Jpn. J. Med. Mycol. Vol. 29, 120-126, 1988 ISSN 0583-0516

A Case of Polymycotic Septicemia Caused by beigelii, albi cans and Candida krusei Takeshi Mori, Tomoo Kohara, Makiko Matsumura, Takao Hirano, Yoshihisa Wakabayashi, Hideo Ikemoto, Akiko Watanabe*, Wako Yumura**, Yoshiro Sakamoto**, Toshikazu Shirai** and Hikaru Kume*** Department of Internal Medicine *Central Laboratory for Medical Sciences, Division of Pathology **Department of Pathology, Juntendo University School of Medicine 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113, Japan ***Department of Pathology, Kitasato University, 1-15-1, Kitasato, Sagamihara, Kanagawa, 228, Japan

[Received for Publication: December 15, 1987]

This report describes a patient with acute leukemia complicated with polymycotic septicemia caused by , C. krusei and Trichosporon beigelii (cutaneum). Oral flucytosine and intravenous miconazole were administered, but the patient died on the 59th hospital day. At autopsy, T. beigelii and C. albicans were isolated from the liver, and T. beigelii was isolated from the lung by cultural examination and pathological investigation by the peroxidase/anti-peroxidase solution method. The patient was intubated with an intravenous catheter for hyperalimentation for a long time. The indwelling intravenous catheter appeared to be the major factor leading to the f ungemia. T. beigelii (cutaneum), a so-called "nonpathogenic ," must be considered a potential cause of . Key words: polymycotic septicemia, Candida albicans, Candida krusei, Trichosporon beigelii (cutaneum), peroxidase/antiperoxidase solution method

Introduction Case Report Advances in chemotherapy have contributed to An 18-year-old male the prolongation of life of patients with malignant He complained of lower abdominal pain in early diseases, but they have conversely led to an September, 1985, but this subsided after medica- increased incidence of opportunistic infections, tion administered by a local physician. However, especially fungal infections. in late September he again experienced lower We experienced a patient with acute leukemia abdominal pain with a cough, sputum, pharyngeal complicated with polymycotic septicemia caused pain and a fever of 37--38C and revisited the by Candida albicans, Candida krusei and same doctor. He was diagnosed as having acute Trichosporon beigelii (cutaneum). These fungi are myeloblastic leukemia, because the WBC count members of Cryptococcaceae. These fungal el- was 11,000/mm3 (Myeloblast 80.5, Band. 1, Seg.1, ements had a similar appearance in histological Eosino. 0.5, and Lymph. 17%) (Auer body was sections, but were differentiated from each other positive). He was admitted to our hospital on by the peroxidase/anti-peroxidase solution October 10, 1985. method. Cases of polymycotic septicemia seem to At admission, the body temperature was 37.4C, be rare. and there was slight anemia but no apparent lymphadenopathy, hepatosplenomegaly, edema or Jpn. J. Med. Mycol. Vol. 29 (No. 2), 1988 121

Table 1. Fungi and bacteria isolated from the patient

*: detected in the tip of the indwelling catheter

B: cultured from blood +: slight growth S: cultured from sputum 2+: moderate growth F: cultured from feces 3+: strong growth purpura. From the time of admission, cefotaxime, aclarubicin, 6-mercaptopurine and prednisolone, tobramycin, polymyxin B and flucytosine (2400 the myeloblasts were not diminished. The patient mg/day) were administered for prophylaxis, and was thus treated with high-dose cytosine ara- he was treated with combination chemotherapy binosite, because the leukemia was resistant to consisting of vindesine, prednisolone, 1-aspar- the therapy. aginase and daunorubicin. The number of leuko- Blood, sputum, feces and urine were frequently cytes decreased to 100/mm3, but the myeloblasts examined, and C. albicans, C. krusei and T. beigelii increased to 94% on the 5th day after the end of were detected from the blood, as shown in Table 1. the combination chemotherapy. Therefore, he was Urine culture was always negative. On December treated again with combination chemotherapy of 12, chest X-rays showed infiltration of the enocitabine, aclarubicin, 6-mercaptopurine and bilateral total lung fields, especially the bilateral prednisolone from November 10. However, at the middle lung fields, and the dose of miconazole was same time, a high fever of 39-40C persisted. increased from 1200mg to 1800mg/day; still a Pseudomonas cepacia was transiently detected in high fever persisted. On December 18, miconazole the venous blood. Cefotaxime was replaced, in was changed to intravenous . turn, with cefmenoxime, ceftizoxime and ce- However, the patient's condition deteriorated, and fotiam, but the fever did not abate. On December he died on December 19, 1985 (59th hospital day). 2, chest X-rays showed a little infiltration in the Intravenous hyperalimentation had been con- right middle lung field. Because the various anti- tinued from the patient's admission through biotics had been ineffective and infiltration ap- death, except for November 11 to December 6. peared on the chest X-ray, a fungal infection was Laboratory tests showed disturbances of the suspected; flucytosine was therefore changed to liver and renal functions; GOT increased from 66 intravenous miconazole (1200mg/day). Even after IU/l on December 9 to 365IU/l on December 16, the combination chemotherapy of enocitabine, GPT increased from 62IU/l on December 9 to 252 122 真菌 誌 第29巻 第2号 昭和63年

