LETTERS References Fatal Algaemia in eramide. Voriconazole (400 mg/day) was used from day 17 to day 27. On 1. Chang WH. Current status of tsutsuga- Patient with Chronic mushi disease in Korea. J Korean Med day 21, Cryptosporidium parvum was Sci. 1995;10:227–38. Lymphocytic detected on parasitologic stool exami- 2. Cook GC, Warrell DA, Bryceson AD. Leukemia nation. Symptoms persisted on day Royal Society of Tropical Medicine and 26, with strong asthenia and deteriora- Hygiene meeting at Manson House, Lon- don, 17 October 1996. Debate: tropical To the Editor: Prototheca spe- tion of general state. At that time, the 9 medicine as a formal discipline is dead and cies are achlorophyllic lower algae, leukocyte count was 178 × 10 /L with should be buried. Trans R Soc Trop Med ubiquitous in nature, which can cause 3.56 × 109/L polymorphonuclear neu- Hyg. 1997;91:372–4, discussion 374–5. human infections, particularly in im- trophils and 172 × 109/L lymphocytes. DOI: 10.1016/S0035-9203(97)90244-3 3. Watt G, Parola P. Scrub typhus and tropi- munocompromised patients (1). Hu- Three peripheral blood samples were cal rickettsioses. Curr Opin Infect Dis. man protothecosis is mostly caused by cultured for detection of bacteria and 2003;16:429–36. DOI: 10.1097/00001432- P. wickerhamii and P. zopfii. Although fungi. On day 27, septic shock devel- 200310000-00009 such infections are infrequent, they oped in the patient. A blood culture 4. Ogawa M, Hagiwara T, Kishimoto T, Shiga S, Yoshida Y, Furuya Y, et al. Scrub can manifest themselves clinically showed an Escherichia coli strain sus- typhus in Japan: epidemiology and clini- as cutaneous lesions, olecranon bur- ceptible to piperacillin-tazobactam, cal features of cases reported in 1998. Am sitis, and, even more rarely, as dis- aminoglycosides, and quinolones. J Trop Med Hyg. 2002;67:162–5. seminated or systemic infections (1). Amikacin was added to the treatment 5. Lee YS, Wang PH, Tseng SJ, Ko CF, Teng HJ. Epidemiology of scrub typhus in east- These infections occur in severely regimen. Nonetheless, the patient died ern Taiwan, 2000–2004. Jpn J Infect Dis. immunocompromised patients, such on day 28. 2006;59:235–8. as persons with AIDS, or patients un- Two blood cultures for bacteria 6. Cao M, Guo H, Tang T, Wang C, Li X, dergoing extensive treatment, such as in aerobic vials grew the day of the Pan X, et al. Spring scrub typhus, People’s Republic of China. Emerg Infect Dis. cancer treatment or organ transplanta- patient’s death, but tests of blood cul- 2006;12:1463–5. tion (1–4). We describe a fatal case of tures for fungus remained negative. 7. Seong SY, Choi MS, Kim IS. Orientia P. wickerhamii algaemia in a patient After Gram staining, gram-positive tsutsugamushi infection: overview and with chronic lymphocytic leukemia. spherical unicellular organisms were immune responses. Microbes Infect. 2001;3:11–21. DOI: 10.1016/S1286-4579 In July 2007, a 79-year-old man, observed (Figure). After 48 hours of (00)01352-6 who had been monitored since 1993 incubation, creamy, yeast-like colo- 8. Okada N. Tsutsugamushi disease found for stage C chronic lymphocytic leuke- nies grew on chocolate agar (bio- in the northern districts of Awaji Island— mia (5), was hospitalized July 13–20 Mérieux, Marcy l’Etoile, France), but epidemiological study of the outbreak sea- son temperature [in Japanese]. Kansen- for a depressive syndrome with fever, not on Sabouraud agar containing gen- shogaku Zasshi. 2003;77:60–7. asthenia, and weight loss (3 kg over 2 tamicin and chloramphenicol (Becton months). Blood and urinary cultures Dickinson). Microscopy and the API Address for correspondence: Jin-Su Choi, on admission were sterile. The patient 20C AUX system (bioMérieux) iden- Department of Preventive Medicine, Chonnam was hospitalized again on July 30 for tified P. wickerhamii. National University College of Medicine, 5 fever (39°C), anorexia, and diarrhea, Sequencing the 18S rDNA with Hakdong, Donggu, Gwangju, South Korea; with ≈7 stools per day. He had lost 10 the primers Pw18SF 5′-TCAAAAA email: [email protected] kg in 2 weeks. Blood cultures for bac- GTCCCGGCTAATCTCGTGC-3′ teria (in BD Bactec Plus Aerobic/F and and Pw18SR 5′-CGCTTTCGTGCCT Letters BD Bactec Lytic Anaerobic/F vials; CAATGTCAGTGTT-3′ confirmed the Letters commenting on recent articles as Becton Dickinson, Le Pont de Claix, identification. The sequence of the well as letters reporting cases, outbreaks, France) and fungi (BD Bactec Mycosis amplified product was compared with or original research are welcome. Letters IC/F; Becton Dickinson) and stool cul- sequences published in the database commenting on articles should contain no more than 300 words and 5 references; tures for bacteria were negative. Blood of the National Center for Biotech- they are more likely to be published if cultures were incubated in a Bactec nology Information (Bethesda, MD, submitted within 4 weeks of the origi- 9240 instrument (Becton Dickinson). USA). The most likely identification, nal article’s publication. Letters report- Aspergillus fumigatus was found in a according to BLAST analysis (www. ing cases, outbreaks, or original research bronchoalveolar lavage specimen, but ncbi.nlm.nih.gov/blast/Blast.cgi), was should contain no more than 800 words and 10 references. They may have 1 no Aspergillus galactomannan antigen P. wickerhamii. Figure or Table and should not be divided was detected in blood. In vitro susceptibility tests were into sections. All letters should contain The patient was treated with performed by the Etest method (AB material not previously published and in- piperacillin-tazobactam, ciprofloxa- Biodisk, Solna, Sweden), on RPMI clude a word count. cin, acyclovir, voriconazole, and lop- agar. P. wickerhamii was found to be Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 7, July 2009 1129 LETTERS Authors affiliations: Centre Hospitalier Ré- gional Universitaire de Tours, Tours, France (P. Lanotte, G. Baty, D. Senecal, C. Darti- geas, E. Bailly, T.H. Duong, J. Chandenier, A. Goudeau); and Université François Rabelais, Tours (P. Lanotte, G. Baty, T.H. Duong, J. Chandenier, A. Goudeau) References 1. Lass-Flörl C, Mayr A. Human prototheco- sis. Clin Microbiol Rev. 2007;20:230–42. DOI: 10.1128/CMR.00032-06 2. Torres HA, Bodey JP, Tarrand JJ, Kontoy- iannis DP. Protothecosis in patients with Figure. Gram-positive spherical unicellular organisms in a blood culture from a 79-year-old cancer: case series and literature review. man with chronic lymphocytic leukemia. Magnification ×1,000. A color version of this figure Clin Microbiol Infect. 2003;9:786–92. is available online (www.cdc.gov/EID/content/15/7/1129-F.htm). DOI: 10.1046/j.1469-0691.2003.00600.x 3. Lass-Flörl C, Fille M, Gunsilius E, Gastl G, Nachbaur D. Disseminated infection susceptible to amphotericin B and bacteria, viruses, or yeasts which with Prototheca zopfii after unrelated posaconazole, with MICs of 0.047 cause co-infections (1), as in this stem cell transplantation for leukemia. J μg/mL and 0.012 μg/mL, respec- case, in which the alga was associ- Clin Microbiol. 2004;42:4907–8. DOI: tively. By contrast, it was resistant ated with E. coli. This association is 10.1128/JCM.42.10.4907-4908.2004 4. Narita M, Muder RR, Cacciarelli TV, to fluconazole (MIC>256 μg/mL), probably the result of disseminated Singh N. Protothecosis after liver trans- voriconazole (MIC>32 μg/mL), and protothecosis in severely immuno- plantation. Liver Transpl. 2008;14:1211–5. caspofungin (MIC>32 μg/mL). It was compromised patients, and the alga DOI: 10.1002/lt.21565 also susceptible to gentamicin (MIC = may cross digestive or cutaneous 5. Binet JL, Auquier A, Dighiero G, Chastang C, Piguet H, Goasguen J, et al. 0.25 μg/mL) but resistant to amikacin barriers. Reasons for septic shock or A new prognostic classification of chronic (MIC>24 μg/mL). death are unclear for most associa- lymphocytic leukemia derived from a However, the patient died before tions of pathogens (2,4). Prototheca multivariate survival analysis. Cancer. the algae were detected in the blood spp. are found in various reservoirs, 1981;48:198–206. DOI: 10.1002/1097- 0142(19810701)48:1<198::AID- culture vials. In this case, antifungal including the environment, animals, CR2820480131>3.0.CO;2-V treatment based on voriconazole use and food (1). In the case described 6. Sheikh-Ahmad M, Goldstein S, Potas- was empiric and ineffective. Some here, the infection may have originat- man I. Prototheca wickerhamii hand authors have described a successful ed from a contaminated well used to infection successfully treated by itracon- azole and voriconazole. J Travel Med. treatment on localized protothecosis obtain water for the patient’s kitchen 2006;13:321–3. DOI: 10.1111/j.1708- with voriconazole (6). Amphotericin garden. However, we were unable to 8305.2006.00062.x B currently seems to be most effective test this hypothesis. 7. Khoury JA, Dubberke ER, Devine SM. agent, although the best treatment re- Disseminated protothecosis is Fatal case of protothecosis in a hematopoi- etic stem cell transplant récipient after in- mains a matter of debate (1,4,7). Al- currently rare but, due to the algae’s fliximab treatment for graft-versus-host though in vitro susceptibility test re- ubiquitous nature, increasing use of disease. Blood. 2004;104:3414–5. DOI: sults are not necessarily well correlated immunosuppressive therapy, and in- 10.1182/blood-2004-07-2720 with results obtained in vivo, the low creasing incidence of hematologic ma- 8. Tortorano AM, Prigitano A, Dho Gio- vanna, Piccinini R, Dapra V, Viviani MA. MIC of posaconazole reported here lignancy, Prototheca spp. may emerge In vitro activity of conventional antifun- may be of interest in clinical practice as opportunistic pathogens.