Le Infezioni in Medicina, n. 2, 153-157, 2016 CASE REPORT 153 Pulmonary infection caused by Talaromyces purpurogenus in a patient with multiple myeloma Altay Atalay1, Ayse Nedret Koc1, Gulsah Akyol2, Nuri Cakır1, Leylagul Kaynar2, Aysegul Ulu-Kilic3 1Department of Medical Microbiology, University of Erciyes, Kayseri, Turkey; 2Department of Haematology, University of Erciyes, Kayseri, Turkey; 3Department of Infectious Disease and Clinical Microbiology, University of Erciyes, Kayseri, Turkey SUMMARY A 66-year-old female patient with multiple myelo- based on the CT images. The sputum sample was sent ma (MM) was admitted to the emergency service on to the mycology laboratory and direct microscopic ex- 29.09.2014 with an inability to walk, and urinary and amination performed with Gram and Giemsa’s stain- faecal incontinence. She had previously undergone au- ing showed the presence of septate hyphae; there- tologous bone marrow transplantation (ABMT) twice. fore voriconazole was added to the treatment. Slow The patient was hospitalized at the Department of growing (at day 10), grey-greenish colonies and red Haematology. Further investigations showed findings pigment formation were observed in all culture media suggestive of a spinal mass at the T5-T6-T7 level, and except cycloheximide-containing Sabouraud dextrose a mass lesion in the iliac fossa. The mass lesion was agar (SDA) medium. The isolate was initially consid- resected and needle biopsy was performed during a ered to be Talaromyces marneffei. However, it was sub- colonoscopy. Examination of the specimens revealed sequently identified by DNA sequencing analysis as plasmacytoma. The patient also had chronic obstruc- Talaromyces purpurogenus. The patient was discharged tive pulmonary disease (COPD) and was suffering at her own wish, as she was willing to continue treat- from respiratory distress. After consultation with an ment in her hometown. Unfortunately, the patient infectious diseases specialist the patient was placed died on December 8, 2014. In conclusion, apart from T. on an intravenous antibiotherapy with piperacillin/ marneffei, less common strains such as T. purpurogenus tazobactam (4.5 g x 3) on 17.10.2014. During pipera- should be considered when clinical samples obtained cillin/tazobactam treatment, the patient suffered from from patients with haematologic/oncologic disorders drowsiness, her general condition deteriorated, and show fungal colonies that form red pigments on the she had rales on auscultation of the lungs. The patient culture media and when microscopic examination underwent thoracic computerized tomography (CT) suggests a morphological appearance similar to Pen- which showed areas of focal consolidation in the low- icillium species. er lobes of the two lungs (more prominent on the left), and increased medullary density. The radiology report Keywords: multiple myeloma, Penicillium, Talaromyces suggested that fungal infection could not be ruled out purpurogenus. n INTRODUCTION the only dimorphic and pathogenic species. This pathogen can cause infections in both healthy in- Penicillium species are common and generally dividuals and immunosuppressed patients, par- non-pathogenic laboratory contaminants that ticularly in those infected with HIV in Southeast are widely found in nature [1]. Among Penicilli- Asia [2]. This species was recently transferred to um species, Penicillium marneffei (P. marneffei) is the Talaromyces genus along with other Penicillium species belonging to the Biverticillium sub-genus [3]. Aside from Talaromyces marneffei (previously Corresponding author named P. marneffei), rare cases of infections related Altay Atalay to species such as Penicillium chrysogenum, Peni- E-mail: [email protected] cillium oxalicum, Penicillium piceum and Penicillium 154 A. Atalay, et al. purpurogenum have also been reported [4-7]. Ac- T6-T7 level and a mass lesion in the iliac fossa. cording to current taxonomic approaches, the last The mass lesion was resected and needle biopsy two Penicillium species have also been transferred was performed during a colonoscopy. The exam- to the Talaromyces genus, with their names being ination of the two specimens revealed plasmacy- changed to Talaromyces piceus and Talaromyces pur- toma. The patient also had chronic obstructive purogenus [3]. pulmonary disease (COPD) and she was suffering In this case report, we discuss the diagnosis and from respiratory distress. A consultation with an clinical significance of a T. purpurogenus strain iso- infectious diseases specialist was performed after lated from the sputum culture of a patient with which the patient was placed on an intravenous multiple myeloma (MM) who previously under- antibiotic therapy with piperacillin/tazobactam went autologous bone marrow