MYCOSES 44, 502±504 2001) ACCEPTED:SEPTEMBER 1, 2001

LETTER TO THE EDITOR

Case Report. Fungaemia due to piceum, a member of the Penicillium marneffei complex

Fallbericht. FungaÈmie durch Penicillium piceum, einem Mitglied des Penicillium marneffei Komplexes

R. HorreÂ1, S. Gilges2, P. Breig3, B. Kupfer1, G. S. de Hoog4, E. Hoekstra4, N. Poonwan5 and K. P. Schaal1

Key words. Penicillium piceum, Penicillium marneffei, Biverticillata, fungaemia. SchluÈ sselwoÈrter. Penicillium piceum, Penicillium marneffei, Biverticillata, FungaÈmie.

Summary. Due to the inability of most Biverticillata von Penicillium,wasdurchrDNS Penicillium to grow at 37 uC, systemic ITS-Sequenzen bestaÈtigt wurde; moÈglicherweise non-marneffei infections are very rare in the human besitzt es aÈhnliche Virulenzfaktoren. host.Wedescribeacaseoffungemiadueto Penicillium piceum inafemalepatient,whodieda Introduction few days after repeated isolation of this from blood cultures. The species is a member of In clinical practice, Penicillium species isolated the section Biverticillata of Penicillium,aswas from non-AIDS patients are mostly discarded as con®rmed by rDNA Internal Transcribed Spacer contaminants. The main reason is their ubiqui- ITS) sequence data, and hence may share tous occurrence as airborne contaminants, which virulence factors with P. marneffei. are generally unable to grow at 37 uC. In the presentarticlewe reporton a fungus thatwas Zusammenfassung. Bedingtdurch die repeatedly isolated from blood of a patient with Tatsache, daû die meisten Penicillium-Spezies cholangiocarcinoma, which initially grew with nichtfaÈhig sind, sich bei 37 uC zu vermehren, sterile mycelium and only in a later stage sind systemische nicht-marneffei Infektionen beim produced conidiophores typical of the Menschen sehr selten. Wir beschreiben einen Fall Penicillium. The species was identi®ed as einer FungaÈmie durch Penicillium piceum bei einer P. piceum,acloserelativeofP. marneffei and Patientin, die wenige Tage nach wiederholter hitherto unknown in clinical pathology. Isolation dieses Pilzes aus Blutkulturen verstarb. Diese Spezies istein Angeho Èriger der Sektion Case report

1Institute for Medical Microbiology and Immunology, A 57-year-old German woman with chronic 2Institute of Hygiene, University of Bonn, 3St. Franziskus- sinusitis and a history of alcohol abuse suffered Hospital, KoÈln, Germany, 4Centraalbureau voor Schimmel- from pain in her back for a few weeks and cultures, Utrecht, the Netherlands, and 5Mycology Section, had observed signi®cantweightloss during the National Institute of Health, Department of Medical Sciences, Nonthaburi, Thailand. last two months before admission to a regional hospital. A CT-scan showed multiple lesions in Correspondence: Dr Regine HorreÂ, Institute for Medical the patient's liver. Histopathology of tissue mate- Microbiology and Immunology, University of Bonn, rial from those lesions revealed tumour meta- Sigmund-Freud-Str. 25, D-53105 Bonn, Germany. Tel: +49±0228±2875952. Fax: +49±0228 2874480. stases. Two weeks later the patient was transferred E-mail: [email protected] to the University Hospital of Bonn, Germany, PENICILLIUM PICEUM FUNGAEMIA 503 for the establishment of a de®nite diagnosis. no serum samples were available and tests for NoprimarycancercouldbefoundbyCT-scan HIV during the patient's life had not been or sonographically. Clinical chemistry gave the performed, both blood culture ¯uids were tested following results, with normal parameters shown for HIV in-house Reverse Transcriptase-PCR), in brackets: c-glutamyltransferase: 229 Ulx1 hepatitis B in-house PCR) and hepatitis C 4±18 Ulx1), glutamic oxalacetic transaminase; in-house RT-PCR). All of these yielded negative 46 Ulx1 15 Ulx1), alkaline phosphatase; results. 1050 Ulx1 55±170 Ulx1), lactate dehydro- genase; 384 Ulx1 100±200 Ulx1), urea; 11.0 mg dLx1 2.3±6 mg dLx1), C-reactive pro- tein; 17.6 mg dLx1 max. 0.8 mg dLx1), leuco- Mycology cytes; 36.2 g lx1 4.0±9.0 g lx1), cholinesterase; Subculturing on Sabouraud glucose agar yielded 984 Ulx1 2800±8500 Ulx1) and haemoglobin: growth after 3 days at 37 uC and after 4 days 8.8 g dLx1 11.5±16.5 g dLx1). Remaining tests at30 uC. Colonies were yellow, soon becoming showed no abnormalities. A gallstone consti- green. On Columbia agar supplemented with pating the biliary duct could be observed. 5% sheep blood, colonies were yellow to orange. Two weeks later the patient developed fever Microscopic examination of yellow parts showed of approximately 38.5 uCaccompaniedby compacted sterile hyphae, while green patches cough. Pulmonary in®ltrates were diagnosed by revealed Penicillium-like morphology. A voucher CT-scan. Blood cultures were sent for micro- strain was deposited in the CBS Culture biological examination. After ®ve days of incub- Collection as CBS 102383 Centraalbureau voor ation at 37 uC, the blood culture system Bactec Schimmelcultures Utrecht, The Netherlands). 9240, Becton Dickinson, Heidelberg, Germany) Identi®cation with P. piceum was performed on showed growth in the aerobic culture bottle. the basis of cultural characteristics and micro- Gram-stained smears of the culture ¯uid showed scopic morphology Fig. 1), and was con®rmed masses of septate hyphae. Amphotericin B by sequencing of the Internal Transcribed therapy was started, but two weeks later the Spacer ITS) domain of the rDNA gene. The patient died of cardiovascular disorder. Two sequence was compared to four reference days before death, another blood culture was sequences of P. piceum,amongstwhichwasthe taken, from which the same fungus was isolated. type strain CBS 361.48, as well as P. marneffei In autopsy specimens of the liver, kidneys and and related species of the subgenus Biverticillata. pleura, a cholangiocarcinoma was diagnosed, The strains with ®nal identi®cation as P. piceum butno fungal elementswere found with all proved to have closely similar ITS sequences Gomori's methenamine-silver stain. Because data not shown).

