Malassezia Furfur Folliculitis in Cancer Patients. the Need for Interaction Of

ANNALS OF CLINICAL AND LABORATORY SCIENCE, Vol. 23, No. 5 Copyright © 1993, Institute for Clinical Science, Inc. Malassezia furfur Folliculitis in Cancer Patients The Need for Interaction of Microbiologist, Surgical Pathologist, and Clinician in Facilitating Identification by the Clinical Microbiology Laboratory* RAMON L. SANDIN, M.D., M.S.,f TZANN-TARN FANG, M.D.,* JOHN W. HIEMENZ, M.D.,t JOHN N. GREENE, M.D.,§ LINA CARD, M.T. (ASCP),t ALEXANDRA KALIK, M.D.,t and JENO E. SZAKACS, M.D.t Departments of Pathology, f Bone Marrow Transplant Service,t and Infectious Diseases,§ H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, Florida 33612-9497 ABSTRACT Malassezia furfur (MF) is a lipophilic yeast which can be found as a member of the indigenous microbiota of human skin. In immunocompro mised transplant patients, MF can cause a distinctive folliculitis which is a clinical look-alike to Candida folliculitis, the latter of more potentially devastating significance. Recovery of MF in culture is dependent upon the addition to culture media of an exogenous source of fatty acids, such as olive oil. The addition of an extra Sabourauds plate with an olive oil overlay to the routine set of media used to inoculate all skin biopsy specimens in order to detect MF is labor-intensive and not cost-effective. Thus, MF may not be isolated in cases of MF folliculitis unless the clinical microbiology laboratory is put on alert by the clinical suspicions of the attending physi cian, or by histopathologic findings suggestive of folliculitis revealed by review of surgical pathology slides. The clinical, pathological, and micro biological findings of two cases of MF folliculitis are presented where an interactive approach featuring communication between the microbiologist, the surgical pathologist, and the clinician guided the microbiology labora tory to the isolation and identification of isolates of MF that were clinically- relevant. These cases underscore how a combined approach which features communication between the laboratory and the clinical services always provides superior guidance in the diagnosis and therapy of infec tious diseases. * Send reprint requests to: Ramon L. Sandin, M.D., Room 2071 Pathology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612-9497. 377 0091-7370/93/0900-0377 $01.20 © Institute for Clinical Science, Inc. 3 7 8 SANDIN, FANG, HIEMENZ, GREENE, CARD, KALIK, AND SZAKACS Introduction from these other conditions on purely clinical grounds is not always feasible, Malassezia furfur (MF) is a lipophilic one alternate approach to diagnosis yeast, which is a member of the indige would be to add an extra Sabourauds nous microbiota of the skin of many plate with an olive oil overlay to the rou warm-blooded hosts.5 Growth of MF on tine set of media inoculated with speci culture media is dependent upon the mens from the skin. addition of an exogenous source of This global approach, however, would medium- to long-chain fatty acids, such be labor-intensive and neither wise nor as olive oil. Malassezia furfur can cause cost-effective, since the mere recovery of an erythematous papulopustular folliculi MF from skin biopsies may be hard to tis that may be more common than is rec- interpret in the absence of clinical suspi ognized in immunosuppressed cion, patient history or of histopathologi- patients4,5,7 and which must be differen cal findings suggestive of a frank follicu tiated from the macronodular lesions of litis. Subsequently, an interactive disseminated candidiasis, as well as approach which features communication other conditions.1,5,6, Since distinction between the microbiologist, the surgical F ig u r es 1A a n d IB. The clinical mani festations of Malassezia furfur (M F ) folliculitis in the two described patients were similar: an erythematous, pruritic, papulopustular rash on the back and shoulders, which can be appreciated in low and high magnifi cation photographs. Some lesions became unroofed and were replaced by scabs. The raised (papu lar) character of these lesions can be appreci ated in the high-power photograph. MALASSEZIA FURFUR FOLLICULITIS 3 7 9 pathologist and the clinician would ture were inoculated onto Sabourauds appear to be the most reasonable way in dextrose agar (SAB), SAB with chloram which to guide the laboratory staff phenicol, and brain heart infusion agar. towards isolation and identification of All were incubated at 30°C. For isolation clinically-relevant isolates of this organ of MF, a few drops of sterile olive oil ism, while decreasing labor and cost. were added to the SAB plate. Tentative Case reports of two patients with fol identification of MF was carried out by licular rashes will be presented which the observation of growth in the pres illustrate the convenience of such an ence, but not in the absence, of olive oil. interactive approach, without which iso Definitive identification relied on colo lation and identification of MF as the nial morphology suggestive of a yeast, etiological agent of folliculitis in these direct smears of colonial growth with the two patients would have been missed. expected microscopic morphology, lack of reactivity in the Vitek YBC yeast iden Materials and Methods tification card* and positive results fol Tissues from skin biopsy specimens submitted to microbiology for fungal cul * Vitek Systems, Hazelwood, MO. Figure IB. Continued. 