First Human Case of Pulmonary Fungal Ball Due to a Perenniporia Species (a Basidiomycete) Anuradha Chowdhary, Kshitij Agarwal, Shallu Kathuria, Pradeep Kumar Singh, P. Roy, S. N. Gaur, Anderson M. Rodrigues, G. S. de Hoog and Jacques F. Meis J. Clin. Microbiol. 2012, 50(11):3786. DOI: Downloaded from 10.1128/JCM.01863-12. Published Ahead of Print 15 August 2012. Updated information and services can be found at: http://jcm.asm.org/content/50/11/3786 http://jcm.asm.org/ These include: REFERENCES This article cites 31 articles, 12 of which can be accessed free at: http://jcm.asm.org/content/50/11/3786#ref-list-1 on February 6, 2014 by Universiteit van Amsterdam CONTENT ALERTS Receive: RSS Feeds, eTOCs, free email alerts (when new articles cite this article), more» Information about commercial reprint orders: http://journals.asm.org/site/misc/reprints.xhtml To subscribe to to another ASM Journal go to: http://journals.asm.org/site/subscriptions/ CASE REPORT First Human Case of Pulmonary Fungal Ball Due to a Perenniporia Species (a Basidiomycete) Anuradha Chowdhary,a Kshitij Agarwal,b Shallu Kathuria,a Pradeep Kumar Singh,a P. Roy,a S. N. Gaur,b Anderson M. Rodrigues,c G. S. de Hoog,c and Jacques F. Meisd,e Departments of Medical Mycologya and Pulmonary Medicine,b Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India; CBS-KNAW Fungal Biodiversity Centre, c d Utrecht, The Netherlands ; Department of Medical Microbiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands ; and Department of Medical Downloaded from Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlandse Perenniporia species are basidiomycetes, resupinate shelf fungi responsible for white rot decay of wood. Here, we report for the first time an intracavitary pulmonary fungal ball due to a species of Perenniporia that has not been recognized so far as a human pathogen. The fungus was identified by sequencing of the partial ribosomal operon of a culture from a clinical specimen. CASE REPORT (ZN) staining and cultured for aerobic pathogens and Mycobacte- http://jcm.asm.org/ rium spp. The Gram and ZN stains were negative, and cytology 55-year-old nonsmoking male from Assam, India, presented was negative for any malignant cells. No Mycobacterium spp. were with complaints of intermittent right-sided nonanginal chest A isolated after 6 weeks of incubation. pain and 5 to 6 episodes of minor hemoptysis over a period of 1 Immunodiffusion of the patient’s serum demonstrated preci- month. The patient gave a history of having received antitubercu- pitins against culture filtrate antigen prepared from the patient’s lar therapy 3 years before with a 6-month-long regimen contain- isolate as described previously (Fig. 2D)(3, 4). In contrast, nega- ing rifampin, isoniazid, ethambutol, and pyrazinamide for spu- tive results were found in tests using antigens of Aspergillus fu- tum-smear-positive pulmonary tuberculosis, with which he had on February 6, 2014 by Universiteit van Amsterdam migatus, Aspergillus flavus, Aspergillus terreus, and Aspergillus ni- been compliant until declared cured by his physician. The patient ger. It was evident from these findings that the patient was was found to have uncontrolled diabetes mellitus as revealed by an suffering from posttuberculosis fibrocavitary disease of the right HbA level of 13%. He was previously evaluated in Assam, where 1c lobe with a fungal ball. Since no episodes of hemoptysis in the a chest radiograph showed a cavity in the right upper and middle recent past were reported by the patient, no active intervention pulmonary zone. A contrast-enhanced computerized tomogra- was done and he was managed conservatively on an outpatient phy (CECT) scan of his thorax revealed the presence of fibropa- basis. He was briefed about the possibility of recurrent episodes of renchymal lesions with mild traction bronchiectasis in the right hemoptysis, for which he was prescribed ethamsylate and cough lung (sequelae of healed pulmonary tuberculosis) associated with suppressants, and was advised to consult a nearby medical facility a fungal ball in the right lower lobe (Fig. 1). The patient was treated for the same in his hometown in Assam. with CT-guided percutaneous intracavitary injection of ampho- The identification of 85/P/10 (CBS 130020) was done by se- tericin B, though records of the dosing schedule could not be quencing of the internal transcribed spacer (ITS) ribosomal DNA obtained. The patient was then referred to Delhi for mycological (rDNA) region and D1/D2 large subunit (LSU) regions as de- diagnosis and further management of the case. The patient under- scribed previously (3, 4). GenBank BLAST searches were per- went a fiber optic bronchoscopy (FOB) to rule out the possibility formed for species