Pseudallescheria boydii (Anamorph Scedosporium apiospermum) Infection in Solid Organ Transplant Recipients in a Tertiary Medical Center and Review of the Literature

Castiglioni, Barbara; Sutton, Deanna A.; Rinaldi, Michael G.; Fung, John J.; Kusne, Shimon

doi:10.1097/00005792-200209000-00001

Cited by 199 publications

(168 citation statements)

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“…This patient was treated by surgical resection of the affected hepatic artery together with combined voriconazole and terbinafine therapy (19). Mortality rates of 79 to 100% have been reported for disseminated infection caused by both S. prolificans and S. apiospermum (4,24).…”

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Fatal Mycotic Aneurysms Due to Scedosporium and Pseudallescheria Infection

et al. 2011

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Angioinvasive complications of Scedosporium infections are rare. We report two cases of mycotic aneurysm, following apparent localized infection, due to Scedosporium apiospermum and Pseudallescheria boydii. The thoracoabdominal aorta was affected in one patient, and cerebral vessels were affected in the other. Despite voriconazole therapy and surgical resection, the patients died. Previously reported cases are reviewed. CASE REPORTSPatient A. A 55-year-old male with diabetes mellitus who was the recipient of a kidney transplant from a living related donor presented in 2009 with a left index finger lesion, following a trivial gardening injury. Immunosuppressive treatment included mycophenolate mofetil (500 mg thrice daily), tacrolimus (3 mg twice daily), and prednisolone (10 mg daily), with a course of therapy with methylprednisolone (1 g daily for 3 days) in the preceding 6 months. A culture of material from the lesion grew Scedosporium apiospermum and Pseudallescheria boydii. The in vitro MIC of voriconazole was 1 g/ml (5). X rays of the hand showed no evidence of osteomyelitis, and there were no abnormalities upon chest X ray and cerebral computed tomography (CT) scanning. He received 3 months of oral voriconazole (200 mg twice daily after a loading dose of 6 mg/kg twice daily), with unchanged immunosuppression, with apparent complete clinical response.Nine months later, the patient developed progressive, severe flank and lower back pain. He was afebrile and his blood pressure was 190/100 mmHg. There was bilateral soft tissue tenderness of the mid-lumbar region but no vertebral or abdominal tenderness. A CT scan of the abdomen revealed nonspecific thickening of the aortic wall at the level of the third and fourth lumbar vertebra (LV3 to LV4). Magnetic resonance imaging (MRI) of the thoracolumbar-sacral vertebra showed destruction of LV4 without evidence of discitis between LV3 and LV4. A paravertebral abscess was observed extending from the 10th thoracic vertebra (TV) to the LV4 level (Fig. 1a), in addition to inflammatory aortitis with aneurysm formation of the aorta from the level of TV9 to LV4 (Fig. 1b).Empirical therapy with vancomycin, rifampin, and ciprofloxacin was commenced. Results from blood cultures were negative for bacteria and fungi. Drainage of the paravertebral abscess yielded 20 ml of purulent material; no organisms were seen on Gram or Ziehl-Nielsen staining. S. apiospermum and P. boydii were cultured after 14 days of incubation. A single, 1-by 2-cm subcutaneous nodule then appeared over the patient's right wrist. Histopathological examination (Gromori-Grocott and periodic acid-Schiff [PAS] staining) of the excised lesion revealed granulomatous inflammation and septate hyaline fungal hyphae; S. apiospermum and P. boydii were recovered after culturing. Treatment with voriconazole was reinitiated (6 mg/kg twice daily and then 4 mg/kg twice daily) in association with a reduction in the intensity of the immunosuppressive regimen. Voriconazole serum levels were checked regularly (trough levels w...

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Fatal Mycotic Aneurysms Due to Scedosporium and Pseudallescheria Infection

et al. 2011

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“…These infections have been known for a long time, but in recent years, a marked increase in severe invasive infections has been noticed, mainly in immunocompromised hosts. The treatment of these infections has not yet been resolved, and the mortality rate is very high (3,17). One of the most typical features of this species, which is very rare in other pathogenic fungi, is its ability to develop sexual structures on routine culture media.…”

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Molecular Phylogeny of the Pseudallescheria boydii Species Complex: Proposal of Two New Species

