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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References
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  Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 37  |  Issue : 3  |  Page : 454-456
 

Fungal infection in a post-renal transplant patient with Diaporthe


1 Department of Microbiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
2 Department of Nephrology, Gleneagles Global Health City, Chennai, Tamil Nadu, India

Date of Submission12-Nov-2019
Date of Decision05-Aug-2019
Date of Acceptance25-Nov-2019
Date of Web Publication29-Jan-2020

Correspondence Address:
Dr. Anupma Jyoti Kindo
Department of Microbiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmm.IJMM_19_96

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 ~ Abstract 


Post-renal transplant fungal infections continue to be a major cause of mortality and morbidity. Universally reported fungi are Candida, especially Candida albicans, Cryptococcus, Aspergillus, Trichophyton rubrum and Pityriasis versicolor. Here, we report a case of infection caused by a rare fungus Diaporthe. It is an endophyte reported as plant pathogens and infrequently in humans and mammals. The patient was a renal transplant recipient on immunosuppressant. He had hypothyroidism and diagnosed with permanent pacemaker due to a complete heart block. The patient was treated with itraconazole (200 mg) successfully.


Keywords: Diaporthe, hypothyroidism, immunosuppressant, permanent pacemaker


How to cite this article:
Vichitra K, Gopal L, Govindarao B, Chandrasekaran V, Kindo AJ. Fungal infection in a post-renal transplant patient with Diaporthe. Indian J Med Microbiol 2019;37:454-6

How to cite this URL:
Vichitra K, Gopal L, Govindarao B, Chandrasekaran V, Kindo AJ. Fungal infection in a post-renal transplant patient with Diaporthe. Indian J Med Microbiol [serial online] 2019 [cited 2020 Oct 28];37:454-6. Available from: https://www.ijmm.org/text.asp?2019/37/3/454/277075





 ~ Introduction Top


Fungi are ubiquitous as well as normal flora of our skin. They become opportunistic and acquire the infection in immunosuppresssed as well as immunocompetent individuals. Fungal infections in renal transplant patients can be invasive or non-invasive. The most commonly encountered include Candida, Aspergillus and Cryptococcus, dermatophytes and non-Aspergillus species such as Fusarium, Trichophyton rubrum, Pityriasis versicolor and Plasmodium ovale.[1] They can acquire infection within days or weeks, months or a year after transplant.[2]Diaporthe is a plant pathogen belonging to Phylum Ascomycota previously referred as Melanconiales or Sphaeropsidales found universally causing fruit rot, dieback, cankers, leaf spots, blights, decay and wilt.[3] They can infect individuals undergoing transplant quite rarely. Here, we present a case of a patient infected after a post-live donor renal transplant with the fungus.


 ~ Case Report Top


A 47-year-old employee working in an office situated in Assam underwent a renal transplant and was on immunosuppressants. He was a known case of hypothyroidism and was on permanent pacemaker due to the complete heart block.

Four months after the transplant, the patient noticed a swelling in the right leg, which was progressive in nature. He came to the nephrology outpatient department 3 months after the onset of swelling. The swelling was insidious in onset, painless and gradually increased in size. Excisional biopsy was done, and a portion was sent for histopathological examination and another part was sent to the microbiology department for Gram's staining, acid-fast bacilli (AFB) staining, 10% KOH mount, GeneXpert and fungal culture. Gram stain showed many pus cells and no organism. AFB smear and 10% KOH mount showed no organisms. GeneXpert was also negative for Mycobacterium tuberculosis, and there was no growth in aerobic culture.

Fungal culture was done on Sabouraud's Dextrose Chloramphenicol Agar and incubated at 25°C and 37°C. After a week a growth of filamentous fungi. On further incubation, it was found to be a phaeoid fungi. The colony morphology revealed white to slight greyish colonies on obverse and dark brown to black at the reverse side [Figure 1]. On lactophenol cotton blue mount, non-sporulating Fungi with septate hyphae was observed on the 9th day of incubation which remained so even on the 45th day of incubation [Figure 2].
Figure 1: Fungal culture of Diaporthe on Sabouraud's Dextrose agar

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Figure 2: Lactophenol cotton blue showing only septate fungal hyphae

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Histopathological examination reported dermal abscess with extensive granulomatous inflammation and fungal infection (septate hyphae) [Figure 3].
Figure 3: Periodic acid–Schiff stain showing fungal hyphae

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On the 9th day of incubation, the culture was sent for molecular identification to the mycology laboratory at a tertiary care centre. The isolate was amplified for internal transcribed spacer (18S rDNA) region using fungal specific primers. The polymerase chain reaction product was further sent for gene sequencing. BLAST sequence analysis of 502 bp compared with 99% similarity to Diaporthe phaseolorum. This has been submitted to the GenBank database (GenBank Accession number: MK064209).

