Pulmonary Pseudallescheria boydii Infection with Cutaneous Zygomycosis After Near Drowning

Abstract

Pseudallescheria boydii is a ubiquitously occurring fungus. While rarely causing opportunistic infection in humans, it is the most common cause of fungal pneumonia in cases of near drowning, and is associated with high mortality. P. boydii typically causes cutaneous mycetomas but may invade the lungs or brain. P. boydii infections are difficult to treat due to amphotericin B resistance and frequent need for surgical resection. Zygomycetous infections, often referred to as "mucormycoses," usually occur in immunocompromised hosts, trauma or burn victims. Like P. boydii, these organisms are found on decaying vegetation and in soil. Zygomycetous infections generally require debridement and prolonged amphotericin B. We report a case of P. boydii pneumonia with a simultaneous brain lesion and cutaneous mucormycosis in a near drowning patient. The pneumonia responded to treatment with voriconazole and the brain lesion resolved without surgery. The cutaneous mucormycosis responded to surgery and amphotericin B. This is the first documented case of simultaneous invasive P. boydii and cutaneous mucormycosis successfully treated with dual systemic antifungal therapy and resection.

Infections Caused byScedosporiumspp

“…Infectious lesions in organs other than the CNS have been reported in 13 of the 21 cases, including in the lung (7 of 21, usually manifested as bronchopneumonia) (78,109,110,179,216,283,448), kidney (3 of 21) (108,110,283), eye (3 of 21, manifested as endophthalmitis or chorioretinitis) (110,283,473), musculoskeletal system (2 of 21, manifested as knee joint synovitis, femoral and tibial osteomyelitis, or spondylodiscitis) (110,144), heart (2 of 21) (108, 110), liver (283), skin (erythematous lesions with purplish-black necrotic centers in arms and abdomen) (110), and thyroid gland (110).…”

“…The diagnosis of P. boydii infection in near-drowning victims was delayed, as the fungus was isolated from respiratory secretions in only 6 of 21 cases (78,109,110,216,283,448) and from cerebrospinal fluid (CSF) obtained by lumbar puncture in only 3 patients (109,131,225). In the majority of cases the organism was isolated from material obtained by aspiration or surgical drainage of brain abscesses.…”

“…The delay in diagnosis together with the previous lack of antifungal drugs with potent activity against P. boydii and good penetration into the CNS may explain the poor outcome of these infections, with a survival rate of 33% (seven cases) among those reviewed. Among the patients who survived, two were treated with high doses of the older azole miconazole (110) and five with voriconazole, alone or in combination with other agents, together with surgical intervention (abscess drainage) when needed (77,78,144,306). The role of voriconazole and newer antifungal agents in the treatment of pseudallescheriasis is discussed more exten-sively in Treatment and Outcomes of Scedosporiosis below.…”

Tracking the Emerging Human PathogenPseudallescheria boydiiby Using Highly Specific Monoclonal Antibodies

“…Wells containing immobilized antigens were incubated successively with hybridoma supernatant for 1 h, followed with goat anti-mouse polyvalent (Ig classes IgG, IgA, and IgM) peroxidase conjugate (Sigma Chemical Company, Poole, United Kingdom) diluted 1 in 1,000 in PBST for a further hour. Bound antibody was visualized by incubating wells with tetramethyl benzidine substrate solution (54) for 30 min, and reactions were stopped by the addition of 3 M H 2 SO 4 . Absorbance values were determined at 450 nm with an MRX automated microplate reader (Dynex Technologies, Billingshurst, United Kingdom).…”

“…The fungus is the most prevalent species after Aspergillus fumigatus in the lungs of cystic fibrosis patients (8), where it causes allergic bronchopulmonary disease (5) and chronic lung lesions simulating aspergillosis (24). Near-drowning incidents and recent natural disasters, such as the Indonesian tsunami in 2004, have shown P. boydii and the related species Scedosporium apiospermum and Scedosporium aurantiacum to be the causes of fatal central nervous system infections and pneumonia in immunocompetent victims who have aspirated polluted water (4,11,12,21,22,25,30,33,57). Its significance as a potential pathogen of disaster evacuees has led to its recent inclusion in the Centers for Disease Control and Prevention list of infectious etiologies in persons with altered mental statuses, central nervous system syndromes, or respiratory illness.…”