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Mixed bloodstream infection with Staphylococcus aureus and Penicillium chrysogenum in an immunocompromised patient: case report and review of the literature

2003; Elsevier BV; Volume: 9; Issue: 11 Linguagem: Inglês

10.1046/j.1469-0691.2003.00718.x

1469-0691

Ewa Swoboda‐Kopeć, Marta Wróblewska, A Rokosz, M. Łuczak,

Actinomycetales infections and treatment

We report a case of an immunocompromised patient who developed a mixed bacterial–fungal bloodstream infection involving Staphylococcus aureus and Penicillium chrysogenum. To date, no reports of such mixed bloodstream infection have been found. We report a case of an immunocompromised patient who developed a mixed bacterial–fungal bloodstream infection involving Staphylococcus aureus and Penicillium chrysogenum. To date, no reports of such mixed bloodstream infection have been found. A 37-year-old man was referred in March 2001 from a regional hospital to a tertiary-care hospital because of pyrexia of unknown origin, lasting for 3 weeks. He presented with fever, arterial hypertension, and microcytic anemia. Ten years earlier he suffered from renal insufficiency, which was treated with regular hemodialysis due to chronic glomerulonephritis. Two years later, he had a kidney transplant and underwent immunosuppressive therapy, but the graft underwent a chronic rejection, and hemodialysis had to be resumed in 2000, while immunosuppressive therapy was continued. The patient also suffered from peptic ulcer of the stomach and gastric polyposis. In 1997, he had an operation because of the hemorrhage from the peptic ulcer, complicated by wound dehiscence. He was treated with multiple blood transfusions. A year later, he underwent removal of a fibrosarcoma of the left mandible, but metastatic lesions were subsequently detected in the ribs, resulting in pathologic fractures. He also suffered from mitral and aortic valve insufficiency, and had a history of hepatitis B virus (HBV), hepatitis C virus (HCV) and cytomegalovirus (CMV) infection. Echocardiographic examination revealed atrial fibrillation, multiple calcifications of the mitral and aortic valves descending to the left ventricle, and pulmonary hypertension. No inflammatory consolidations were detected in a chest X-ray. Five sets of blood specimens were collected over 3 days and sent for culture. The samples were processed in the BacT/Alert computerized system (Organon Teknika, Durham NC, USA), and two sets yielded growth of microorganisms. Piperacillin combined with tazobactam and fluconazole was empirically administered intravenously to the patient, but, despite the treatment, he died. Autopsy examination was not done. In the positive cultures, the growth of a Gram-positive coccus and a fungus was detected. The bacterial strain was identified as Staphylococcus aureus with an ID 32 STAPH test (bioMerieux, Marcy L'Etoile, France). The strain was resistant to penicillin G, but susceptible to methicillin. It was susceptible to other antimicrobials included in the ATB STAPH (bioMerieux) test. The fungal isolate obtained from the same two sets of samples was identified by means of standard mycologic procedures (morphology of the colonies as well as microscopic appearance of typical conidia) as Penicllium chrysogenum. Susceptibility testing of the mold showed sensitivity of the strain to 5-fluorocytosine (MIC < 0.5 mg/L), amphotericin B (MIC < 0.5 mg/L), ketoconazole (MIC < 1.0 mg/L), and itraconazole (MIC < 0.5 mg/L), but resistance to fluconazole (MIC > 64.0 mg/L). A diagnosis was made of a mixed bacterial–fungal bloodstream infection involving S. aureus and P. chrysogenum. The most common opportunistic fungi are classified within the genera Aspergillus, Penicillium, Mucor, Rhizopus, and Absidia [1Smith LA Fothergill AW Sulton DA Harris JL Medically significant fungi.in: Mahon CR Manuselis GT Textbook of diagnostic microbiology. WB Saunders, Philadelphia2000: 709-754Google Scholar]. Clinical conditions that predispose to these infections are mainly immune deficiencies due to neoplasms, organ transplantation, chemotherapy, or HIV infection. Penicillium spp. may occasionally cause opportunistic infections called penicilliosis in humans [1Smith LA Fothergill AW Sulton DA Harris JL Medically significant fungi.in: Mahon CR Manuselis GT Textbook of diagnostic microbiology. WB Saunders, Philadelphia2000: 709-754Google Scholar]. They have been implicated as etiologic agents of fungemia, pneumonia, peritonitis, urinary tract