The patient was started on oral itraconazole 100 mg twice daily. Two months later, while on treatment, he presented with a recurrence of swelling on the same site. A wide excision with local flap cover was done. The excised tissue grew the same fungi; itraconazole dose was increased to 200 mg twice daily and advised for regular follow-up. He responded to therapy, and there is no further recurrence at 6 months follow-up.


 ~ Discussion Top


The members of genus Diaporthe belong to the Diaporthaceae family. They are filamentous, paraphyletic[4] saprophytic on plants and trees. Around 800 species of Diaporthe have been identified and 60 of them are pathogenic to plants. Diaporthe phaseolorum is one of the pathogens causing disease on dead twigs, fruit trees, chronic canker and fruit rot of deciduous fruit trees or citrus melanose.[3]D. phaeseolorum consists of five subspecies, namely D. phaseolorum var. batatae, var. caulivora, var. meridionalis, var. phaseolorum and var. sojae, based on their colony morphology.[3] The anamorph of Diaporthe is Phomopsis, and their species Phomopsis phaseoli and Phomopsis longicolla, are primary agent affecting the seed quality and germination. Based on the conidial morphology, they are divided into alpha- and beta-conidial development where P. longicolla is absent for beta-conidia and sexual state. Grouping of Diaporthe complex has been a challenge. Morphological differentiation has been used but provides inconsistent or inappropriate results. The use of molecular investigation helps in identifying the genus as well as closely related species.

The present case is the third case causing human infection by D. phaseolorum, as two cases were reported in Brazil.[5],[6] Other cases of Diaporthe sp. and closely related anamorph Phomopsis were also reported involving keratitis, osteomyelitis relating to farmers and gardeners.[7],[8],[9]D. phaseolorum was first isolated in India from Bacopa monneiri (Brahmi)[10] However, this is the first case to be isolated and reported in India from the human infection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ~ References Top

1.
Khan A, El-Charabaty E, El-Sayegh S. Fungal infections in renal transplant patients. J Clin Med Res 2015;7:371-8.  Back to cited text no. 1
    
2.
Shoham S, Marr KA. Invasive fungal infections in solid organ transplant recipients. Future Microbiol 2012;7:639-55.  Back to cited text no. 2
    
3.
Gomes RR, Glienke C, Videira SI, Lombard L, Groenewald JZ, Crous PW. Diaporthe: A genus of endophytic, saprobic and plant pathogenic fungi. Persoonia 2013;31:1-41.  Back to cited text no. 3
    
4.
Gao Y, Liu F, Duan W, Crous PW, Cai L. Diaporthe is paraphyletic. IMA Fungus 2017;8:153-87.  Back to cited text no. 4
    
5.
Iriart X, Binois R, Fior A, Blanchet D, Berry A, Cassaing S, et al. Eumycetoma caused by Diaporthe phaseolorum (Phomopsis phaseoli): A case report and a mini-review of Diaporthe/Phomopsis spp invasive infections in humans. Clin Microbiol Infect 2011;17:1492-4.  Back to cited text no. 5
    
6.
Mattei AS, Severo CB, Guazzelli LS, Oliveira FM, Gené J, Guarro J, et al. Cutaneous infection by Diaporthe phaseolorum in Brazil. Med Mycol Case Rep 2013;2:85-7.  Back to cited text no. 6
    
7.
Mandell KJ, Colby KA. Penetrating keratoplasty for invasive fungal keratitis resulting from a thorn injury involving Phomopsis species. Cornea 2009;28:1167-9.  Back to cited text no. 7
    
8.
Gajjar DU, Pal AK, Parmar TJ, Arora AI, Ganatra DA, Kayastha FB, et al. Fungal scleral keratitis caused by Phomopsis phoenicicola. J Clin Microbiol 2011;49:2365-8.  Back to cited text no. 8
    
9.
Sutton DA, Timm WD, Morgan-Jones G, Rinaldi MG. Human phaeohyphomycotic osteomyelitis caused by the coelomycete Phomopsis saccardo 1905: Criteria for identification, case history, and therapy. J Clin Microbiol 1999;37:807-11.  Back to cited text no. 9
    
10.
Ghosh SK, Banerjee S. First report of Diaporthe phaseolorum on Bacopa monnieri in India. J Plant Pathol 2015;97. p.68  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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