Systemic mycosis due to Trichosporon cutaneum: a report of two additional cases

Invasive Trichosporon cutaneum infection in an infant with wilms' tumor

Fungal infections are increasingly being reported in immuno-compromised patients. In this study we report a case of systemic Trichosporon cutaneum infection in an infant with Wilms’ tumor. This is the first time that an invasive infection for T. cutaneum has been reported in a Wilms’ tumor patient.

Fungal Infections

The incidence of invasive fungal infections has increased dramatically over the past two decades, mostly due to an increase in the number of immunocompromised patients.1–4 Patients who undergo chemotherapy for a variety of diseases, patients with organ transplants, and patients with the acquired immune deficiency syndrome have contributed most to the increase in fungal infections.5 The actual incidence of invasive fungal infections in transplant patients ranges from 15% to 25% in bone marrow transplant recipients to 5% to 42% in solid organ transplant recipients.6,7 The most frequently encountered are Aspergillus species, followed by Cryptococcus and Candida species. Fungal infections are also associated with a higher mortality than either bacterial or viral infections in these patient populations. This is because of the limited number of available therapies, dose-limiting toxicities of the antifungal drugs, fewer symptoms due to lack of inflammatory response, and the lack of sensitive tests to aid in the diagnosis of invasive fungal infections.1 A study of patients with fungal infections admitted to a university-affiliated hospital indicated that community-acquired infections are becoming a serious problem; 67% of the 140 patients had community-acquired fungal pneumonia.8

Endophthalmitis due to Trichosporon beigelii in acute leukemia

We describe 2 patients with hematologic malignancy who developed endophthalmitis due to Trichosporon beigelii during the course of treatment with multiagent chemotherapy. Blood cultures revealed T beigelii for both patients. Although one of the patients was treated with fluconazole (FLCZ) and 5-fluorocytosine, the trichosporonous endophthalmitis was resistant to both drugs. This patient subsequently received amphotericin B (AMPH-B) therapy, and the eyes were treated with vitrectomy. The second patient also received AMPH-B for FLCZ-resistant trichosporonous chorioretinitis. In both patients, systemic treatment with AMPH-B successfully resolved the trichosporonous endophthalmitis that was resistant to multiple antifungal drugs. Endophthalmitis due to trichosporonosis is difficult to treat. The administration of AMPH-B is likely to be more effective in treating endophthalmitis due to trichosporonosis when the disease is at an early stage.

Autopsy case of disseminated Trichosporon inkin infection identified with molecular biological and biochemical methods

Trichosporon species are usually opportunistic pathogens. Disseminated trichosporonosis is uncommon but is increasingly reported with a high mortality rate, especially in immunocompromised patients. Although Trichosporon asahii and T. mucoides are known as the most common pathogens of disseminated trichosporonosis, cases of systemic infection due to T. inkin have been reported recently. However, no autopsy case of disseminated T. inkin infection has been reported. Herein is presented an autopsy case of disseminated trichosporonosis caused by T. inkin in a 30-year-old man with allogenic peripheral blood stem cell transplantation for acute myelocytic leukemia. In the present case, identification of T. inkin was performed with morphological, molecular biological and biochemical methods. It is difficult to make a diagnosis of Trichosporon infection on only histological examination; therefore, molecular biological and biochemical methods are needed in a diagnosis of disseminated trichosporonosis.

Itraconazole therapy for white piedra affecting scalp hair

BACKGROUND

Treatment of white piedra remains an area of therapeutic frustration. Several topical and systemic antifungal agents have failed to eradicate the fungus and prevent disease recurrence. Itraconazole is a safe and effective systemic antifungal agent for various superficial and deep mycotic infections of the skin and hair. In vitro studies have shown significant antifungal activity against Trichosporon beigelii.

OBJECTIVE

Our study was intended to assess the efficacy of itraconazole in the treatment of uncomplicated white piedra affecting the scalp hair.

METHODS

The study was designed as an open trial involving 12 female patients with white piedra of the scalp hair. They were administered oral itraconazole 100 mg once daily until culture negativity was achieved; they were then followed up for 3 months.