infections, endocarditis, and disseminated infections, which are fatal in over 50% of cases, despite aggressive treatment with antifungal compounds [2Hall WJ III Penicillium endocarditis following open heart surgery and prosthetic valve insertion.Am Heart J. 1974; 87: 501-506Abstract Full Text PDF PubMed Scopus (20) Google Scholar, 3DelRossi AJ Morse D Spagna PM Lemole GM Successful management of Penicillium endocarditis.J Thorac Cardiovasc Surg. 1980; 80: 945-947PubMed Google Scholar, 4Alvarez S Systemic infection caused by Penicillium decumbans in a patient with acquired immunodeficiency syndrome.J Infect Dis. 1990; 162: 283Crossref PubMed Scopus (17) Google Scholar, 5Equils O Deville JG Shapiro AM Sanchez CP Penicillium peritonitis in an adolescent receiving chronic peritoneal dialysis.Ped Nephrol. 1999; 13: 771-772Crossref PubMed Scopus (4) Google Scholar]. P. marnaffei recently emerged as an opportunistic pathogen in patients with AIDS [6Supparatpinyo K Khamwan C Boassoung V Nelson KE Sirisanthana T Disseminated Penicillium marneffei infection in South-east Asia.Lancet. 1994; 334: 110-113Abstract Scopus (472) Google Scholar, 7Duong TA Infection due to Penicillium marneffei, an emerging pathogen: review of 155 reported cases.Clin Infect Dis. 1996; 23: 125-130Crossref PubMed Scopus (254) Google Scholar, 8Cooper Jr, CR McGinnis MR Pathology of Penicillium marneffei. An emerging acquired immunodeficiency syndrome-related pathogen.Arch Path Lab Med. 1997; 121: 798-804PubMed Google Scholar]. Strains of P. chrysogenum are ubiquitous in nature, but very rarely cause human infections [9Eschete ML King JW West BC Oberle A Penicillium chrysogenum endophthalmitis.Mycopathologia. 1981; 74: 125-127Crossref PubMed Scopus (33) Google Scholar, 10D'Antonio D Violante B Farina C et al.Necrotizing pneumonia caused by Penicillium chrysogenum.J Clin Microbiol. 1997; 35: 3335-3337PubMed Google Scholar, 11Lopez-Martinez R Neumann L Gonzales-Mendoza A Case report: cutaneous penicilliosis due to Penicillium chrysogenum.Mycoses. 1999; 42: 347-349Crossref PubMed Scopus (13) Google Scholar]. The fungus may also be involved in allergic conditions [12Cooley JD Wong WC Jumper CA et al.An animal model for allergic penicilliosis induced by the intranasal instillation of viable Penicillium chrysogenum conidia.Thorax. 2000; 55: 489-496Crossref PubMed Scopus (33) Google Scholar]. No reports, however, have been found to date of a mixed bloodstream infection in humans involving S. aureus and P. chrysogenum. In the reviewed literature (covering the period 1981–2001), only rare cases of P. chrysogenum infection in humans have been described [9Eschete ML King JW West BC Oberle A Penicillium chrysogenum endophthalmitis.Mycopathologia. 1981; 74: 125-127Crossref PubMed Scopus (33) Google Scholar, 10D'Antonio D Violante B Farina C et al.Necrotizing pneumonia caused by Penicillium chrysogenum.J Clin Microbiol. 1997; 35: 3335-3337PubMed Google Scholar, 11Lopez-Martinez R Neumann L Gonzales-Mendoza A Case report: cutaneous penicilliosis due to Penicillium chrysogenum.Mycoses. 1999; 42: 347-349Crossref PubMed Scopus (13) Google Scholar]. None of them, however, involved a mixed bacterial–fungal etiology. Antibacterial treatment administered empirically was appropriate; the S. aureus strain, isolated from the blood culture samples, was susceptible to β-lactam antibiotics, except penicillin. However, cases of penicilliosis are characterized by a high mortality rate, despite aggressive antifungal therapy. Amphotericin B, with or without itraconazole, may be used successfully [13Gelfand MS Cole FH Baskin RC Invasive pulmonary penicilliosis: successful therapy with amphotericin B.South Med J. 1990; 83: 701-702Crossref PubMed Scopus (7) Google Scholar, 14Fahhoum J Gelfand MS Peritonitis due to Penicillium sp. in a patient receiving continuous ambulatory peritoneal dialysis.South Med J. 1996; 89: 87-88Crossref PubMed Scopus (9) Google Scholar, 15Sirisanthana T Supparatpinyo K Perriens J Nelson KE Amphotericin B and itraconazole for treatment of disseminated Penicillium marneffei infection in human immunodeficiency virus-infected patients.Clin Infect Dis. 1998; 26: 1107-1110Crossref PubMed Scopus (157) Google Scholar]. In the case we report here, the P. chrysogenum strain implicated in the bloodstream infection was susceptible to these agents. Therefore, in an immunocompromised individual, the significance of the isolates of Penicillium spp. needs to be thoroughly investigated, and intravenous therapy with amphotericin B should be considered.