Hashimoto et al. BMC Infectious Diseases (2019) 19:684 https://doi.org/10.1186/s12879-019-4319-2 CASE REPORT Open Access A case report of pulmonary Botrytis sp. infection in an apparently healthy individual Seishu Hashimoto1*, Eisaku Tanaka1, Masakuni Ueyama1, Satoru Terada1, Takashi Inao1, Yusuke Kaji1, Takehiro Yasuda1, Takashi Hajiro1, Tatsuo Nakagawa2, Satoshi Noma3, Gen Honjo4, Yoichiro Kobashi4, Noriyuki Abe5, Katsuhiko Kamei6 and Yoshio Taguchi1 Abstract Background: Botrytis species are well known fungal pathogens of various plants but have not been reported as human pathogens, except as allergenic precipitants of asthma and hypersensitivity pneumonitis. Case presentation: The asymptomatic patient was referred because of a nodule revealed by chest X-ray. Computed tomography (CT) showed a cavitary nodule in the right upper lobe of the lung. He underwent wedge resection of the nodule, which revealed necrotizing granulomas and a fungus ball containing Y-shaped filamentous fungi, which was confirmed histopathologically. Culture of the specimen yielded white to grayish cotton-like colonies with black sclerotia. We performed multilocus gene sequence analyses including three single-copy nuclear DNA genes encoding glyceraldehyde-3-phosphate dehydrogenase, heat-shock protein 60, and DNA-dependent RNA polymerase subunit II. The analyses revealed that the isolate was most similar to Botrytis elliptica. To date, the pulmonary Botrytis sp. infection has not recurred after lung resection and the patient did not require any additional medication. Conclusions: We report the first case of an immunocompetent patient with pulmonary Botrytis sp. infection, which has not recurred after lung resection without any additional medication. Precise evaluation is necessary for the diagnosis of pulmonary Botrytis infection because it is indistinguishable from other filamentous fungi both radiologically and by histopathology. The etiology and pathophysiology of pulmonary Botrytis infection remains unclear. Further accumulation and analysis of Botrytis cases is warranted. Keywords: Botrytis sp., Pulmonary infection, Immunocompetent host, DNA sequence analysis Background sweet wine in the right conditions. With regard to other Botrytis species are important pathogens of nursery Botrytis species, B. squamosa, B. allii, and B. aclada at- plants, vegetables, orchard crops, and can colonize tack bulbs of onion, garlic and leek, while B. tulipae and stored and transported agricultural products [1]. In par- B. elliptica attack flower bulbs such as tulip and lily. ticular, Botrytis cinerea is responsible for gray mold dis- Airborne exposure to Botrytis sp. has been reported ease on more than 200 host plants [2] and has been globally but the prevalence of Botrytis is different by isolated from numerous places around the world, espe- regions and seasons. Botrytis exposure is especially cially humid, temperate and subtropical regions [1–3]. significant in occupational setting such as greenhouses In contrast, winegrowers and viniculturists sometimes and grain mills. Although many people may inhale welcome B. cinerea, which facilitates a concentrated spores of Botrytis species, it is of interest that Botrytis species have not been reported as human pathogens, except as allergenic precipitants of asthma and hyper- * Correspondence: [email protected] 1Department of Respiratory Medicine, Tenri Hospital, 200 Mishima-cho, Tenri, sensitivity pneumonitis [3]. Nara 632-8552, Japan Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hashimoto et al. BMC Infectious Diseases (2019) 19:684 Page 2 of 8 We report an apparently immunocompetent Japanese (maximum standardized uptake value = 2.2). Laboratory man with pulmonary Botrytis sp. infection, which to date tests (Table 1) showed that serum creatinine was ele- has not recurred after lung resection. vated at 1.2 mg/dL. The hemoglobin level, white cell and Preliminary results of this case report have been pre- platelet counts, and results of coagulation and liver func- sented in a poster discussion at the annual meeting of tion were normal. C-reactive protein was below 0.2 mg/ the American Thoracic Society [4]. dL. The erythrocyte sedimentation rate was slightly ele- vated at 12 mm/h. Serum tests for 1, 3-β-D-glucan, As- Case presentation pergillus antigen, anti-Aspergillus antibody, and A 62-year-old Japanese man from Tenri City in Nara Cryptococcus antigen were all negative. Hemoglobin A1c prefecture