RESULTS

Eleven patients (91.67%) showed disease remission after 8 weeks of treatment. One patient (8.33%) showed no improvement, and the disease recurred in 2 patients (16.67%) after completion of therapy. No significant side effects were noted.

Generalized lymphadenopathy caused by Trichosporon asahii in a patient with Job's syndrome

Of the six species of Trichosporon known to cause human infections, T. asahii is the main agent of invasive trichosporonosis. We describe an unusual case of generalized lymphadenopathy due to T, asahii in a 10-year-old boy with Job's syndrome (markedly elevated IgE with eosinophilia). The diagnosis was based on the presence of blastic conidia and hyphal elements breaking into arthroconidia in biopsied tissue of the cervical lymph node and isolation of the causal agent T, asahii in pure culture. The patient responded initially to amphotericin B therapy, but the infection recurred within 4 weeks and did not respond to therapy of liposomal amphotericin B and 5-fluorocytosine for 10 days. The patient left the hospital against medical advice.

Trichosporon asahii: an unusual cause of invasive infection in neonates

Trichosporon asahii causes white piedra, an infection of hair shafts and onychomycosis in immunocompetent patients, as well as various localized or disseminated invasive infections in immunodeficient hosts. We describe a 26-week gestation 890-g vaginally delivered female neonate who had severe respiratory distress syndrome and on the sixth day of life developed Klebsiella pneumoniae sepsis. At the same time two blood cultures were positive for T. asahii. The neonate was also colonized with T. asahii in the pharynx and perineum. The infant was successfully treated with conventional amphotericin B.

Trichosporon beigelii infection: experience in a regional burn center

Trichosporon beigelii is a fungus once thought to cause only superficial infections, but recently has been increasingly identified as an opportunistic systemic pathogen in immunocompromised patients. There have been very limited reports of this organism in the burn patient population. We describe the first report of pharmacological management of invasive T. beigelii with a combination of amphotericin B and high dose fluconazole in a burn patient. Antifungal susceptibility testing of T. beigelii determined a change in minimum inhibitory concentrations (MICs) of amphotericin B and a consistent resistance pattern with the use of flucytosine. This paper will review our experience with T. beigelii fungus in a regional burn treatment center and review the literature on other experiences in the burn population.

Disseminated infection with Trichosporon asahii

Trichosporon fungaemia and disseminated, purpuric, papular skin lesions developed on the head, trunk and extremities of a 5-year-old female with acute lymphocytic leukaemia. Histopathologically, the skin lesions demonstrated dermal budding yeasts. She died despite treatment with antifungal drugs. The isolate from the blood was further identified morphologically and physiologically as Trichosporon asahii, based on the revision of the genus Trichosporon by Guého et al. (1992). According to the new revision, T. asahii is the only taxon regularly involved in systemic mycoses, so that most of the isolates previously reported as T. beigelii (formerly, T. cutaneum) in human deep mycoses are now thought to belong to T. asahii.

Trichosporon beigelii pneumonia in patients with hematologic malignancies

Trichosporon beigelii is a causative agent of hypersensitivity pneumonia in immunocompetent individuals and of invasive pneumonia in immunocompromised patients. The actual incidence and clinical manifestations of T beigelii pneumonia are obscure because the diagnosis is sometimes difficult. We studied eight patients with T beigelii pneumonia diagnosed by immunohistochemical investigation of lung tissue sections and/or isolation of the organism from the lung, sputum, or blood. All patients had underlying hematologic malignancies for which they had received cytotoxic chemotherapy, resulting in profound neutropenia. The clinical manifestations were persistent fever unresponsive to broad-spectrum antibiotic therapy, cough, bloody sputum, and rapidly progressive dyspnea. The chest radiographs showed diffuse alveolar infiltrates in four patients, diffuse interstitial infiltrates in one, patchy reticulonodular infiltrates in one, and focal alveolar infiltrates in two. Histopathologic examination demonstrated numerous centrally necrotic foci with minimal cellular inflammatory reaction, intra-alveolar hemorrhage, and edema. Trichosporon beigelii consisting of both yeast and hyphal forms was located predominantly in the alveolar vessels. In neutropenic patients with hematologic malignancies, this fungus appears to enter the lung not only through the airways but also via the hematogenous route. In vitro susceptibility testing indicated borderline susceptibility to amphotericin B and showed that some azoles were active against T beigelii at safely achievable serum concentrations.

