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Subcutaneous Mycosis and Fungemia by Aureobasidium Pullulans: a Rare Pathogenic Fungus in a Post Allogeneic BM Transplant Patient

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Subcutaneous Mycosis and Fungemia by Aureobasidium Pullulans: a Rare Pathogenic Fungus in a Post Allogeneic BM Transplant Patient Bone Marrow Transplantation (2010) 45, 203–204 & 2010 Macmillan Publishers Limited All rights reserved 0268-3369/10 $32.00 www.nature.com/bmt LETTER TO THE EDITOR Subcutaneous mycosis and fungemia by Aureobasidium pullulans: a rare pathogenic fungus in a post allogeneic BM transplant patient Bone Marrow Transplantation (2010) 45, 203–204; We present here the case of an 11-year-old boy, who was doi:10.1038/bmt.2009.111; published online 1 June 2009 diagnosed with Fanconi’s anemia in August 2007 and had undergone a matched sibling BM transplant in January 2008. He rejected this graft within 7 months of transplant. Fungal infections in BM transplant patients are being seen A second allogeneic peripheral blood stem cell transplant with greater frequency than ever before. The most common was performed in September 2008 using the same donor. fungal organisms isolated are Candida, followed by the The conditioning regimen used during the second trans- Aspergillus species. In addition, a growing list of unusual plant was fludarabine (30 mg/m2 i.v.) once daily from day and unexpected etiological agents presents a unique and À7 to day À3, BU (1 mg/kg per oral (p.o.)) 6 hourly difficult challenge to clinicians and microbiologists. from day À6 to day À4 and horse anti-thymocyte globulin Aureobasidium is a demataceous fungus commonly isolated (20 mg/kg i.v.) once daily from day À4toÀ2. He was on from soil and the indoor air environment. This genus itraconazole prophylaxis and had no evidence of fungal includes 14 species, among which, Aureobasidium pullulans infection before the second transplant. The patient devel- is the only well-known pathogen causing s.c. infection oped fever with erythematous papules over the right or phaehyphomycosis.1 We report a case of systemic forearm, both distal lower limbs and swelling in small A. pullulans infection during the first week of allogeneic joints of the hand on day 0 of the second transplant stem cell transplant. (Figure 1). The patient was started on a broad spectrum of antibiotics the same day. However, in view of the progressive increase in size and number of skin lesions over the next 2 days, the patient was started on voriconazole by injection on day þ 3 with a clinical suspicion of candide- mia. A blood culture from the central venous catheter lumen was initially suggestive of growth of a yeast-like organism, hence the catheter was removed. Chest X-ray was normal. Further evaluation of the blood culture showed multicellular filamentous hyphae of varying sizes accompanied by budding yeast-like cells, both in the BACTEC 9050 (Becton Dickinson, Franklin Lakes, NJ, USA) and in the colonies growing on Sabouraud’s dextrose agar media (Hi-Media, Mumbai, India). These fungal isolates were subsequently classified as A. pullulans because Figure 1 Erythematous maculopapular skin lesions over the shin of the of their classical pigment production (Figure 2a). A skin tibia (bilateral). biopsy carried out on day þ 6 from the nodular lesion on Figure 2 (a) Auerobasidium pullulans by colony morphology and microscopic appearance of hyaline blastoconidia that developed into chains of thick- walled darkly pigmented arthroconidia in isolate recovered from the blood of the patient, which grew on Saboraud’s dextrose agar for 4 days. (b) Gomori methenamine silver-stained sections of a skin biopsy specimen. Letter to the Editor 204 the shin showed the presence of similar organisms patients received antifungal treatment for 4–8 weeks.2,3 Our (Figure 2b). As the patient had persistent fever, liposomal patient is now 5 months post second transplant and is amphotericin-B (3 mg/kg i.v.) daily was administered on doing well with no chronic sequelae of infection. day þ 9. The patient responded to the above treatment, A Joshi1, R Singh1, MS Shah1, S Umesh2 and N Khattry1 became afebrile on day þ 15 and the skin lesions gradually 1BMT Unit, Department of Medical Oncology, Advanced resolved. He received liposomal amphotericin-B for a total Center for Treatment, Research and Education in Cancer, of 12 days, and voriconazole (p.o.) was continued for the Tata Memorial Center, Kharghar, Navi Mumbai, India and next 2 months on an outpatient basis. 