was referred to our hospital because of a was normal at 5.6%. Both anti-human immunodeficiency nodular shadow on chest X-ray taken at a regular health virus antibody and anti-human T-cell leukemia virus checkup. He did not have cough, sputum, hemoptysis, type 1 antibody were negative. Bronchoscopic examin- fever, night sweats, chest pain and weight loss. He had ation was performed, and bronchial brush specimens smoked two packs of cigarettes per day for 30 years until and bronchial washing fluids were obtained under fluor- 12 years previously and occasionally consumed alcohol. oscopy. However, the examination revealed no remark- He was an office worker and had been to China and able malignant cells or microorganisms including fungi Taiwan on business for several days approximately 30 and mycobacteria. Wedge resection of the cavitary nod- years previously. He had no known occupational or in- ule in the right upper lobe using video-assisted thoraco- halational exposures. He had never grown any plants, scopy was undergone to diagnose the nodule and fruits, or vegetables. He had diabetes mellitus, hyperlip- exclude malignancy. idemia and gout and had been treated with a combin- Histopathological examination of the resected speci- ation of mitiglinide and voglibose, vildagliptin, menshowednecrotizinggranulomasandafungus rosuvastatin, and allopurinol. He had no known tubercu- ball containing Y-shaped filamentous fungi (Fig. 2b-f). losis, bronchiectasis, or allergies. Family history was un- Grocott’s methenamine silver stain revealed that the remarkable and there was no family history of fungal septated hyphae branched dichotomously (Fig. 2g). disease. On examination, his temperature was 36.4 °C, Vascular invasion was not seen in the tissue. The blood pressure 144/88 mmHg, and resting pulse was 85 histopathological features resembled those of chronic beats per minute, with 12 breaths per minute. The oxy- cavitary pulmonary aspergillosis. gen saturation was 98% while breathing ambient air. He The lung biopsy material was cultured for fungi, had normal vesicular sounds on auscultation. The re- mycobacteria and other bacteria. Because molds were mainder of the examination was normal. observed in the intraoperative frozen section, culture for A chest X-radiograph showed a cavitary nodule in the fungi was incubated at 25 °C on potato dextrose agar right upper lung field (Fig. 1b), which was not seen on (PDA) for 7 days. The culture yielded white to grayish X-ray film taken 18 months previously (Fig. 1a). Com- cotton-like colonies with black sclerotia around the col- puted tomography (CT) revealed a nodule with cavitary onies (Fig. 3a). No other microorganisms were isolated. lesion, measuring 25 mm in diameter, in the right upper The multilocus gene sequence analyses identified the lobe (Fig. 2a). 18F-fluorodeoxy-glucose positron emission fungus as Botrytis sp. as shown in Tables 2, 3, 4 and tomography revealed mild accumulation in the nodule Additional file 1: Figures S1-S5. He was diagnosed with Fig. 1 Imaging studies of the chest. a A chest X-radiograph obtained 18 months earlier reveals no abnormal findings. b A chest X-radiograph on admission shows a cavitary nodule (arrow) in the right upper lung field. Hashimoto et al. BMC Infectious Diseases (2019) 19:684 Page 3 of 8 Fig. 2 Imaging study of the chest and histopathological images of resected specimens. a Computed tomography of the chest reveals a cavitary nodule with thin wall and pleural indentations in the right upper lobe. b The bronchioles surrounding the areas of inflammation and fibrosis are seen in hematoxylin and eosin stained section through a magnifying glass. c The necrotizing granuloma (arrows) destroying and invading the wall of bronchiole is seen in hematoxylin and eosin stained section at low magnification. d A fungus ball (arrow) is seen in the cavity at the other hematoxylin and eosin stained section through a magnifying glass. e A fungus ball (arrow) is shown at low magnification view in hematoxylin and eosin stained section. f Y-shaped filamentous fungi in the fungus ball are seen in hematoxylin and eosin stained section at higher magnification. g The organisms are well outlined with Grocott’s methenamine silver stain. The dichotomous branching hyphae and scatter septations can be observed at higher magnification pulmonary Botrytis sp. infection. As the patient was im- Yokohama, Japan). The PCR was performed using the pri- munocompetent