|Year : 2014 | Volume
| Issue : 1 | Page : 72-74
Fungemia due to Trichosporon mucoides in a diabetes mellitus patient: A rare case report
S Padhi, M Dash, S Pattanaik, S Sahu
Department of Microbiology, Maharaja Krishna Chandra Gajapati Medical College and Hospital, Berhampur, Odisha, India
|Date of Submission||30-Apr-2013|
|Date of Acceptance||19-Sep-2013|
|Date of Web Publication||4-Jan-2014|
Department of Microbiology, Maharaja Krishna Chandra Gajapati Medical College and Hospital, Berhampur, Odisha
Source of Support: None, Conflict of Interest: None
Trichosporon species are widely distributed in nature and can occasionally belong to the human microbiota. For many years, Trichosporon beigelii, the only species of this genus, was found as the aetiological agent of superficial skin infection called white piedra. However, many cases of invasive trichosporonosis caused by different newly delineated species of Trichosporon have been published in increasing numbers in recent past years, especially in immunocompromised persons. We report a rare case of fungemia due to Trichosporon mucoides in a diabetes mellitus patient, which will add to the emerging list of trichosporonosis infections.
Keywords: Fungemia, immunocompromised host, Trichosporon mucoides
|How to cite this article:|
Padhi S, Dash M, Pattanaik S, Sahu S. Fungemia due to Trichosporon mucoides in a diabetes mellitus patient: A rare case report. Indian J Med Microbiol 2014;32:72-4
|How to cite this URL:|
Padhi S, Dash M, Pattanaik S, Sahu S. Fungemia due to Trichosporon mucoides in a diabetes mellitus patient: A rare case report. Indian J Med Microbiol [serial online] 2014 [cited 2019 Aug 20];32:72-4. Available from: http://www.ijmm.org/text.asp?2014/32/1/72/124324
| ~ Introduction|| |
Trichosporon species are the fungi that commonly inhabit the soil and other environmental sources and can colonise the skin, gastrointestinal tract and respiratory tract of humans.  Long known as the cause of superficial infection such as white piedra, a distal infection of hair shaft, the genus is now labelled as the second most commonly reported cause of disseminated yeast infection in humans.  Previously, all the pathogenic members of the genus were regarded as a single species, Trichosporon beigelii. However, more recently, based on morphological, biochemical and molecular studies T. beigelii has been divided into distinct species, at least nine of which have the potential to cause human disease: Trichosporon asahii, Trichosporon mucoides, Trichosporon inkin, Trichosporon cutaneum, Trichosporon asteroids, Trichosporon ovoides, Trichosporon pullulans, Trichosporon loubieri and Trichosporon japonicum. Among these newly delineated species, T. asahii and T. mucoides are associated with severe life-threatening infections while others are associated with superficial infections.  We report a case of fungemia due to T. mucoides in a diabetes mellitus patient, which to the best of our knowledge is the first to be reported.
| ~ Case Report|| |
A 47-year-old Hindu male, teacher by profession, presented to a tertiary care hospital with complaints of continuous high grade fever for three days and burning micturition and polyuria for past 8 days. The patient was a known case of Type 2 diabetes mellitus and was on oral hypoglycemic drugs (glyclazide 80 mg and metformin 1000 mg per day) for past 8 years. On examination, the patient was found to be febrile (104.6°F) with pulse rate 114/minute, BP 90/78 mmHg with dry tongue, bilateral pedal oedema and suprapubic tenderness. Chest X-ray was suggestive of bilateral pneumonitis; ultrasonography of abdomen gave evidence of bilateral renal disease and cystitis. Haematological examination revealed neutrophilia with presence of toxic granules, ESR 125 mm/1 st h, total leucocyte count 15000/cumm. Fasting blood sugar level was 340 mg/dL; serum urea and creatinine were 155 mg/dL and 1.8 mg/dL, respectively. The level of glycosylated haemoglobin (HbA1c) was found to be 11.5%. Routine and microscopic examination of urine revealed 25 pus cells/HPF, and albumin in urine (++). The patient was found to be HIV-seronegative.