Disseminated Trichosporon beigelii infection in patients with malignant diseases: immunohistochemical study and review

Trichosporon beigelii is a causative agent of opportunistic infection and summer-type hypersensitivity pneumonitis in Japan. However, as the diagnosis of Trichosporon beigelii infection is sometimes difficult, the actual incidence of this disease may be underestimated. Of 203 autopsy patients with malignant disease, seven (7.7%) were diagnosed with disseminated Trichosporon beigelii infection by immunohistochemical investigation of formalin-fixed, paraffin-embedded tissue sections. Including these seven, a total of 43 patients with Trichosporon beigelii infection have been reported in Japan. The majority of them had underlying hematologic malignancies, for which they received cytotoxic chemotherapy resulting in neutropenia. This study indicates that the immunohistochemical method, which can be applied to biopsy specimens, is an excellent tool for specific diagnosis of Trichosporon beigelii infection, which is an emerging fatal mycosis in immunocompromised patients with profound neutropenia.

Invasive Trichosporon beigelii infection in immunosuppressed rats

Fulminant systemic mycoses were seen as complications in rats undergoing drug trials for the treatment of Pneumocystis carinii pneumonia. Rats were immunosuppressed with corticosteroids and by feeding with a low-protein diet. Homogenized pulmonary tissue from a rat with pneumocystosis was inoculated transtracheally. Secondary invasive mycosis was found in 56 of 59 rats examined. Trichosporon beigelii was identified as the causative agent in the majority of cases. After examining possible sources of infection, a Pneumocystis inoculum contaminated with fungi was found to be the obvious source. T. beigelii infections are becoming increasingly significant in immunocompromised human patients. The need for suitable and reproducible animal models is therefore also increasing. Observations described in this paper may help in the further development of such models.

Orofacial fungal infections. Nine pathogens that may invade during chemotherapy

Immunosuppression due to antineoplastic drugs or malignant tumor leaves patients extremely vulnerable to infection. Opportunistic fungi that rarely infect healthy persons can have very severe consequences in these patients. Candida albicans is the pathogen found most often, but several other Candida species may cause infection as well. Aspergillosis is the second most frequently seen fungal infection of the face and mouth in patients receiving chemotherapy. Less commonly seen but equally dangerous are infections with Torulopsis glabrata, Mucor, Absidia, Rhizopus oryzae, Histoplasma capsulatum, Cryptococcus neoformans, Coccidioides immitis, Fusarium species, and Trichosporon cutaneum. Restoration of impaired host defenses and use of nystatin (Mycostatin, Nilstat, O-V Statin), clotrimazole (Mycelex), amphotericin B (Fungizone Intravenous), and flucytosine (Ancobon) when appropriate are methods of control.

Cutaneous manifestations in systemic trichosporonosis

Trichosporonosis due to Trichosporon beigelii is increasingly recognized in neutropenic immunocompromised patients. We report the clinical and histological presentation of three cases, as well as a study of the prevalence of T. beigelii colonization of normal-looking skin in patients receiving intensive chemotherapy for cancer.

Prevalence of Trichosporon beigelii. Colonization of normal perigenital skin

Although the natural habitat of Trichosporon species is considered to be the soil, the role of normal skin in the carriage of Trichosporon beigelii is unknown. The purpose of this study was to determine the prevalence of T. beigelii colonization on normal perigenital skin. Inguinal skin scrapings were obtained from 322 asymptomatic volunteers. There were 261 males and 61 females ranging in age from 18 to 89; 136 were white, 134 were black, and 52 were Hispanic. Specimens were cultured on Sabouraud's glucose agar containing 500 micrograms ml-1 chloramphenicol, and incubated at 23-26 degrees C for up to 4 weeks. The overall incidence of T. beigelii colonization was 12.4%. However, this varied with patient's age, sex, race and socioeconomic background. The highest prevalence (27.1%) was found in black males who attended a Veterans Affairs hospital. The prevalence was lowest in females (1.6%), and no patients who attended a private clinic were colonized. It was concluded that T. beigelii colonizes normal skin with some regularity.