IU/1 on December 16, BUN increased from 21 mg/dl on December 12 to 74mg/ml on December 19 and serum creatinine increased from 0.8mg/ml on December 12 to 2.7mg/ml on December 19. Microscopic hematuria was detected on December 18. A Candida hemagglutination test on the patient's serum was negative (1:80-160; positive titer is 1:>320). The minimal inhibitory concentrations (MICs) of amphotericin B, miconazole and flucytosine for the isolate C. albicans, C. krusei and T. beigelii were determined by the agar dilution technique1). The MICs of amphotericin B, miconazole and flucytosine for C. albicans were 1.56, 6.25 and 0.78 ag/ml, while they were 3.13, 3.13 and 12.5ug/ml for C. krusei, and 6.25, 3.13 and over 100ug/ml for Fig. 1. Fungal elements in the liver by scanning T. beigelii. electron microscopy.

Autopsy Findings The bone marrow was found to be filled with myeloblastic leukemic cells, but there was no evidence of infiltration of leukemic cells into the other organs. The characteristic findings were extensive mycoses in the liver, lungs, kidneys, spleen, and also microscopic fungal lesions in the adrenal glands, pancreas and myocardium. T. beigelii was cultured from the liver and the lung, while C. albicans was cultured only from lung tissues obtained at autopsy. Scanning electron microscopy showed the mor- phologic fungal elements to be of various sizes (Fig. 1) and developed from cracks in the tissue and through Kohn's pores in the lung (Fig. 2). However, the fungal elements of Candida spp. Fig. 2. Electron microscopic fungal elements in could not be distinguished from those of T. the lung, developing through Kohn's pores or beigelii. cracks in the tissue. For the purpose of differentiation of the fungal elements, the same specimens of the liver and 3). The same specimens in Fig. 3 was stained by lung used for culture studies were also investi- the PAP method using anti-C. albicans rabbit gated by the peroxidase/anti-peroxidase solution serum (Fig. 4) and also stained by the PAP method method (PAP method) using anti-T. beigelii and using anti-T. beigelii rabbit serum (Fig. 5). Thus, anti-C. albicans rabbit sera. In the liver, the fungal the fungal elements of C. albicans and T. beigelii elements were stained violet by PAS staining (Fig. were differentiated from each other by the PAP Jpn. J. Med. Mycol. Vol. 29 (No. 2), 1988 123

method and found to be in very close proximity. But, in the lung tissue, only fungal elements of T. beigelii were detected.