et al. 2005

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Pseudallescheria boydii (anamorph Scedosporium apiospermum) is the species responsible for human scedosporiosis, a fungal infection with a high mortality rate and which is difficult to treat. Recently, it has been demonstrated that high genetic variation exists within this species. We have performed a morphological and molecular study involving numerous strains of clinical or environmental origins and from different countries. The analysis of partial sequences of the ␤-tubulin (two loci) and calmodulin genes and the internal transcribed spacer region of the rRNA gene has demonstrated that P. boydii is a species complex. The combined analysis of the sequences of the four loci of 60 strains has showed the presence of 44 haplotypes in the ingroup. Three species morphologically related to P. boydii sensu stricto, i.e., Pseudallescheria angusta, Pseudallescheria ellipsoidea, and Pseudallescheria fusoidea, which had previously been considered synonyms, could be differentiated genetically from P. boydii in our study. It is relevant that two of the three strains now included in P. ellipsoidea have caused invasive infections. The species Pseudallescheria minutispora and Scedosporium aurantiacum are clearly phylogenetically separated from the other species studied and are here proposed as new. Morphological features support this proposal. All the strains included in S. aurantiacum species have a clinical origin, while those included in P. minutispora are environmental. Further studies are needed to demonstrate whether all the species included in the P. boydii complex have different clinical spectra and antifungal susceptibility.Pseudallescheria boydii (anamorph Scedosporium apiospermum) is a ubiquitous ascomycetous fungus that causes a wide array of human infections that can affect practically all the organs of the body (8). These infections have been known for a long time, but in recent years, a marked increase in severe invasive infections has been noticed, mainly in immunocompromised hosts. The treatment of these infections has not yet been resolved, and the mortality rate is very high (3, 17). One of the most typical features of this species, which is very rare in other pathogenic fungi, is its ability to develop sexual structures on routine culture media. The presence of spherical ascomata (cleistothecia) and fusiform or ellipsoidal ascospores allows easy identification of this species and its differentiation from the other species of Scedosporium, Scedosporium prolificans, whose sexual state still remains unknown.On the basis of nuclear DNA-DNA reassociation, some studies have proved that important genetic variation exists in P. boydii. Gueho and de Hoog (10) found three infraspecific ecological and clinical groups. Rainer et al. (16) reported the existence of five different small-subunit rRNA gene sequence lengths. Random amplified polymorphic DNA studies also demonstrated that numerous and very different genotypes can be found (7). Other authors have reported considerable differences with respect to growth and sp...

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“…Aspergillus flavus was the most commonly identified pathogen in that series of patients as well as others (8). Additional Aspergillus spp., Pseudallescheria boydii, Rhizopus spp., Mucor spp., Fusarium spp., and Alternaria have also been reported to cause sinus disease in immunocompromised patients (3,8,13). Those patients treated with systemic antifungal agents and surgery had the best chance for survival (8).…”

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Invasive Fungal Sinusitis Caused byScytalidium dimidiatumin a Lung Transplant Recipient

Dunn

Wolfe²,

Trachtenberg

et al. 2003

J Clin Microbiol

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We describe a case of invasive fungal sinusitis caused by Scytalidium dimidiatum in a lung transplant recipient. Treatment was complicated by renal failure with amphotericin B therapies. Following 6 months of voriconazole treatment, the patient remained radiographically and clinically stable for a short time before dying of respiratory failure precipitated by graft rejection. CASE REPORTA 51-year-old female, who underwent lung transplantation two and a half years ago for end-stage chronic obstructive pulmonary disease, was admitted for management of suspected left maxillary fungal sinusitis. The patient had a long history of chronic rhinosinusitis treated with multiple trials of antibiotics and sinus surgery 10 years ago. During the month prior to presentation, the patient complained of increasing left maxillary sinus tenderness, sinus drainage with thick yellow discharge, dental pain, and subjective fever and chills. An endoscopic sinus evaluation done at an outside facility revealed chronic inflammatory changes and a marked amount of necrotic tissue. Pathology revealed branching fungal elements with septate hyphae suggestive of Aspergillus spp. infection. She was transferred to the University of Utah hospital in stable condition for further management.The patient was from and lived in Salt Lake City, Utah. Additional social history was notable for the absence of tobacco, alcohol, or illegal drug use, recent domestic or foreign travel, and exposure to ill contacts. The patient's medications included tacrolimus (5 mg orally twice a day), methotrexate (10 mg orally once a week), prednisone (5 mg every other day), ganciclovir (1,000 mg three times a day), and trimethoprimsulfamethoxazole (one tablet Mondays and Thursdays).On admission to the University of Utah hospital, the temperature was 35.7°C, blood pressure 88/55 mm Hg, pulse was 92/min, respirations 12/min, and the oxygen saturation was 92% on room air. She was awake and oriented. There was marked tenderness over the left maxillary sinus without any obvious nasal discharge. She had no proptosis, and the extraocular muscles movements were intact. Her visual acuity was intact, and the tympanic membranes were clear. The left lung was clear to auscultation and percussion, but the right hemithorax had decreased lung sounds. Examination of the heart, abdomen, and extremities revealed no abnormalities. Likewise, the skin revealed no rash or lesions.Initial laboratory testing results included a white blood cell count of 1,400/l (28% polymorphonuclear leukocytes, 1% bands, 69% lymphocytes, 1% eosinophils), hemoglobin level of 8.1 g/dl, hematocrit result of 23.1%, mean cell volume of 100 fl, and platelet count of 228,000/l. Chemistry results included a normal chemistry panel with the exception of a blood urea nitrogen level of 28 mg/dl and a creatinine level of 2.4 mg/dl. Serum protein was at 4.8 g/dl, and the albumin level was 2 g/dl. Liver function tests were normal.A computed tomography scan of the sinuses without contrast revealed postoperative changes of the bila...

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Pseudallescheria boydii (Anamorph Scedosporium apiospermum) Infection in Solid Organ Transplant Recipients in a Tertiary Medical Center and Review of the Literature

Cited by 199 publications

References 54 publications

Fatal Mycotic Aneurysms Due to Scedosporium and Pseudallescheria Infection

Fatal Mycotic Aneurysms Due to Scedosporium and Pseudallescheria Infection

Molecular Phylogeny of the Pseudallescheria boydii Species Complex: Proposal of Two New Species

Invasive Fungal Sinusitis Caused byScytalidium dimidiatumin a Lung Transplant Recipient

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