Two cases of disseminated Trichosporon beigelii infection treated with combination antifungal therapy

Two patients with acute leukemia in whom disseminated Trichosporon beigelii infection developed are reported. The T. beigelii infection developed in the first patient while he was receiving 5-fluorocytosine. He was treated with amphotericin B in addition to 5-fluorocytosine. Despite the continued antifungal therapy, multiple organs were invaded by the organisms at autopsy. The second patient was treated with miconazole and norfloxacin. Although this combination antifungal therapy seemed to be effective, this patient required splenectomy for cure of the infection.

White piedra and Trichosporon beigelii: the incidence in patients attending a clinic in genitourinary medicine

To assess the occurrence of white piedra and the asymptomatic carriage rate of T beigelii, 100 heterosexual and 49 homosexual/bisexual men were entered into the study. White piedra of the scrotal hair was discovered in a total of four (2.7%) patients (two heterosexual, one homosexual and one bisexual), while in addition a positive scrotal culture for T beigelii was noted in a further seven (4.8%) patients (four heterosexual and three homosexual). Rectal carriage rates were 1% in the heterosexual and 4% in the homosexual/bisexual groups, while there was no pharyngeal carriage in either group.

Trichosporon beigelii infection in an immunocompromised host

A case of Trichosporon beigelii infection in a patient with non-Hodgkins lymphoma that illustrates some of the associated diagnostic and chemotherapeutic problems, is described. Despite prolonged isolation of the yeast from blood cultures, the patient recovered from the infection after treatment with amphotericin B and flucytosine. Presenting features, diagnosis and monitoring of antifungal therapy in renal failure are discussed.

Postoperative Trichosporon beigelii soft tissue infection

A case of postsurgical cutaneous infection with Trichosporon beigelii in an apparently immunocompetent individual is reported. This is a rare surgical complication and the first report of localized skin infection by this organism postoperatively.

An autopsy case of disseminated trichosporonosis with candidiasis of the urinary bladder

A case of disseminated trichosporonosis associated with Candida infection of the urinary bladder is presented. Coffee bean shaped or crescent shaped yeast-like elements are characteristic of Trichosporon and useful in differentiating Trichosporon from Candida but such histological features are less efficient than the immunohistochemistry in identifying mixed fungal infection. In the present case, an application of avidin-biotin-complex (ABC) method with anti-Trichosporon antiserum and anti-Candida antiserum enabled us to diagnose a mixed infection by both fungi.

Application of a monoclonal antibody for the detection of Trichosporon beigelii in paraffin-embedded tissue sections

Trichosporon beigelii is a normal inhabitant of soil and is occasionally found as normal flora of the skin and mouth. Opportunistic infection by this fungus has been increasingly reported in immunocompromised patients. The diagnosis of this infection depends on positive cultures or histological evidence. However, it is sometimes difficult to distinguish this fungus from Candida species in tissue section. We have generated two monoclonal antibodies that can distinguish T. beigelii from other fungi including several species of Candida. One of these antibodies (K-16) reacts with T. beigelii in formalin-fixed, paraffin-embedded tissue sections and will be useful as an aid to the accurate diagnosis of trichosporonosis.

Disseminated Trichosporon capitatum infection in a patient with acute leukemia

Disseminated Trichosporon capitatum infection in a 14-year-old boy with acute lymphoblastic leukemia is described. T. capitatum causes opportunistic infection in immunocompromised hosts.

A case of disseminated trichosporonosis: a case report and immunohistochemical identification of fungal elements

Trichosporon beigelii was isolated from blood cultures of a 69-year-old Japanese male who had been treated for chronic myeloid leukaemia with cytotoxic agents and broad spectrum antibiotics. He died of sepsis 4 days after a positive blood culture was obtained. A postmortem examination revealed abundant budding yeasts and hyphae in sections of lung, liver, bone marrow and other organs. All the fungal elements in the sections were identified as Trichosporon species by their histological features and by immunohistochemical findings using rabbit antiserum raised against the strain isolated from the patient.