Discusion In severely immunocompromised patients, systemic fungal infections may often occur, and they can be fatal. The most frequent causative fungi are Candida and species. Sys- temic occurs in about 10 percent of patients with acute leukemia, 1 percent of pa- tients with malignant lymphoma and 0.5 percent Fig. 3. Fungal elements in the liver by PAS staining. (original magnification X100). of patients with solid tumors2). The incidence of fungemia caused by Candida species has increased each year3). Predisposing factors to systemic fungal infec- tions are neutropenia caused by administered anticancer drugs, gastrointestinal ulceration due to increased use of broad-spectrum antibacterial agents (which has been associated with increases in both the frequency and degree of colonization of the gastrointestinal tract by fungi), and indwelling catheters which are used in cancer patients to facilitate the administration of medication4). Candida species are a part of the normal flora of the human body. Trichosporon is a normal in- Fig. 4. Same microscopic field as in Fig. 3. Candidal pseudohyphae stained with peroxidase/ habitant of the soil and is considered to be a anti-peroxidase solution method using anti-C. noninvasive , but it occasionally appears in albicans rabbit serum. (original magnification the normal flora of the human body. Therefore, X100). when Trichsporon is detected in clinical speci- mens, an infection by Trichosporon is often over- looked or belatedly diagnosed, and its major clinical presentation is a superficial infection of the hair shaft known as white . Only rarely has T. beigelii been reported as the cause of deep- tissue infections or disseminated diseases. Candidal pneumonia due to aspiration of in- fected secretion is an infrequent infection, and it is usually secondary to hematogenous dis- semination. T. beigelii, similar to Candida species, rarely causes primary pulmonary infections. In this Fig. 5. Same microscopic field as in Figs. 3 and 4. Fungal elements of T. beigelii stained by PAP patient, we couldnot conclude that the infection method using anti-T. beigelii rabbit serum. was aspiration pneumonia. At autopsy, there were (original magnification X100). small hemorrhages but no ulceration. Therefore, 124 真菌 誌 第29巻 第2号 昭 和63年 we couldnot assume that the fungus entered via helpful for identifying patients with fungal in- the gastrointestinal tract. We suspect that the site fection because there is a high frequency of of entry of the fungus was probably the indwelling colonization by Candida species, especially in catheter, because T. beigelii, C. albicans and C. patients treated with broad-spectrum antibiotics. krusei were detected in the tip of this catheter, T. In most patients with fungemia, Candida can be beigelii and C. albi cans were also cultured from the isolated from other locations prior to or at the liver tissue, and T. beigelii was cultured from lung same time as its appearance in the blood. The tissue obtained at autopsy. pathogenicity is significant when the fungus is Histopathologically, fungal elements were de- detected from two or more materials6) and a fever tected in the liver, lungs, kidneys, spleen, adrenal and leucocytosis are present; the outcome may be glands, pancreas and myocardium. fatal if the patient is not treated. T. beigelii and Candida species are pseudo- A problem arises with respect to the predilec- hyphae-forming and members of the family tion of Trichosporon and Candida to involve the Cryptococcaceae. They stain similarly in lesions. liver and kidneys, thereby impairing the functions It is said that Candida yeasts can be distinguished of those organs. Since antifungal agents, espe- from those of Trichosporon by their smaller size. cially amphotericin B, are also known to com- But, in actual practice, differentiation of T. promise the liver and kidney, it may be difficult to beigelii and Candida species in histologic sections distinguish whether liver and renal problems can be difficult. Therefore, we tried to differ- arising during the course of treatment are caused entiate the fungal elements using the PAP by the drug or by the invading fungus7). method, and we were able to recognize the fungal The minimal inhibitory concentration data elements of T. beigelii and C. albicans in the liver showed that T. beigelii was sensitive to micona- and T. beigelii in the lung. zole but resistant to flucytosine. The clinical The rabbit sera used for the PAP method response, however, may show poor correlation showed no cross-reactivity between C. albicans with the MICs. In general, MIC determinations and T. beigelii. for antifungal agents vary greatly in terms of Histopathological examination by the PAP methodology, and the data may be difficult to method and culture studies were performed on relate to the clinical response. In the defense small portions of the liver and lung. If larger against invading fungi, the most important factor portions of the liver, lungs, kidneys, spleen and so may be ingestion by phagocytes and/or digestion8) on had been examined, perhaps C. albicans and/or within phagosomes. In the presence of antifungal C. krusei would have been detected. But it was drugs, fungi are inactive but they may be able to surmised that T. beigelii was predominant at survive if they are not phagocytized by macro- autopsy, and why C. krusei was not detected at phages. Therefore, it is important to achieve autopsy needs further study. control of the underlying disease. T. beigelii and