identification. The LSU sequence of CBS of reactivation of tuberculosis and for an investigative work-up for 130020 showed 99% identity with Megasporoporia setulosa hemoptysis. The FOB showed no endobronchial lesion, active GU566007 (strain MG38) and 100% identity with an unidentified bleeding, or blood clots in the bronchi. A diagnostic bronchoal- Perenniporia species, strain 1V2/2 (GQ982883). The ITS region veolar lavage (BAL) fluid sample was taken from the apical seg- sequence of the isolate exhibited 100% identity with the Peren- ment of the right lower and postero-anterior basal segment of the niporia strain 1V2/2 (GQ982890). The nearest neighbor, Megas- right upper lobe. poroporia setulosa JF894111, showed 90% similarity. The ITS and Mycological investigations. Direct microscopy of KOH wet LSU nucleotide sequences for the isolate CBS 130020 were depos- mounts of the BAL fluid specimen revealed hyaline septate hyphae ited in GenBank under the accession numbers JX271779 and (Fig. 2A). Cultures yielded multiple white, cottony colonies of JX292098, respectively. identical molds on Sabouraud’s glucose agar (SGA) plates incu- ITS sequences from reference isolates belonging to the genera bated for 7 days at 28°C and 37°C. Subcultures on potato dextrose agar (PDA) incubated at 28°C and 37°C showed dense white cot- tony growth after 7 days (Fig. 2B), and slide cultures of the mold Received 16 July 2012 Returned for modification 27 July 2012 isolates on PDA at 28°C revealed hyaline septate hyphae with chla- Accepted 9 August 2012 mydospore-like cells (Fig. 2C). No clamp connections or hyphal Published ahead of print 15 August 2012 pegs were seen during up to 3 weeks of incubation. The isolate was Address correspondence to Anuradha Chowdhary, [email protected]. assigned accession no. VPCI 85/P/10 (CBS 130020) for molecular Copyright © 2012, American Society for Microbiology. All Rights Reserved. identification and antifungal susceptibility testing. BAL fluid was doi:10.1128/JCM.01863-12 also investigated microscopically after Gram and Ziehl-Neelsen 3786 jcm.asm.org Journal of Clinical Microbiology p. 3786–3791 November 2012 Volume 50 Number 11 Case Report cates (10). A discrete gamma distribution was used to model evo- lutionary rate differences among sites. The complete alignment included 79 sequences. Aligned se- quences of the ITS were 866 bp long, including 340 invariable characters, 324 variable parsimony-informative (37.4%) charac- ters, and 108 singletons. Positions containing gaps and missing data were eliminated. The tree comprised 31 described Perennipo- ria species, including the generic type species P. medulla-panis. All of the unresolved deeper branches exhibited bootstrap values be- low 80%, raising concern about the cluster of related species. Fur- Downloaded from thermore, the tree (outside the ancestral Abundisporus branches) included species of Donkioporia, Megasporoporia, Polyporus, Pyro- fomes, and Trametes, which may indicate possible misidentifica- tion. The clinical isolate CBS 130020 shared a supported clade (bootstrap, 94%) with unidentified Agaricomycetes and a Megas- poroporia sp. and was found to be identical to the unnamed basid- FIG 1 High-resolution CECT scan of the patient showing a fungal ball within iomycetous endophyte 1V2/2, described by Pinruan et al. (20) a cavity located in the lower lobe of the right lung (arrows). (Fig. 3). The nearest taxa are Perenniporia subacida and http://jcm.asm.org/ Perenniporia narymica, located in a sister clade at a 90% bootstrap level. Abundisporus (n ϭ 5), Agaricomycetes (n ϭ 2), Donkioporia (n ϭ Antifungal susceptibility testing (AFST) of the isolate was per- 1), Megasporoporia (n ϭ 6), Microporellus (n ϭ 1), Perenniporia formed by the CLSI broth microdilution method (5). The antifun- (n ϭ 53), Perenniporiella (n ϭ 7), Polyporus (n ϭ 1), Pyrofomes gals tested were amphotericin B (Sigma, St. Louis, MO), flucona- (n ϭ 1), and Trametes (n ϭ 1), described by Guglielmo et al. (14), zole (Pfizer, Groton, CT), itraconazole (Lee Pharma, Hyderabad, Robledo et al. (23), Pinruan et al. (20), Yuan et al. (32), and Zhao India), voriconazole (Pfizer), posaconazole (Schering-Plough, and Cui (33), were included in the analyses (Table 1 ). Evolution- Kenilworth, NJ [now Astellas]), isavuconazole (Basilea Pharma- on February 6, 2014 by Universiteit van Amsterdam ary analyses were conducted in MEGA5 (30) with the maximum ceutica, Basel, Switzerland), flucytosine (Sigma), caspofungin likelihood method. Evolutionary distances were computed using (Merck, Whitehouse Station, NJ), micafungin (Astellas, Toyama, the Kimura 2-parameter method (16) with 1,000 bootstrap repli- Japan), and anidulafungin (Pfizer). For the broth microdilution FIG 2 (A)