2Department of Microbiology, Advanced Center for This is probably the first case report of A. pullulans Treatment, Research and Education in Cancer, Tata fungemia after allogeneic stem cell transplant to our Memorial Center, Kharghar, Navi Mumbai, India knowledge. In our case, the blood culture initially grew E-mail: [email protected] yeast-like colonies suggestive of Candida species. However, on subculture, the characteristic colony morphology (moist and creamy colonies in 2 days, which matured into shiny brownish black colonies with a gray fringe Conflict of interest and pigment production) was suggestive of A. pullulans fungemia. The source of fungemia in this patient was the The authors declare no conflict of interest. central venous catheter. A. pullulans is a very rare cause of systemic infection in humans. Reports have suggested that it may cause References keratomycosis (corneal and scleral ulcer), meningitis, splenic abscess, jaw abscess, pulmonary mycosis, sepsis 1 Rinaldi M. Phaeohyphomycosis. Clin Dermatol 1996; 14: and other opportunistic infections, as well as cutaneous 147–153. mycoses such as eumycotic dermatitis.2 It has also been 2 Michael H, Robert R, Crystal S, Wendy V. Aureobasidium isolated from peritoneal fluids and central venous catheters, pullulans infection: fungemia in an infant and a review of human but when isolated from healthy subjects, it is considered as cases. Diagn Microbiol Infect Dis 2005; 51: 209–213. a contaminant.3 Disseminated systemic infection as in our 3 Bolignano G, Criseo G. Disseminated nosocomial fungal patient has been reported in only four cases so far. Of the infection by Aureobasidium pullulans var. melanigenum: a case 4 report. J Clin Microbiol 2003; 41: 4483–4485. four cases, one had AML, the second patient had ovarian 4 Kaczmarski EB, Liu Yin JA, Tooth JA, Love EM, Delamore 5 carcinoma (both had Hickman catheters in situ), the third IW. Systemic infection with Aureobasidium pullulans in a patient had met with a road traffic accident with accidental leukemic patient. J Infect 1986; 13: 289–291. inoculation of pathogen3 and the fourth was a child with 5 Girardi LS, Malowitz R, Tortora GT, Spitzer ED. Aureobasi- congenital heart disease who had undergone closure of an dium pullulans septicemia. Clin Infect Dis 1993; 16: 338–339. atrial septal defect with a Goretex patch.2 Cutaneous 6 Redondo BP, Idoate M, Rubio M, Ignacio Herrero J. involvement by Aureobasidium is also rare, and on an Chromoblastomycosis produced by Aureobasidium pullulans extensive search of the literature we could find only two in an immunosuppressed patient. Arch Dermatol 1997; 133: case reports in patients of kidney and liver transplant.6,7 663–664. There is no standard treatment for infection caused by 7 Franco A, Aranda I, Fernandez MJ. Chromomycosis in a renal transplant recipient. Nephro Dial Transplant 1996; 11: 715–716. A. pullulans because of the paucity of human cases reported 8 Clark EC, Silver SM, Hollick GE, Rinaldi MG. Continuous in literature. Amphotericin-B alone or in combination with ambulatory peritoneal dialysis complicated by Aureobasidium 3–5,8,9 azoles has been tried with variable success. Combina- pullulans peritonitis. Am J Nephrol 1995; 15: 353–355. tion therapy is probably the treatment of choice. 9 Jones FR, Christensen GR. Pullularia corneal ulcer. Arch The duration of treatment is not certain, though most Ophthalmol 1974; 92: 529–530. Bone Marrow Transplantation.
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