In addition to three blood culture sets collected from three different sites at an interval of half an hour, aseptically collected urine and sputum samples were sent for microbiological examinations. Urine and sputum samples were subjected to Gram staining and culture on CLED agar, blood agar plates and two sets of SDA slants. The inoculated plates and one set of SDA slant were incubated at 37°C while the other set of SDA slant was incubated at 25°C. Pus cells, along with arthroconidia and blastoconidia were noticed on the Gram films of both sputum and urine [Figure 1]. After overnight incubation, yeast like white opaque circular colonies were noticed on agar plates and both sets of SDA slants which on Gram staining revealed oval yeast cells and rectangular arthroconidia. On further incubation, the colonies appeared as moist, shiny, elevated, with cerebriform growth in the centre and smooth periphery with some deep narrow radial fissures [Figure 2]. Based on colony morphology; positive urease test; growth at 37°C and formation of long hyphae with short lateral branches terminating in clavate conidia, arthroconidia and lateral blastoconidia in cornmeal agar [Figure 3], the isolate was identified as T. mucoides. A repeat culture of urine and sputum was performed to confirm its isolation, which yielded the growth of the same fungi. Yeast-like colonies with similar characters were also isolated from all the three blood culture bottles. The isolated yeast was confirmed by the standard sugar assimilation test. It had assimilated sorbitol (Sb) along with dextrose (De), arabinose (Ar), galactose (Ga), inositol (Is), lactose (La), maltose (Ma), sucrose (Su), cellobiose (Ce) and raffinose (Rf). Adonitol (Ad) and trehalose (Te) were not assimilated till 48 h of incubation [Figure 4].
|Figure 1: Gram fi lm of urine showing pus cells along with arthroconidia and blastoconidia of yeast like cells|
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|Figure 3: Appearance of hyphae with arthroconidia and lateral blastoconidia in cornmeal agar|
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Due to isolation of T. mucoides from urine and sputum on two occasions, as well as from blood culture from a diabetes mellitus patient having high grade fever with neutrophilia, increased total leucocyte count and radiological evidence of infection in lungs, kidneys and urinary bladder, the case was diagnosed as fungemia due to T. mucoides. Hence, intravenous fluconazole 200 mg twice daily for one week was administered to the patient who had already started insulin therapy. During the course of treatment, the patient recovered well and all the haematological parameters except fasting blood sugar (220 mg/dL) were found within the normal range. The patient was changed to oral fluconazole at a dose of 200 mg once daily and was discharged with the advice to continue it for 8 weeks. After completion of fluconazole course, though the fasting blood sugar and HbA1c of the patient were 180 mg/dL and 8.5%, respectively, his blood culture yielded no fungal or bacterial growth.
| ~ Discussion|| |
Trichosporon species are emerging as pathogens in humans, especially with immuno-compromised host defence mechanisms by causing dissemination to multiple organs of the body like liver, spleen, lungs, gastrointestinal (GI) tract, kidney often resulting in death.  Hence isolation of Trichosporon species capable of growing at 37°C, especially from immunocompromised patients, should be regarded as significant. 
Trichosporon, a genus of the basidiomycetous arthroconidial yeasts, has been revised using molecular characteristics. Though several new species have been introduced, the species involved in animal mycoses are different to those found in the environment. Thus, infections by Trichosporon spp. are probably transmitted through human or animal vectors. The first reported case of a deep infection with Trichosporon species occurred in 1970 in a 39-year-old African woman, who had a T. cutaneum brain abscess associated with metastatic adenocarcinoma.  Since then, many cases of infection due to Trichosporon species have been reported. Previously it was considered that disseminated Trichosporon infections were associated with two species, T. capitatum and T. beigelii; but according to revised taxonomic classification T. capitatum is no longer considered a member of the genus Trichosporon; rather it is classified as Blastoschizomyces capitatus. Currently, the genus Trichosporon includes T. cutaneum, T. asahii, T. mucoides, T. inkin, T. asteroides, T. ovoides, T. pullulans, T. loubieri, T. japonicum as human pathogens. Though it is possible to identify the members of this genus by typical colony morphology, biochemical reactions and formation of different types of conidia on cornmeal agar, there is a consensus that molecular methods are required for their accurate identification, which are still costly and not suitable for most laboratories. 
Trichosporon species have been reported to be the most common non-candida yeast infection in patients with haematological malignancies and the infections were associated with high mortality rates despite antifungal therapy.  Fungemia due to Trichosporon asahii in a neutropenic child and blood stream infection due to Trichosporon beigelii in a burn patient have already been reported.  Trichosporon mucoides has been recovered from a heart and kidney transplant recipient and from three premature new-borns. ,
Trichosporon mucoides has been found to be the prevalent species in groin infections of humans in Africa and is frequently isolated from other superficial infections in Europe.  Hence, fungemia due to Trichosporon species can be found in different types of immunocompromised conditions.
In the present discussed case, except being diabetic for 8 years, no other risk factors were noticed. Isolation of the same organism from blood, sputum and urine of a diabetic patient and recovery of the patient following antifungal treatment confirm the pathogenic role of T. mucoides. Hence careful microbiological evaluation of the clinical samples, especially from immunocompromised persons should be carried out for fungal pathogens in order to reduce their morbidity and mortality.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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