Uncommon yeastlike zoopathogens and commercial systems for their identification

Opportunistic infections caused by yeasts or yeastlike fungi have increased in incidence in recent years as a result of clinical and therapeutic factors. Several formerly uncommon yeastlike zoopathogens--Candida lusitaniae, Candida paratropicalis (sucrose-negative variant of Candida tropicalis), Trichosporon beigelii, Blastoschizomyces capitatus, and Rhodotorula species--have been isolated from patients with invasive infections. The increased isolation of such opportunistic pathogens from a variety of clinical specimens has created a demand for simple, rapid, reliable, and accurate commercial systems to assist laboratorians in identification. Here we summarize the manual and automated systems currently available and present detailed descriptions of three representative commercial products, i.e., API 20C, Abbott Quantum II, and API Yeast-Ident.

Systemic infections with Trichosporon beigelii (cutaneum). Report of three new cases

Three new cases of systemic mycosis due to Trichosporon cutaneum are reported and compared with the 23 previous reports. Two patients had acute leukemia and one patient had a lymphoblastic lymphoma. Blood cultures in two patients and cerebrospinal fluid in the third patient were positive for T. cutaneum. Only one patient recovered after antimycotic therapy and concomitant remission of his leukemia. At autopsy, the two other patients showed widespread infection with T. cutaneum. The authors conclude that diagnosis and management of such infection in the immunosuppressed host are difficult and the prognosis is poor.

Successful treatment of disseminated Trichosporon beigelii (cutaneum) infection with associated splenic involvement

Fungemia caused by Trichosporon beigelii (cutaneum) has been recently recognized as a fatal infection afflicting immunocompromised patients. The authors report the case of a leukemic patient who developed splenic infection from disseminated T. beigelii. Treatment with amphotericin B, 5-fluorocytosine, and splenectomy proved successful. The etiology of disseminated T. beigelii infection, visceral seeding, and combination antifungal therapy also are discussed.

Disseminated Trichosporon beigelii infection in a patient with malignant histiocytosis

A case of disseminated Trichosporon beigelii infection is reported. Trichosporon inhabits the soil, but may also be present in the human skin and mouth as a normal flora. Occasionally it causes superficial mycotic infection, but it is rarely invasive. A review of literature disclosed 21 reported cases of invasive Trichosporon beigelii infection, to date. Of these, two cases were from Japan. The scarcity of reports on this invasive infection may be due to a lack of awareness of the organism. Histologically, it should be carefully differentiated from Candida.

Immunoblot analysis of the serological response in invasive Trichosporon beigelii and Blastoschizomyces capitatus infections

The serological response to Trichosporon sp. was examined by the immunoblot technique. Antibodies to a range of antigens (200 to 16 kilodaltons) were detectable in three patients with invasive Trichosporon beigelii or Blastoschizomyces capitatus infections and 10 uninfected controls. High levels of preexisting antibodies may contribute to the rarity of systemic infections.

Cutaneous side effects of cancer chemotherapy

Chemotherapeutic agents are used with increasing frequency to treat a wide variety of neoplastic and inflammatory disorders. These drugs may inadvertently affect the skin, mucous membranes, hair, and nails, producing many undesirable reactions including alopecia, stomatitis, hyperpigmentation, hypersensitivity reactions, and photosensitivity. Awareness of these relatively common complications may help physicians caring for patients on these medications.

Detection of a Trichosporon beigelii antigen cross-reactive with Cryptococcus neoformans capsular polysaccharide in serum from a patient with disseminated Trichosporon infection

Latex beads coated with anti-Cryptococcus neoformans antibody were agglutinated by serum from a bone marrow transplant recipient having a disseminated infection caused by Trichosporon beigelii. The cryptococcal latex agglutination titer in the serum of the patient rose to 1:2,560 by the time of his death. Necropsy confirmed the disseminated Trichosporon infection and absence of C. neoformans. Cell wall extracts of the isolate of the patient and two additional strains of T. beigelii agglutinated anti-Cryptococcus-coated latex beads. The antigen in the serum of the patient and in the extracts responsible for the agglutination was not destroyed by proteolytic enzymes or heat. A single antigen reactive with rabbit anti-Trichosporon serum could be identified in the serum of the patient and the cell wall extracts by rocket immunoelectrophoresis and crossed immunoelectrophoresis. Rocket immunoelectrophoresis and indirect fluorescent-antibody staining demonstrated that anti-Trichosporon antibody recognized the capsular polysaccharide of C. neoformans.

