Disseminated Trichosporon mycotoxinivorans, Aspergillus fumigatus, and Scedosporium apiospermum Coinfection after Lung and Liver Transplantation in a Cystic Fibrosis Patient

Abstract

Trichosporon mycotoxinivorans is a novel pathogen recently found in cystic fibrosis patients. We report the first case of a disseminated fatal infection with T. mycotoxinivorans associated with invasive Aspergillus fumigatus and Scedosporium apiospermum infection after lung and liver transplantation in a cystic fibrosis patient. CASE REPORTA 35-year-old man with cystic fibrosis (CF) was admitted for rapid respiratory deterioration and high-level oxygen requirements with respiratory acidosis. He was a nonsmoker and was still working actively as a farmer until a few days before his admission. His past medical history included sinonasal polyposis and diabetes mellitus. He was in good general condition despite a severe obstructive pulmonary disease that had been stable over the previous 5 years, with a forced expiratory volume in the first second at 20% of that predicted. He also had a 5-year bronchial colonization with Pseudomonas aeruginosa and Aspergillus fumigatus.Because of respiratory deterioration despite noninvasive ventilation and antibiotics, an extracorporeal membrane oxygenation, inotropic support, and hemodialysis were started and an emergency double lung transplantation (LT) was performed. The immunosuppression included basiliximab and high-dose methylprednisolone for induction, a standard dose of tacrolimus, mycofenolate mofetil, and methylprednisolone for maintenance. Due to immediate postoperative acute liver failure, an emergency liver transplantation was performed on day 2 post-LT. Another dose of basiliximab and high dose of methylprednisolone were given. Antifungal prophylaxis with caspofungin (70 mg) started on the day of LT was discontinued the next day due to liver dysfunction. Amyloidosis AA (deposition of amyloid protein A) was diagnosed on explanted liver. The patient's condition remained stable, although invasive ventilation and hemodialysis were maintained. Routine bronchoalveolar lavage specimens at days 1 and 6 post-LT were positive for P. aeruginosa (treated with ceftazidime, ciprofloxacin, and meropenem) and A. fumigatus. Caspofungin was resumed (50 mg daily) at day 6 post-LT because an Aspergillus galactomannan detection test (Platelia Aspergillus antigen; Bio-Rad) became positive in serum.On day 9 post-LT, nonfebrile sleepiness was noted. Within 4 days, the neurologic condition worsened, with tetraparesis and coma. Cerebral magnetic resonance imaging (MRI) showed multiple foci of cortical, subcortical, and periventricular hyperinten-

Identification of Medically Relevant Species of Arthroconidial Yeasts by Use of Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry

“…For instance, T. mycotoxinivorans, a newly recognized pathogen associated with cystic fibrosis (47,48), was correctly identified. Examination of the relevance, accuracy, and taxonomic resolution of MALDI-TOF MS also was undertaken, to establish whether the identification results obtained were consistent with available molecular data from ITS and LSU bar-coding (15,24,27).…”

Purification and Characterization of a Mycelial Catalase from Scedosporium boydii, a Useful Tool for Specific Antibody Detection in Patients with Cystic Fibrosis

“…Although usually asymptomatic, this fungal colonization of the airways may sometimes lead to allergic bronchopulmonary mycoses, sensitization, or respiratory infections (8,13). In addition, due to the propensity of these fungi to hematogenously disseminate in cases of immunodeficiency and to their low susceptibility to current antifungals, a prior colonization of the airways by these fungi may compromise the success of lung transplantation, and several cases of fatal infections have been reported in CF patients who had undergone lung transplantation and were colonized by species of the S. apiospermum complex (14)(15)(16)(17).…”

Trichosporon mycotoxinivorans Infection in Patients with Cystic Fibrosis

“…The first case of human infection was reported in 2009 (7), and the report documented a fatal case of pneumonia caused by the organism in an adult CF patient. In a second report, T. mycotoxinivorans was one of the organisms associated with a disseminated fatal infection in a CF patient who had received lung and liver transplantation (8). The final case was reported in a cohort of CF patients who had Trichosporon infection: among eight cases, only one was reported to have T. mycotoxinivorans.…”

“…Standard laboratory methods alone are not reliable for this particular organism, as consistently shown in the literature and in our study. Definitive identification relies on DNA testing (7,8), which is not readily available in most clinical laboratories. The identification of the disseminated case in the second report required 16 days (8).…”

“…Definitive identification relies on DNA testing (7,8), which is not readily available in most clinical laboratories. The identification of the disseminated case in the second report required 16 days (8). In the present study, identification of the 4 isolates at the specialized reference laboratory using combined phenotypic and DNA sequencing methods required 9 to 15 days.…”