Disseminated Trichosporonosis in a Burn Patient: Meningitis and Cerebral Abscess Due to Trichosporon asahii

Abstract

A 44-year-old diabetic female presented to a hospital in Jamaica with thermal burns. Trichosporon asahii was isolated from facial wounds, sputum, and a meningeal swab. Dissemination of the fungus was demonstrated in stained histological sections of the meninges and a brain abscess at autopsy. Pure growth of the fungus from patient samples submitted and an environmental isolate obtained from a wash basin in the hospital supported the diagnosis. CASE REPORTA 44-year-old hypertensive, diabetic woman presented with partial and full-thickness thermal burns involving 50% of her total body surface area, including the face and neck, torso, upper limbs, and proximal portion of the lower limbs. She was admitted to the intensive care unit (ICU) for ventilatory support for suspected inhalational injury. Her initial hemoglobin level was 5.2 g/dl, her white blood cell count was 6.4 ϫ 10 9 /liter, her platelet count was 239 ϫ 10 9 /liter, and her blood urea nitrogen (BUN) and creatinine levels were 2 mmol/liter and 54 mol/liter, respectively. Management included fluid resuscitation, topical and systemic antibiotic therapy, surgical intervention for control of wound sepsis, and limb perfusion. She also received ceftriaxone for empirical antibiotic coverage, tetracycline ointment for facial burn wounds, and twice daily application of dressings using flumazine to the wounds on the body. Nursing and dietary supportive measures were also instituted.The patient was clinically stable on admission when a primary culture of sputum yielded a light growth of a yeast reported as "yeast not Candida albicans." However, despite broad-spectrum antibiotic coverage, signs of sepsis appeared within 5 days of admission. She developed multiorganism infection of the burn wounds, which were culture positive for Pseudomonas aeruginosa, Streptococcus group D, Bacteroides, Alcaligenes sp., and Stenotrophomonas maltophilia. Blood culture and culture of a femoral central venous catheter tip were also positive for Streptococcus group D and Acinetobacter sp. Sputum and urine cultures were negative at that time. Appropriate antibiotic intervention following antibiotic susceptibility testing of isolates was commenced, and 0.25% acetic acid was included in the dressings applied to wounds that were positive for Pseudomonas. Despite the continued use of antibiotics, she persistently showed clinical, biochemical, and hematological signs of sepsis. The patient's clinical status continued to deteriorate, and she developed multiorgan dysfunction.Over the period of hospitalization, gradually increasing BUN levels (mean, 20.9 mmol/liter; range, 9.1 to 32.1 mmol/ liter) and creatinine levels (mean, 287.2 mol/liter; range, 54 to 353 mol/liter) were recorded. Levels remained relatively high throughout the remainder of the patient's hospital stay and were consistent with renal failure.

Epidemiological study ofTrichosporon asahiiinfections over the past 23 years

“…Current research indicates that risk factors for Trichosporon infection include neutropaenia (an abnormally low amount of neutrophils), organ transplantation, diabetes, end-stage renal disease, HIV infection and use of immunosuppressive agents and invasive medical equipment [5,6,[20][21][22][23][24][25][26][27]. Trichosporonosis is associated with a variety of infection types, including superficial skin and hair infections, summer-type hypersensitivity pneumonitis (SHP), chronic pneumonia, meningitis, endocarditis, disseminated infections and fungaemia [28][29][30][31][32][33][34][35][36][37][38][39][40][41].…”

Candidemia in major burns patients

“…Candida albicans is the species most frequently isolated in major burn patients with fungal infection, even though some recent series have pointed to the predominance of non‐ albicans species . In addition to disseminated candidiasis, other invasive infections such as trichosporonosis, geotrichosis and saccharomycosis have been reported in these patients as well as infections by filamentous fungi ( Aspergillus , Fusarium and Mucor, among others) …”

Recurrent trichosporonosis with central nervous system involvement in an allogeneic hematopoietic stem cell transplant recipient

“…CNS trichosporonosis is uncommon in both the immunocompromised and the immunocompetent host. Reports of this condition in the literature are limited to case reports (5,(7)(8)(9). CNS trichosporonosis is usually fatal.…”