Indian294 Journal of Medical Microbiology, (2006) 24 (4):294-6 Case Report

URINARY TRACT INFECTION BY ASAHII

S Sood, D Pathak, *R Sharma, S Rishi Abstract

Trichosporon asahii is a basidiomycetous which causes white and in immunocompetent hosts as well as various localized and disseminated invasive infections in immunodeficient hosts. caused by Trichosporon asahii is rare. One month after posterior urethral valve surgery a seven-month-old male child presented with fever, severe vomiting and crying on micturition for five - to six days. Yeast-like was isolated in pure cultures from three consecutive urine samples. It was identified as Trichosporon asahii using standard techniques. The response to antifungal therapy was dramatic. To the best of our knowledge this is the first report of a urinary tract infection caused by Trichosporon asahii from Western India.

Key words: Trichosporon asahii, urinary tract infection

Trichosporon Behrend is a genus of anamorphic yeast can be isolated from the sputum, the urine, the skin and (, Hymenomycetes, Trichosporonales) with the . Trichosporon spp. were also indicated as the cause distinct morphological characters of budding cells and true of sepsis in immature infants and summer-type mycelium that disarticulates to form arthroconidia.1 It is present hypersensitivity pneumonitis (SHP) in Japan.2 in the external environment and is isolated mainly from the soil. It may also be present in water, air and organic substrata.2 Case Report

In the past, a sole species T. beigelli (T. cutaneum) was A seven-month-old male child (weight 6.5 Kgs) was correlated to human pathology. It was recognized as the cause admitted in Sir Padampat Maternal and Child Health Institute, of superficial infections such as , and Jaipur in August 2005. He was diagnosed as a treated case of infected nails. Genus Trichosporon has recently undergone posterior urethral.com). valve infection. As per his medical records extensive taxonomic re-evaluation. Several morphological and he had undergone cystoscopy with valve fulgration for biochemical patterns were recognized amongst clinical and valvular obstruction of posterior urethra in July 2005. The environmental isolates of Trichosporon beigelli. Ultra surgery was performed under cover of antibiotics such as structural and DNA studies have confirmed these findings and ampicillin and gentamicin starting a day prior to the surgery T. beigelli has been divided into a number of distinct species. and continued for five days post operatively. These were then There are seven species that are pathogenic for humans:.medknow followed by co-trimoxazole for three weeks. The patient was Trichosporon asahii, Trichosporon asteroides, Trichosporon also catheterized for five days to aid free flow of urine. The cutaneum, Trichosporon inkin, Trichosporon mucoides, patient recovered following surgery and was discharged. One Trichosporon ovoides and Trichosporon loubieri.3 month later he presented with complaints of fever, severe (www vomiting and crying on micturition for five to six days, which Disseminated trichosporonosis is an uncommon but necessitated his re-admission in pediatric surgical ward in increasingly reported and frequently a fatal fungal infection August 2005. Upon physical examination his general condition in immunocompromisedThis patients. PDFa site It is believedhosted available that mostby casesforMedknow freewas founddownload Publications satisfactory butfrom he had pyrexia of 10oF. His blood of trichosporonosis attributed previously to T. beigelli and T. parameters were as follows: Hb 13.2 g/dL, TLC 9200/mL (N52%, cutaneum were probably caused by T. asahii which is now L44%, M1%, E0.3%), Serum urea 38 mg/dL, Serum creatinine emerging as an important life-threatening opportunistic 0.7 mg/dL and Serum electrolytes (Na+ 136 mmol/L, K+ 4.1 systemic pathogen, especially in granulocytopenic and mmol/L and Cl– 95 mmol/L). immunocompromised hosts.4 The patient’s urine sample was sent for routine culture Clinically, trichosporonosis appears with fever, pulmonary and sensitivity testing. The sample was inoculated on blood infiltrates, azotemia, renal dysfunction and skin lesions. The agar and MacConkey’s agar plates and incubated overnight at 37oC. Tiny, creamy- white, dry, wrinkled colonies were seen *Corresponding author (email: [email protected] >) on blood agar. The Gram stain of the colony revealed the Department of Microbiology and Immunology, SMS Medical College, presence of septate hyaline hyphae with arthrospores and Jaipur - 302 005, Rajasthan, India few budding yeast cells (Fig. 1). The colony was sub Received : 07-03-06 cultured on sets of Sabouraud dextrose agar (SDA) slants Accepted : 15-03-06 (with and without supplementation of antibiotics). These

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294 CMYK October 2006 Sood et al – Urinary Tract Infection by T. asahii 295

