Medical Journal of the Volume 18 Islamic Republic ofIran Number 2 Summer 1383 August 2004

PEACILOMYCES INFECTION IN AN IMMUNOCOMPROMISED PATIENT

SHAHINDOKHT BASSIRI JAHROMI AND ALI ASGHAR KHAKSAR

From the Department ofMedical Mycology, Pasteur Institute ofIran, Tehran, Iran

ABSTRACT

Paecilomyces sp, is a saprophytic which has rarely been associated with human disease. We report the first case of invasive subcutaneous infection caused by this fungus in a 78-year-old female from Damghan, Iran, with diabetes and chronic renal failure. A biopsy provided an initial diagnosis of the in tissue. Multiple posi­ tive fungalcultures which were obtained from the biopsied tissue were subsequently identified by microscopic and macroscopic characteristics to be sp. This case was successfullytreated by oral ketoconazole (200 mg/day). MJIR1, Vol. 18, No.2, 181-184,2004. Keywords: Paecilomyces infection -fungal infection - immunocompromised patients.

INTRODUCTION known. 18 The present article describesPaecilomyces spp. from subcutaneous tissue in the insulin induction site. Paecilomyces spp. is seldom associated with human infections. Most of the cases recorded have been of a CASE REPORT mycotic keratitis. Several cases are now on record of endocarditis following valve replacement,1 and The patient was a 78-year-old woman residing in endophthalmitis following lens implantation.2 Damghan, This com­ Iran, diagnosed with chronic renal failure and mon air-borne contaminant is resistant to most steriliz­ diabetes mellitus for a long time. The patient referred to ing techniques. the MedicalMycology Department, Pasteur Institute of Several nosocomial infections have oc­ curred in which tbe organism was growing in the disin­ Iran with pruritic, erythematous, edematous subcutane­ fectant used for surgical instruments. ous nodules of the left hand with adjacent suppurative In that outbreak there were 12 cases of endophthalmitis following in­ lymphatics. His problem began28 days before she refered Downloaded from mjiri.iums.ac.ir at 8:00 IRST on Saturday September 25th 2021 traocular lens implantation2'3 The first case of to the Medical Mycology Pasteur Institute laboratory. endophthalmitis was reported byUys4 in 1963, Organisms had inoculated in the left hand in the in­ and it is typical of these cases. sulin induction site. Paecilomyces was isolated from The patient had spiking fever and the blood, from a thrombus overlying the mitral valve, multiple subcutaneous abscesses in the left forearm(Fig. and from an embolus in the iliac artery following the I). Fever had started 12 days after her problem began. death of a patient who had had a valve replacement." Urine culture and tissue culture for bacteria were nega­ Paecilomyces spp. was recovered from the renal pel­ tive . vis by Sherwood and Dansky, who reviewed Her clinical history revealed that she had chronic re­ Paecilomyces infections up to 1983.5 nal failure over a period of25 years and diabetes melli­ Pulmonary infusion6•7•8 and pneumonia9 have been tus for over 14 years. She received insulin for 4 years noted. Georg befor her problem began. Biopsy specimens of the le­ et al. 10 isolatedPaecilomyces fumosoroseus from pulmonary lesion in a giant tortoise. Mycelium was sions were performed. present in many small abscesses throughout the lung. Specimens were directly examined with 10% potasium Most cases are cutaneous or concern transient cath­ hydroxide. The biopsy specimen showed hyphae (Fig. eter-related infections, but also deep infections are 2) The tissue sections were stained by hematoxylin and eosin and periodic acid schiff stains. Sections revealed a granulomatous reaction. Ground tissues were cultured E-mail:[email protected] on Sabouraud dextrose agar, sabouraud dextrose with

181 Peacilomyces Infection in an lmmunocompromised Patient

Fig. 3. Colony of Paecilomyces�p. on sabouraud dextrose agar.

Fig.I. Clinical appearance of the subcutaneous lymphatic ab­ scesses.

Fig. 4. Slide culture stained by cotton-blue method.