transplantation (4.5 g x 3) on 17.10.2014. During piperacillin/ta- (ABMT) twice and later developed plasmocyto- zobactam therapy, the patient developed suffered ma. The strain in question was initially presumed from drowsiness, her general condition deterio- to be T. marneffei due to red pigments scattered in rated, and there were rales on auscultation of the the sputum culture, but it was later identified cor- lungs. Thoracic computerized tomography (CT) rectly as T. purpurogenus using DNA sequencing scan was then performed. Lymph nodes with analysis. short axes smaller than 1 cm were observed in the mediastinum, and there was minimal free fluid in the left hemithorax. Focal consolidated areas and n CASE REPORT increases in medullary density were observed bi- laterally in the lower lobes of the lungs that were A 66 year-old female patient, who was diagnosed more prominent in the left lung. It was noted that with MM at another healthcare center in 2010, these findings could not rule out a possible fun- had previously received vincristine, adriamy- gal infection (Figure 1). In laboratory tests, white cin and dexamethasone (VAD) chemotherapy. blood cell count was 7.63 x 103/ µL (68.9% neu- The patient subsequently underwent ABMT at trophils), hemoglobin was 9.0 g/dL, and plate- the Hematology Unit of our hospital in 2011 and lets was 208 x 103 µL. The sputum culture sent to 2013. Then the patient was followed at 3-monthly the bacteriology laboratory on October 30, 2014, intervals in remission. However, the patient was showed growth of Acinetobacter baumannii, and admitted to the emergency service of our hospital the patient was placed on a therapy with colistin on September 29, 2014, with the complaints of uri- and sultamicillin based on the antibiotic suscep- nary and fecal incontinence and inability to walk. tibility tests. Direct microscopic examination was The patient was hospitalized at the department performed on the sputum culture sent to the my- of hematology and further investigations showed cology laboratory in the same day, and the sam- findings suggestive of a spinal mass at the T5- ples were inoculated onto Sabouraud dextrose Figure 1 - Computerized tomography scan shows pulmonary fungal lesions. Pulmonary infection caused by Talaromyces purpurogenus in a patient with multiple myeloma 155 agar (SDA; Oxoid, United Kingdom) with and (RefGen) by using PCR products and primers without antibiotics (containing cycloheximide and the ABI 3100 Genetic Analyzer device. The and chloramphenicol) after Gram and Giemsa’s data of sequence analysis was analyzed using the staining, and then incubated at 37ºC and 25ºC. “National Center for Biotechnology Information Direct microscopic examination performed with (Bethesda, ABD)” BLAST system (http://www. Gram and Giemsa’s staining showed presence of ncbi.nlm.nih.gov/BLAST/), and DNA of the iso- septate hyphae. The voriconazole (4 mg/kg x 2) late was found to be 100% consistent with Talaro- was added to the treatment. Slow growing (at day myces purpurogenus. Antifungal susceptibility test 10), gray-greenish colonies were observed at both was not performed routinely. The isolated strain 37ºC and 25ºC in all culture media except cyclo- could not be reproduced when an antifungal sus- heximide-containing SDA and red pigment was ceptibility test was attempted for the purpose of diffusely scattered on the culture medium (Figure this case report. There was no bacterial or fungal 2). The isolate was initially considered to be T. growth in blood and subsequent sputum cultures. marneffei; however, this possibility was ruled out The patient tested negative for human immuno- when it was observed that the isolate did not form deficiency virus antibodies (anti-HIV) and galac- circular white colonies similar to those of yeast on tomannan antigen. The patient was administered sheep blood agar at the suitable temperature. In IVIG due to low IgG levels. Blood gas analy- corn meal-Tween 80 agar slide culture; non-spe- sis was performed as the patient had persistent cific septate, hyaline hyphae, conidiophores, and tachypnea and tachycardia. The results of blood bottle shaped phyllitis on some metulae branch- gas analysis were found to be consistent with re- ing from conidiophores, and circular conidium spiratory alkalosis; a repeat thoracic CT was then chains branching from each phyllitis were ob- performed on November 16, 2014, which revealed served (Figure 3). DNA analysis of the clinical healing and newly formed nodules, and a newly species was performed at a private laboratory formed consolidation in the left upper lobe. The Figure 2 - Colony of Talaromyces pur- purogenus and red pigment forma- tion. Figure 3 - Talaromyces purpurogenus in slide culture. 156 A. Atalay, et al. patient