380 SANDIN, FANG, HIEMENZ, GREENE, CARD, KALIK, AND SZAKACS lowing the rapid urea test. Skin biopsy enteritis and mucositis. Owing to persistent fevers, specimens sent to surgical pathology empiric antifungal coverage with amphotericin B was begun five days post transplant. By this time, were formalin-fixed, paraffin-embedded, the skin rash had begun to resolve. Skin biopsy sug and stained with hematoxylin and eosin gested fungus; however, the rash had significantly improved before cultures of the skin biopsy grew (H & E), gomori-methenamine silver Malassezia furfur. By day 10 post transplant, WBC stain (GMS), and periodic acid-Schiff was 1,200 and the ANC was >500 per mm3. The stain (PAS). patient defervesced and was subsequently dis charged from hospital 19 days post-transplant with her rash resolved. Case Reports Case #2 Case #1 A 22-year-old white female presented with a his A 34-year-old white female with breast cancer tory of Burkitt’s lymphoma of the distal ileum diag metastatic to bone was first diagnosed in January nosed at laparotomy. After resection of the tumor, 1991. The patient had initial response to cyclophos the patient was treated with five cycles of cyclo phamide, adriamycin, and 5-fluorouracil systemic phosphamide, adriamycin, vincristine, and pred chemotherapy but showed progressive disease by nisone along with prophylactic intrathecal metho October 1991, as evidenced by increased bone pain, trexate. The patient did well off therapy from Jan worsening metastatic disease on bone scan, and ris uary to March 1992 when she was noted to have a ing tumor markers (CEA and CA 15-3). The patient mandibular and intra-abdominal relapse with retro was referred to the H. Lee Moffitt Cancer Center at peritoneal and mesenteric adenopathy. Reinduc the University of South Florida and relapse therapy tion was accomplished with high dose cytosine ara- was begun with standard dose ifosfamide, carbo- binoside and cisplatinum in April 1992. The patient platinum, and etoposide. After documenting subsequently was referred to the H. Lee Moffitt response the patient underwent peripheral stem Cancer Center and received two cycles of standard cell harvest after intravenous cyclophosphamide. dose chemotherapy with ifosfamide, carbo The patient was admitted to the bone marrow platinum, and etoposide achieving a com transplant unit on April 1, 1992 for high dose che plete remission. motherapy and peripheral blood stem cell rescue. In order to minimize the risk or relapse, the On admission, the patient was found to be well patient was admitted to the bone marrow transplant developed and in no acute distress. She was afe unit in July 1992 for high dose chemotherapy and brile with stable vital signs. No skin rash or lesions autologous bone marrow transplantation. On admis were seen. There was no adenopathy. Admission sion, examination revealed the patient to be a well laboratory exam revealed a white blood cell (WBC) developed, well nourished young female in no dis count of 3,100 and an actual neutrophil count (ANC) tress. There were no skin rash or lesions. Head and of 2,100. Renal and liver functions were normal. neck exam showed resolution of the mandibular Preadmission scans revealed boney metastatic dis tumor and no other abnormalities. Admission labo ease and were otherwise unremarkable. ratory evaluation revealed WBC 7,200 and ANC Therapy was begun with high dose ifosfamide, 6,300. Chemistry panel was unremarkable with nor carboplatinum, and etoposide daily for six days. mal renal and liver functions. Preadmission com Treatment was delivered in a single patient hospital puterized tomography showed resolution of previ room equipped with laminar air flow and HEPA ous adenopathy. filters. Nystatin was used for oropharyngeal candi Upon admission, the patient underwent harvest diasis prophylaxis, and aerosolized pentamidine for of 922 ml of bone marrow from the posterior iliac Pneumocystis carinii prophylaxis. No systemic anti crests. The following day she began high dose che bacterial or antifungal prophylaxis was utilized. motherapy with ifosfamide, carboplatinum, and After completion of chemotherapy, two days were etoposide given daily for six days. After two days of allowed for drug elimination, and cryopre- rest for drug elimination, cryopreserved bone mar served stem cells were then thawed and rein row was thawed and reinfused intravenously. All fused intravenously. therapy was delivered in a single bed hospital room The patient tolerated chemotherapy relatively equipped with laminar air flow and HEPA filters. well except for nausea controlled with antiemetics Nystatin was used for local oropharyngeal Candida and dexamethasone.

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