Fig. 2. Histopathological section of biopsy specimen, showing numerous hyphae (hematoxylin - eosin stain). Downloaded from mjiri.iums.ac.ir at 8:00 IRST on Saturday September 25th 2021 DISCUSSION

chloramphenicol(50 mg/mL), blood agar and brain heart Paecilomyces spp. is a common fungus in the air and infusion agar(BBL); Duplicate cultures on each medium can grow in environments with high ambient tempera­ were incubated at 35°C and 25"C, cultures of specimens tures. The fungus has been reported to be the causative gave rise to Paedlomyces spp. Microscopic features of agent of humanmycoses in the literature, mostly occur­ the isolates were studied by slide culture preparation. ring in conjunctionwith prosthetic implants or immuno­ Paecilomyces colonies turned lilac in the substatum suppression. Cases include ,20-21 peritonitis, 11- (Fig. 25 a fatal infection of a ventriculoperitoneal shuntl9 a case 3). Microscopic examination showed hyaline septate of pyelonephritis, 26 fungemia,17 soft tissue infection of hyphae similar to Penicillium spp., but the phialides the heeJ,28 sinusitis29-30 endophthahnitis,31 chronic sup­ are single or verticillate on well- developed conid­ purative ,32 cutaneus infection,33-34 and a my­ iophores or directly on vegetative hyphae (Fig. 4). cosis at the incision site of a patient who underwent a The phialides end in a long tapered tube and bear cesarean section.35 Essential data are summarised inTa ble long chains of lemon-shaped or nearly cylindrical I. conidia. Chlamydoconidia and aleurioconidia are Anderson et al13 described infectious complications also produced. The patient was treated for 40 days in 80% of renal transplant patients or renal failure, asso­ with oral ketoconazole (200 mg/day). ciated with high-dose corticosteroid therapy, hypergly-

182 S. Bassiri Jahromi and A.A. Khaksar

cemia, leukopenia, or age over 40 years. These risk fac­ patient survived with an tifungal treatment. This treatment in­ tors operated presumably by effects on suppression of cluded ketoconazole (200 mg per day) for 40 days. humoral and cellular immunity and impairment of poly­ morphonuclear leukocyte function.11 Our patient's in­ REFERENCES fection was caused by the opportunistic fungus

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Table I. Review of human Paeci/omyces spp. infection. Infection References Age/sex Underlying conditions I Treatment Outcome pneulllonia 20 Hairy cell leukemia I

pneumonia 21 OM i , peritonitis 22 i II 121M CAPO peritonitis -- AMB (IOdays) CUI'ed peritonitis II 60/F CAPO i AMB (4weeks) Cured

peritonitis II 56/F CAPO i KTZ (l Odays) Cured

peri ton itis II 391M CAPO i KTZ I Cured I peritonitis 25 Infant CAPO FLZ Cured

;' peritonitis _.1 CAPO ,

peritonitis 24 65/F CAPO i AMB Cured

CNS( disseminated?) 19 57/F VSP I Died

CNS 12 60/F Cancer, CT, OM I AMB Died : pyelonephritis 26 Nephrolithiasis, VSP

Fungemia 27 IF BMT I AMB+ITZ Cured

son tissue 28 81M CGO AMB (4weeks) Cured

Downloaded from mjiri.iums.ac.ir at 8:00 IRST on Saturday September 25th 2021 I +ITZ (I year)

Sinusitis 29 I

Sinusitis 30 I Surgical I Cured Cutaneous 33 ! Cutaneous 34 251M i

I Surgical site infection 35 31/F Cesarian incision Cured

Endophthalmitis 31 !

Chronic 32 I Cured Suppurative I I otitis media

I Airway 36 CF,LT I : colonization

Sub cutaneous This study 78/F RF, OM ! KTZ(40 days) Cured

M, male; F, fe male; OM, diabetes mellitus; CAPO, continuous ambulatory peritoneal dialysis; VSP, ventriculoperitoneal shunt place­ ment; CT, chemotherapy; BM1� allogenic bone marrow transplant; CGO, chronic granulomatous disease; LT, lung transplant; CF, cystic tibrosis, RF; renal failure.

183 Peacilomyces Infectionin an ImmunocompromisedPatient

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