Figure 1: Gram stain of the colony (1000x) demonstrating septate Figure 2: Cornmeal agar morphology after 48 hrs. of incubation (400x) hyaline hyphae with arthrospores and few budding yeast cells demonstrating rectangular arthroconidia were incubated at 28oC and 37oC. At both these temperatures infection in the patient. The fact that there was clearance of numerous colonies of yeast like fungus were obtained in pure organisms from the urinary tract with recovery of the patient cultures, within 24 hours. Two more consecutive urine following antifungal treatment strongly associates the yeast samples of the patient were obtained and analyzed. The as a cause of UTI. diagnosis was established by demonstration of yeast forms in the urinary precipitate and budding yeast cells and Factors that enhance mucosal colonization and arthroconidia in the cultures. subsequent invasion of Trichosporon spp. include broad spectrum antibiotic treatment and breaks in mucosal barriers.8 The yeast was identified with corn meal agar morphology Our patient exhibited risk factors such as trauma during (Fig. 2), hydrolysis of urea, carbohydrate fermentation - surgery, presence of indwelling catheter and use of broad assimilation tests and nitrate assimilation tests.5,6 Depending spectrum antibiotics. upon morphology, cultural and biochemical characteristics, the isolate was identified as T. asahii. Trichospor.com).on spp. are occasionally a part of normal flora of human skin. In fact this yeast has been documented on On the basis of our preliminary report, antifungal therapy intact perigenital skin in 12.4% of the population in one study.2 with hamycin was initiated and the condition of the child Therefore, it is possible that the organism colonized the improved dramatically. After four weeks of antifungal catheter from the human flora during catheterization and treatmenthis urine sample was sent for repeat fungal culture subsequently progressed towards invasive trichosporonosis. and it was found to be negative for the fungus. .medknowNosocomial urinary tract infection due to T. asahii has been reported from Chile.9 Discussion Trichosporonosis is usually an insidious disease but it can The increase in profoundly immunocompromized(www patients present as an acute opportunistic infection in susceptible has been accompanied by an increase not only in frequency persons. Its diagnosis is likely to be missed particularly in of opportunistic fungal infections but also in the variety of developing countries, because of a general lack of awareness species involved. This PDFa site is hosted available by forMedknow freeand lackdownload ofPublications acquaintance from with the salient diagnostic features of the etiologic agent. Trichosporon spp. is one of the emerging mycoses in neutropenic patients, usually in the setting of a haematological References malignancy. Trichosporon asahii causes white piedra, a superficial infection of shafts mainly restricted to tropical 1. Middelhoven WJ. Identification of clinically relevant regions and less commonly onychomycosis in Trichosporon species. Mycoses 2003;46:7-11. immunocompetent humans. In immunodeficient hosts it has 2. Pini G, Faggi E, Donato R, Fanci R. Isolation of Trichosporon been isolated from blood, skin and viscera causing various in a hematology ward. Mycoses 2005;48:45-9. localized or disseminated deep infections.7 To the best of our knowledge this is the first report from Western India 3. Ahmad S, Al-Mahmeed M, Khan ZU. Characterization of implicating T. asahii as an agent of urinary tract infection. Trichosporon species isolated from clinical specimens in Kuwait. J Med Microbiol 2005;54:639-46. Isolation of the same yeast in three consecutive urine 4. Chowdhary A, Ahmad S, Khan ZU, Doval DC, Randhawa HS. samples and the fact that no bacteria were isolated, establishes Trichosporon asahii as an emerging etiologic agent of Trichosporon asahii as an etiological agent of urinary tract disseminated trichosporonosis: A case report and an update.

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Indian J Med Microbiol 2004;22:16-22. 8. Wolf DG, Falk R, Hacham M, Theelen B, Boekhout T, Scorzetti G, et al. Multidrug-Resistant Trichosporon asahii Infection of rd 5. Koneman EW, Roberts GD. Practical laboratory mycology. 3 Nongranulocytic Patients in Three Intensive Care Units. J Clin ed. Williams and Wilkins: Baltimore; 1985. p. 175-92. Microbiol 2001;39:4420-5.

nd 6. Chander J. Textbook of Medical Mycology. 2 ed. Mehta 9. Silva V, Zepeda G, Alvareda D. Nosocomial urinary tract Publishers: New Delhi; 2002. p. 302-4. infection due to Trichosporon asahii. First two cases in Chile. Rev Iberoam Micol 2003;20:21-3. 7. Panagopoulou P, Evdoridou J, Bibashi E, Filioti J, Sofianou D, Kremenopoulos G, et al. Trichosporon asahii an unusual cause of invasive infection in neonates. Pediatr Infect Dis Jr 2002;21:169-70. Source of Support: Nil, Conflict of Interest: None declared.

Announcement .com). IX National Conference of Hospital Infection Society of India (IX HISICON-2007) Organized by: Department of Microbiology, Government Medical College Hospital, Sector 32, Chandigarh (February 16-18, 2007)

February 15, 2007: CME on.medknow “Nosocomial Fungal Infections” February 16-18, 2007: Conference Theme “Infection Control: The Challenge Ahead” Conference highlights are as follows: There will be symposia and(www free paper sessions. (Oral and Poster Presentations) Likely topics to be covered during symposia are:

� ThisReuse ofPDFa single site isuse hosted available items by forMedknow free download� PublicationsNutrition and from infection � Infection in NICU � Hospital infection surveillance � Device related infections � OT Sterilization and Disinfection � Environmental Disinfection � Occupational infection hazards � Drug resistance � Surgical chemoprophylaxis � Surgical site infections � Hospital waste management � Nosocomial viral infections � Importance of Hand Washing � Unsafe injection practices � HIV and health care worker � Role of hospitals in community outbreaks � Hospital design

For further details and brochure, kindly contact: Dr. Jagdish Chander Organising Secretary, IX HISICON-2007, Professor and Head, Department of Microbiology, Government Medical College Hospital, Sector-32, Chandigarh - 160030. Phone No.: 0172-2624566, Email: [email protected], Website: http://gmch.gov.in

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