The treatment consisted of antituberculous and antimycotic drugs, bronchodilators, bronchial aspirations and local endoscopic administration of antimycotic drugs.

Disseminated Geotrichum infection

Intensive chemotherapy has prolonged survival in cancer patients. Unfortunately it has also predisposed them to unusual infections because of their immunocompromised state. We report a case of fungal septicaemia caused by Geotrichum candidum, an imperfect yeast of low virulence in a young girl with acute lymphoblastic leukaemia. It was successfully treated with amphotericin B. The morphological characteristics of this fungus leading to its identification are described.

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.

Gastrointestinal phycomycosis in acute nonlymphatic leukemia

A 37-year-old patient with acute nonlymphatic leukemia developed gastrointestinal phycomycosis during failure in bone marrow production. The clinical presentation was of acute typhlitis. Laparotomy revealed a necrotic mass in the region of the iliocecal valve, and on histologic examination hyphae of phycomycetes with invasion of the blood vessels were seen. The patient died as a result of widespread infection.

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.

Necrotizing mycotic dermatitis in snakes: clinical and pathologic features

Necrotizing mycotic dermatitis was diagnosed in 6 snakes. Cutaneous lesions involved ventral and lateral scales. Each clinical diagnosis was confirmed by fungal culture and light microscopic evaluation of biopsied scales. The differential clinical considerations included contact dermatitis and bacterial dermatitis.

Cutaneous geotrichosis in the red flamingo (Phoenicopterus ruber)

In three flamingos (Phoenicopterus ruber), which died showing extensive necrotic inflammation of the skin of the webs and the legs, the presence of abundant mycelium and arthrospores was shown in the altered dermis and epidermis. From all the lesions Geotrichum Candidum was isolated in pure culture. Inoculation of suspensions of the fungus into domestic chickens and mice produced granulomas or more purulent nodules with central growth of abundant mycelium. From 20 of 28 experimental animals, G. candidum was reisolated from the lesions in pure culture 2 weeks after the inoculation. It is suggested that alteration of the skin by e.g., prolonged contact with pondwater, the presence of small wounds and the advanced age of the birds, acting as predisposing factors may be necessary in establishing this disease.

The ultrastructure of Geotrichum candidum hyphae

Complete septa divide the hyphae of Geotrichum candidum into many compartments or cells. Two cell types are readily recognizable, (i) the apical cell, delimited by one septum and the surrounding cell wall, and (ii) the sub- or non-apical cell, delimited by two septa and the surrounding cell wall. Vacuolation of the apical cells is slight compared with that of subapical cells. Apical cells contain many vesicles, some of which are elongated and branched, possibly forming an interconnecting tubular network; other vesicles were observed distributed about the apical zone or aggregated to form an apical body (the Spitzenkörper). Vesicles are also evident in subapical cells, but only in association with developing septa. Golgi bodies were not observed in any cells, their function in vesicle production possibly being taken by a modification of part of the endoplasmic reticulum. Both cell types contained mitochondria with contrasting electron-staining properties. Some stages of mitosis were observed. The nucleus appears to retain its envelope throughout division and exhibits intranuclear microtubules attached to spindle plaques. Septa were formed by a centripetal deposition of wall material, plasmodesmata developing during this process. Another deposition of wall material occurs after the centripetal deposition thus allowing a secondary thickening of the septum to take place.