Trichosporon beigelii: survey of isolates from clinical material

Two hundred and eight isolates of Trichosporon beigelii were identified over the period January 1973 to July 1983. 45.7% of these were from skin, 25.0% from nail, 22.6% from tissues and fluids, 3.4% from hair and 3.4% from sputum. Tr. beigelii was isolated in association with a recognized pathogen in 23 cases, 9 with a yeast, 14 with a dermatophyte. In 38 cases, Tr. beigelii was the only organism isolated when direct microscopic examination of clinical material showed the presence of hyphae and/or yeast cells. Although Tr. beigelii could only be assigned a definite pathogenic role in 6 cases of genital white piedra, and in one case of peritonitis associated with chronic ambulatory peritoneal dialysis, we believe that this organism was pathogenic in many cases of skin infection. In most of the cases where it was isolated from tissue or fluids at Royal North Shore Hospital, Tr. beigelii was not considered to be significantly contributing to the disease process.

Prosthetic valve endocarditis caused by Trichosporon cutaneum

We report, to our knowledge, the first case of Trichosporon cutaneum endocarditis which developed in a 58-year-old woman 14 months after mitral valve replacement. The patient had not had antibiotic therapy. She was treated with an oral antifungal agent, ketoconazol, and prosthetic valve replacement. The initial outcome was favorable, but she died 5 months later of aortic valve endocarditis. Fungal infection was documented by isolation of the fungus from blood cultures, by anatomical and pathological examination and by the changes in serology.

Metastatic fungal chorioretinitis developing during Trichosporon sepsis

A 70-year-old woman treated for acute myelogenous leukemia developed systemic trichosporosis and presumptive trichosporon chorioretinitis. The elevated choroidal lesion appeared during an episode of trichosporon sepsis and increased in size during immunosuppression. Possible retinal vein occlusion and neovascularization were further complications that may be due to the angioinvasive properties of the organism.

Systemic infection with Trichosporon cutaneum in a patient with acute leukemia: report of a case

A case of disseminated infection with Trichosporon cutaneum, a fungus that causes white piedra, is described. The patient, a 58-year-old barber with acute leukemia, had fever, myalgias and skin lesions. He was receiving cytotoxic drug therapy and prednisone, was severely neutropenic and was being treated with broad spectrum antibiotics. Blood cultures and a biopsy of the skin lesion grew T. cutaneum. He died despite amphotericin B therapy. At autopsy, widespread infection with T. cutaneum was present. T. cutaneum is another fungus capable of causing widespread systemic disease in the immunocompromised host.

Disseminated Trichosporon beigelii (cutaneum)

Two cases of invasive Trichosporon beigelii (syn. cutaneum) infection are reported and are compared with the eight other previous reports. All affected patients were either immunosuppressed or had recently undergone a surgical procedure. The diagnosis had been delayed and the prognosis was poor. Only two patients recovered after vigorous antimycotic therapy and concomitant remission of their leukemia. A biopsy of the skin lesion, as illustrated in one of our patients, may prove to be useful in the early diagnosis.

An unexpected fungal infection in a patient with leukaemia

A 58-year-old man, who was entering remission from acute monocytic leukaemia, died unexpectedly after five days of fever. Cultures of necropsy material grew the yeast Trichosporon beigelii, and subsequent histological examination showed a widely disseminated infection. This fungus usually causes a localised lesion of the hair shaft (piedra). Deep-seated infections due to Trichosporon spp. have been recorded infrequently and disseminated infections on only five previous occasions. None of these has been from the United Kingdom. This case report describes some of the difficulties of diagnosis.