have Prophylactic antifungal treatments are admin- been shown to share a common antigen. Cross- istered to prevent in patients with reactivity was observed in the cryptococcal latex malignant diseases. In our case, medication with agglutination testy. This test has been found oral flucytosine was performed, but -in retro- helpful when applied in the clinical evaluation of spect-the dosage was too low (73.4mg/kg/day). patients with fungemia due to T. beigelii. For prevention of mycoses, administration of an Candidemia frequently represents a problem of adequate dosage of flucytosine (150mg/kg/day) is transcs utaneous catheter contamination and often necessary. However, prolonged use of flucytosine undergoes natural cure after catheter removal. may be unwise because fungi can become resist- Therefore, screening of cultures is not very ant to this drug. Oral administration of high-dose Jpn. J. Med. Mycol. Vol. 29 (No. 2), 1988 125 amphotericin B (syrup) results in an elevated nancy. serum level. This treatment may be effective against gastrointestinal fungal infections, but not References against fungemia or systemic infections occurring 1) Uchida, K. and Yamaguchi, H.: Bioassay for mic- due to an indwelling intravenous catheter. There onazole and its level in human body fluids. Che- was a report that prophylactic treatment with motherapy 32: 541-546, 1984. ketoconazole prevented or postponed the develop- 2) Bodey, G. P.: Fungal infection and fever of unknown ment of clinical mycoses and had very few side origin in neutropenic patients. Am. J. Med. 80 effects9). In another report10), a patient recovered (suppl 5C): 112-119, 1986. after amphotericin B, flucytosine and ketocona- 3) Meunier-Carpenter, F., Kiehn, T.E. and Armstrong, zole therapy and achieved concomitant remission D.: Fungemia in the immunocompromised host; of leukemia. changing patterns, antigenemia, high mortality. Am. J. Med. 71: 363-370, 1981. Murray-Leisure et al.11) reported 21 cases of 4) Dyess, D. L., Garrison, R. N. and Fry, D. E.: Candida disseminated T. beigelii infection. Only four cases sepsis; implications of polymicrobial blood-borne recovered. For treatment, mainly intravenous infection. Arch. Surg. 120: 345-348, 1985. amphotericin B was primarily used, but the out- 5) McManus, E. J., Bozdech, M.J. and Jones, J. M.: Role come depended upon the status of the underlying of the latex agglutination test for cryptococcal disease. E1-Ani and Castillo12). reported a patient antigen in diagnosing disseminated infections with with myeloproliferative syndrome in whom a Trichosporon beigelii. J. Inf. Dis. 151: 1167-1169, disseminated infection by T. beigelii developed in 1985. spite of chemotherapy with amphotericin B. And 6) Solomkin, J. S., Flohr, A.M. and Simmons, R.L.: Bhansali et al.13)described the case of a young man Indications for therapy for fungemia in postoper- with leukemia who developed splenic granulomas ative patients. Arch. Surg. 117: 1272-1275, 1982. in association with a disseminated T. beigelii 7) Rivera, R. and Cangir, A.: Trichosporon sepsis and leukemia. Cancer 36: 1106-1110, 1975. infection. The disease improved with combination 8) Otsuka, F., Seki, Y., Takizawa, K. and Kurita, A.: chemotherapy of amphotericin B and flucytosine, Ultrastructural observations of fungal elements in a but splenectomy was required for cure. Combina- Trichosporon cutaneum infection of the skin. J. tion chemotherapy with amphotericin B and Dermatol. 9: 1-5, 1982. flucytosine is not sufficient for a disseminated T. 9) Brincker, H.: Prevention of mycosis in granulo- beigelii infection. Another paper reported that a cytopenic patients with prophylactic ketoconazole patient with aplastic anemia was cured by com- treatment. Mykosen, 26: 242-247, 1983. bination chemotherapy with amphotericin B, 10) Yung, C. W., Hanauer, S. B., Fretzin, D., Rippon, flucytosine and itraconazolel4) J. W., Shapiro, C. and Gonzalez, M.: Disseminated The only previously reported case of systemic Trichosporon beigelii (cutaneum). Cancer 48: 2107- T. beigelii infection associated with other fungal 2111, 1981. infections was documented by Saul et al.15) To our 11) Murray-Leisure, K. A., Aber, R. C., Rowley, L. J., knowledge, our case is the first one describing Applebaum, P.C., Wisman, C.B., Pennock, J.L. and Pierce, W. S.: Disseminated Trichosporon beigelii polymycotic septicemia caused by T. beigelii and (cutaneum) infection in an artificial heart recipient. Candida spp. JAMA 256: 2995-2998, 1986. Early recognition of T. beigelii as a systemic 12) El-Ani, AS. and Castillo, N. B.: Disseminated in- in the immunocompromised patient is fection with Trichosporon beigelii, N. Y. State Med. J. important to ensure prompt initiation of anti- 84: 457-458, 1984. fungal therapy for a disseminated infection. But 13) Bhansali, S., Karanes, C., Palutke, W., Crane, L., cure of the polymycotic septicemia may depend Kiel, R. and Ratanatharathorn, V.: Successful largely on remission of the underlying malig- treatment of disseminated Trichosporon beigelii 126 真 菌誌 第29巻 第2号 昭 和63年

(cutaneum) infection with associated splenic invo- 15) Saul, S. H., Khachatoorian, T., Poorsattar, A., lvement. Cancer 58: 1630-1632, 1986. Myerowitz, R. L., Geyer, S.J., Pasculle, A. W. and Ho, 14) Walsh, T. J., Newman, K. R., Moody, M., Wharton, M.: Opportunistic Trichosporon pneumonia, associ- R. C. and Wade, J.C.: in patients ated with invasive . Arch. Pathol. Lab. with neoplastic diseases. Medicine 65: 268-279, Med. 105: 456-459, 1981. 1986.