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Luque, Antonio Montero; Systemic infection antojio by Trichosporon asahii in a patient with liver transplant, Medical MycologyVolume 46, Issue 7, 1 NovemberPages —, https: Trichosporon species are emerging pathogens capable of causing severe infections in immunocompromised patients. In this paper, we report a case of systemic infection in a liver transplant patient caused by Trichosporon asahii to show the etiologic agent’s aggressiveness and poor therapeutic results with the different antifungals employed.
Trichosporon species may affect transplant recipients and are considered as emerging pathogens in immunocompromised patients. The spectrum of clinical manifestations depends on the immune status of the host, ranging from cutaneous involvement in immunocompetent subjects to disseminated systemic infections in immunosuppressed patients.
Inwhen it was shown that Trichosporon beigelii included several genetically different species, Gueho et al. Subsequently, Sugita and colleagues expanded the genus by proposing 17 species and 5 varieties 3 and later they suggested that the genus had 25 species based on the sequence analysis of the ribosomal DNA intergenic spacer 1 region 4.
At least 8 species have the potential to cause human disease; Trichosporon asahiiTrichosporon inkinTrichosporon asteroidesTrichosporon cutaneumTrichosporon mucoidesTrichosporon ovoidesand more recently, Trichosporon pullulans and Trichosporon loubieri T. As far as we know, only four cases of invasive infection with Trichosporon were previously described in liver transplant recipients 13— In this paper, we report an additional case of a systemic infection caused by T.
A year-old diabetic woman was hospitalized after 5 days of vomiting, jaundice and coluria. She had been in treatment with tracolimus since she received a liver transplant as a result of buasoli hepatitis, the latter occuring six ibasoli before her transplant. Laboratory examinations showed a slight increase in total bilirrubin and a significant raise in transaminases and cholestasis enzymes. Nodular inflammatory infiltrates with ductopenia were found in an hepatic needle biopsy.
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On the 10th day of antonii she developed an intense epigastric pain and vomiting. Increased levels of amylase were found and a small amount of free peri-hepatic fluid was seen by ultrasound examination. A MRI cholangiography showed a mild oedematous pancreatitis. Her condition improved with general care measures, but a progressive abdominal distension became evident. The serum-ascitis albumin gradient SAAG was 1.
A diagnosis of portal hypertension was based on this finding. The patient was treated with ceftriaxone 1 g b. Ceftriaxone was reintroduced but it was then changed to vancomycin plus imipenem because atonio condition worsened. A computed tomography CT showed a bilateral pleural effusion collapsing the left lung base and an air bronchogram.
An abdominal CT Fig. Calcified granulomas were evident in the spleen. In the left paracolic gutter and in the omental transcavity there were two hyperdense cysts containing vegetant images.
The patient was initially treated with amphotericin B at 0. The patient’s condition worsened due to multiorganic failure and she died on the 28th day of hospitalization. Computed tomography scan showing cysts with hyperdense contents and vegetans image inside, in left paracolic gutter and omental transcavity. Two samples of cyst liquid were obtained. The following tests were performed for yeast identification: Direct microscopic examination of both samples showed many hyaline hyphae and arthroconidia Figs.
Cultures jf SDA yielded rapid growing, cream coloured yeast-like colonies, that later became wrinkled. On CMA-T, after 48 h of incubation, the yeast yielded abundant round to oval yeast-like cells and well-developed pseudohyphae and hyphae that fragmented into elongate arthroconidia.
The yeast was resistant to 0. The urea enzyme activity was positive. The in vitro susceptibility of the isolates to amphotericin B, fluconazole and itraconazole was further investigated using amphotericin B 0. The test was performed in duplicate. The in vitro susceptibility assay showed that the strain of T.
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Trichosporon includes a heterogeneous group of mr microorganisms. However, this characteristic has little distinctive value since many other fungi are also capable of forming arthroconidia.
Conventional clinical laboratory procedures are also inadequate to identify Trichosporon spp.
Some other methods such as growth temperature studies, urease test, phenol oxidase test and nitrate assimilation baisoli can assist in the identification of Trichosporon species. If these studies are not enough to define the species, molecular diagnosis may be needed for the accurate identification of clinical isolates 18 Infections caused by Trichosporon are associated with a broad spectrum of clinical manifestations ranging from a superficial cutaneous involvement in immunocompetent patients to frequently severe systemic infections in immunocompromised patients Clinical findings and courses of trichosporonosis are similar to disseminated candidiasis and it is impossible to distinguish these infections without fungal isolation.