Figure 1. Microscopic morphology of Penicillium piceum. mycoses 44, 502±504 2001) 504 R. HORREÂ ET AL.

Discussion mycotoxin verruculogen, a tremorgenic toxin previously known as toxin-X [6]. This toxin was Penicillium piceum [1]isanuncommonrepresenta- shown to cause solitary or multiple lesions in the tive of the genus Penicillium, which does not liver of mice and chickens after feeding with belong to the normal ¯ora of hospital air. The contaminated foods [7]. Our patient was initially same fungus was isolated from two different observed to have abnormalities in the liver; the blood cultures with an interval of two weeks. No possibility that the fungus had an impact on liver other microorganisms were encountered. This function cannot be excluded. strongly suggests that this fungus was present as an agent of disseminated disease and that it may have contributed to the patient's death. Species Acknowledgement of the related genus Aspergillus in general cannot be isolated using blood cultures; however this is We are indebted to R. C. Summerbell for his possible with P. marneffei [2, 3] and the Penicillium comments on the manuscript. species, which is currently recognized as patho- gen, P. piceum. Both species belong to the sub- genus Biverticillata of Penicillium. This group contains species showing close phylogenetic References coherence, are morphologically similar and fre- quently produce red pigments into the agar. A 1 Raper, K. B. & Fennell, D. I. 1948) New species of Penicillium: Penicillium piceum sp. nov. Mycologia 40, 533±535. remarkably large number of strains have been 2 Cheng, N. C., Wong, W. W., Fung, C. P. & Liu, C. Y. 1998) isolated from systemic infections in humans Unusual pulmonary manifestations of disseminated Penicillium and warm-blooded animals G. S. de Hoog & marneffei infections in three AIDS patients. Med. Mycol. 36, N. Poonwan, unpublished data). P. piceum shows 429±432. faster growth at 37 uCthanat25uC. This sug- 3 Pitt, J. I. 1979) The Genus Penicillium and Ist Teleomorphic States Eupenicillium and . London: Academic Press. gests an opportunistic potential of P. piceum.The 4 Viviani, M. A. & Tortorano, A. M. 1998) Penicillium marneffei. species may share some virulence factors with In: Collier, L., Balows, A., Sussman, M. eds), Medical P. marneffei, which is found ata shortphylo- Mycology, Topley and Wilson's Microbiology and Microbial Infections genetic distance. As in our case, P. marneffei 9th edn. Vol. IV. New York: Oxford University Press Inc., infection is frequently characterized by fever, pp. 409±419. 5 Austwick, P. K. C. & Venn, J. A. J. 1961) Mycotic abortion weightloss, chronic co ugh and abnormal liver in England and Wales 1954±60. Proceedings of the 4th function [2, 4]. Unlike our P. piceum case, International Congr. Anim. Reprod., The Hague, Martinus P. marneffei is almostexclusively found in patients Nyhoff. pp. 562±568. with AIDS. Until recently P. piceum was known 6 Patterson, D. S., Shreeve, B. J., Roberts, B. A. & as a soil fungus [2, 3], but the culture collections MacDonald, S. M. 1981) Verruculogen produced by soil fungi in England and Wales. Appl. Environ. Microbiol. of the CBS and the International Mycological 42, 916±917. Institute IMI) hold several clinical isolates, from 7 Parathasarathy, V. V. & Shanmugasundaram, E. R. human sputum CBS 250.56 and CBS 435.62) 1973) Nephro- and hepatotoxicity for mice and chicks in and pig lung tissue IMI 140718). The species Penicillium piceum contaminated food. Experientia 29, were previously reported as a cause of two cases 1099±1100. 8 De Hoog, G. S., Guarro, J., GeÂne, J. & Figueras, M. J. 2000) ofmycoticabortionincattle[5].Withasys-Atlas of Clinical Fungi, 2nd edn. Utrecht, Reus: Centraalbureau temic infection, disease processes may have been voor Schimmelcultures & Universitat Rovira I Virgili, aggravated due to the fungus' production of the pp. 836±837.

mycoses 44, 502±504 2001)