Disseminated Nosocomial Fungal Infection by Aureobasidium pullulans var. melanigenum : a Case Report

Abstract

We report on a rare case of disseminated nosocomial fungal infection due to Aureobasidium pullulans var. melanigenum in a severely traumatized patient. Repeated blood and urine cultures yielded multicellular filamentous hyphal structures of varying size accompanied by budding yeast-like-cells of ellipsoidal morphology. The patient became asymptomatic after fluconazole therapy. CASE REPORTThe patient, a 28-year-old male, was admitted to the intensive care unit of the Ospedali Riuniti of Reggio Calabria, Reggio Calabria, Italy, following multiple traumas due to a road accident. The patient suffered a head trauma and had a Glasgow coma scale rating of III-IV. After initial treatment with standard life support measures to stabilize hemodynamic and respiratory parameters, the patient underwent a total-body computed tomography scan, which showed diffuse cerebral edema, hemoperitoneum, multiple fractures of the left femur and tibia, a suspected pelvic fracture, and multiple ruptures of the liver's right lobe, which made immediate surgery mandatory. After surgery, the patient underwent mechanical ventilation and prolonged total parenteral nutrition.Following the isolation of a methicillin-resistant strain of Staphylococcus epidermidis from a blood culture (BCB-Slide system; Roche Products Pty. Ltd.) antibiotic therapy was started, with teicoplanin at 800 mg/day plus vancomycin at 2 g/day, divided into two doses daily. Four days later, following the onset of dyspnea and fever (37.5 to 38°C), a pulmonary infection was suspected. Laboratory data included a total leukocyte count of 10.7 ϫ 10 9 /liter with 70% neutrophils, 26% lymphocytes, and 4% monocytes. Microbiological examination of a bronchial aspirate showed the presence of Acinetobacter anitratus var. anitratus. Antibiotic therapy was therefore changed, replacing teicoplanin with ceftazidime pentahydrate at 4 g/day. After an initial decrease in body temperature lasting 3 days, fever increased again to 40°C. Therefore, a new blood culture was carried out, leading to the isolation of Pseudomonas aeruginosa. On the basis of antibiogram results, antibiotic treatment was changed again, with aztreonam at 6 g/day plus tobramycin at 300 mg/day, divided into three doses daily. Six days later, since fever was stable at around 38°C and the patient's condition was not improving, new cultures from blood and urine were made. After 72 h of incubation, the blood culture became diffusely turbid and several smooth and mucoid colonies appeared on agar growth media (chocolate agar and malt agar) enclosed in the BCB-Slide Roche system (Fig. 1). The urine culture, in contrast, was negative.Microscopic examination of fungal cultures revealed multicellular filamentous hyphal structures of varying size accompanied by budding ellipsoidal yeast-like cells, both in the blood culture and in the colonies growing on agar media. These fungal isolates were subsequently classified as Aureobasidium pullulans.Immediately before starting antifungal therapy, a new set of blood and urine cultures and a cu...

Aureobasidium pullulans infection in a patient with chronic lymphocytic leukemia

“…Its pathogenic ability in humans is becoming recognized, especially in situations of immunosuppression. However, its pathogenic mechanism remains unknown [2][3][4][5][6] .…”

Subcutaneous mycosis and fungemia by Aureobasidium pullulans: a rare pathogenic fungus in a post allogeneic BM transplant patient

“…2 It has also been isolated from peritoneal fluids and central venous catheters, but when isolated from healthy subjects, it is considered as a contaminant. 3 Disseminated systemic infection as in our patient has been reported in only four cases so far. Of the four cases, one had AML, 4 the second patient had ovarian carcinoma 5 (both had Hickman catheters in situ), the third patient had met with a road traffic accident with accidental inoculation of pathogen 3 and the fourth was a child with congenital heart disease who had undergone closure of an atrial septal defect with a Goretex patch.…”

“…3 Disseminated systemic infection as in our patient has been reported in only four cases so far. Of the four cases, one had AML, 4 the second patient had ovarian carcinoma 5 (both had Hickman catheters in situ), the third patient had met with a road traffic accident with accidental inoculation of pathogen 3 and the fourth was a child with congenital heart disease who had undergone closure of an atrial septal defect with a Goretex patch. 2 Cutaneous involvement by Aureobasidium is also rare, and on an extensive search of the literature we could find only two case reports in patients of kidney and liver transplant.…”

“…The duration of treatment is not certain, though most patients received antifungal treatment for 4-8 weeks. 2,3 Our patient is now 5 months post second transplant and is doing well with no chronic sequelae of infection.…”

“…Amphotericin-B alone or in combination with azoles has been tried with variable success. [3][4][5]8,9 Combination therapy is probably the treatment of choice. The duration of treatment is not certain, though most patients received antifungal treatment for 4-8 weeks.…”