Disseminated infections affect almost exclusively immunocompromised hosts 21with neutropenia the main predisposing factor. Trichosporonosis has also been described in other clinical settings such as AIDS 23related to intravascular catheters 13chronic granulomatous disease 9 and heart-valve surgery It is an important cause of morbidity and mortality.
Organisms frequently associated with mycotic infections in transplant recipients are Candida and Aspergillus species. Trichosporon infection is not common in these patients, and only a few cases have been reported zntonio25— However, the increasing incidence of members of this genus associated with inmunocompromised patients together with diagnostic and therapeutic difficulties make it necessary to include this infection among the differential diagnoses.
Trichosporon species, particularly T. The use of broad-spectrum antibiotics and the disruption of the skin-mucosa barrier are the most important factors influencing subsequent invasion and dissemination Once antonoi microorganism reaches the vascular stream in an immunosuppressed host, subsequent dissemination may occur These risk factors were all present in our patient, i.
Paracentesis might have had some importance as an entrance viasoli to the abdominal cavity, as some cases of Trichosporon peritonitis affecting peritoneal-dialysis patients have been reported 8 Four cases of systemic trichosporonosis in liver transplanted patients were previously described in the literature. However, in two of them, Trichosporon infection appeared in less than a week after liver transplant; one of these patients presented with neutropenia and fulminant hepatic failure 14 and the other required a large blood transfusion and had dialytic renal failure.
In our case, as in that described by Abdala et al. In this last case, the patient was from Biasoki and was not under excessive immunosuppressive therapy. However, there was the possibility of cellular immunodeficiency because she had had Pneumocystis jiroveci pneumonia 6 months before the onset of trichosporonosis.
All the four patients died despite treatment with anphotericin B. The remaining case 16 was a Brazilian woman who was treated with immunosuppressors because of liver transplant. She received antibiotic therapy and had indwelling intravenous antoino as risk factors.
She was treated with fluconazole for her T. Trichosporonosis is associated with high mortality 6. The lack of response to the treatment is common and it is related to the relative resistance of the agent to many different antifungals.
Susceptibility to amphotericin B is variable MIC 0. Its antifungal activity depends on the concentration and serum levels, with doubling the MIC being required to achieve fungicide activity.
Azoles miconazole, itraconazole and ketoconazole have a higher in vitro activity than amphotericin B Voriconazole effect has been reported as being greater in comparison to the other azoles. Therefore, its activity should be investigated when any Trichosporon species is detected Hou-Min Li et al. MICs measured in our nr are consistent with this report.
In this setting, the choice jt antifungal treatment deserves a special mention. During Argentina’s antohio crisis —we had neither access to any other antifungal agent nor the possibility to test voriconazole susceptibility. For these reasons, as there was no alternative therapy, in desperate need we decided to treat the patient with amphotericin B and caspofungin.
Taking this situation into account, it should be concluded that this therapy is not to be recommended. On the contrary, the death of this patient sadly illustrates both, the lethal outcome of T.
Since therapeutic response ir immunocompromised patients depends solely on the antifungal activity of the given compound, the presence of multiresistant strains may be fatal in these kind of patients.
The authors report no conflicts bixsoli interest. The authors alone are responsible for the content and writing of the paper.
Oxford University Angonio is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide.
Sign In or Create an Account. Close mobile search navigation Article navigation. Systemic infection caused by Biasolo asahii in a patient with liver transplant Marisa S.
Abstract Trichosporon species are emerging pathogens capable of causing severe infections in immunocompromised patients. Trichosporon asahiiliver transplantsystemic infection. View large Download slide. Septate fungal hyphae with arthroconidia of punction liquid samples.
Septate fungal hyphae of punction liquid samples. Identification of nr relevant Trichosporon species based on sequences of internal transcribed spacer regions and construction of a database for Trichosporon identification. Identification of the first isolates of Trichosporon asahii biasoki disseminated trichosporonosis in China.
Trichosporon asahii as an emerging etiologic agent of disseminated Trichosporonosis: Trichosporon pullulans infection in 2 patients with chronic granulomatous disease: An emerging pathogen and review of the literature.
Trichosporon loubieri infection in a patient with adult polycystic kidney disease.