PHOTO QUIZ
crossm Answer to Photo Quiz: Scedosporium prolificans Infectious Diseases, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USAa; Department of Pathology Anatomy and Cell Biology, Clinical Microbiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USAb; Department of Infectious Diseases, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USAc
KEYWORDS Scedosporium prolificans, fungal infections, lymphoma, febrile neutropenia, antifungal therapy, fungemia
S
cedosporium prolificans is a filamentous fungus that was discovered in greenhouse soil in 1974 (1). Scedosporium species are ubiquitous saprophytic fungi found in soil and polluted water. Infection is acquired following traumatic implantation or aspiration of contaminated water. The most common clinical presentations are disseminated infection, pulmonary mycosis, and osteomyelitis/arthritis; in rare cases, cutaneous, ocular, sinus, ear, or cerebral infections occur (2). Disseminated S. prolificans infection occurs mainly in immunocompromised patients and has a mortality rate as high as 87% (2). Positive blood cultures are reported for approximately 80% of the patients with disseminated scedosporiosis (2–4). However, most of the blood cultures become positive close to the time of death, limiting their diagnostic utility (2). Two common methods for fungal detection in blood are the Isolator system (Wampole Laboratories) and the Bactec Myco/F Lytic bottle. The two systems are similar in the recovery of most yeasts and molds, with the exception of some dimorphic fungi. The dimorphic fungus Histoplasma was recovered more often from the Isolator system (5). In this patient presentation, Scedosporium was detected by the BD Bactec FX system. Two separate blood cultures were collected the same day in two BD Bactec Plus Aerobic/F bottles and in Lytic/10 Anaerobic/F culture vials. Both aerobic bottles were positive after 48 h and were subcultured to both routine and fungal media. Gram staining showed hyphal elements in both bottles. Upon subculture, the mold grew in 1 day and was identified morphologically by a touch preparation stained with Myco Perm Blue mounting medium. S. prolificans typically grows rapidly within 5 days. Colonies on Sabouraud dextrose agar are flat, suede-like in texture, and olive-gray in color, with a lighter peripheral edge. Microscopically, S. prolificans forms septate hyphae and conidiogenous annellides, producing oval or slightly truncate conidia. The annellides have swollen bases with a narrowing tip, which differentiates this species from other Scedosporium species. Molecular tools for diagnosis are currently investigational. The in vitro resistance of S. prolificans to most antifungals makes treatment challenging. The currently available antifungals are typically ineffective in treating these infections. Synergistic effects between amphotericin B, triazoles, terbinafine, and polymorphonuclear leukocytes have been observed (6–8). Successful control of infection with voriconazole in combination with terbinafine or an echinocandin has been described (9). Infections with S. prolificans seldom respond to medical therapy alone. Reversal of immunosuppression, surgery, and possibly additive antifungal therapy are the only potential therapeutic options currently available. October 2017 Volume 55 Issue 10
Journal of Clinical Microbiology
Citation Nambiar PH, Tokarczyk M, DeSimone JA, Jr. 2017. Answer to Photo Quiz: Scedosporium prolificans. J Clin Microbiol 55:3149 –3150. https://doi.org/10.1128/JCM .02488-15. Editor P. Bourbeau Copyright © 2017 American Society for Microbiology. All Rights Reserved. Address correspondence to Puja H. Nambiar, [email protected]. See page 2877 in this issue (https://doi.org/10 .1128/JCM.02485-15) for photo quiz case presentation.
jcm.asm.org 3149
Downloaded from http://jcm.asm.org/ on September 25, 2017 by King's College London
Puja H. Nambiar,a Mindy Tokarczyk,b Joseph A. DeSimone, Jr.c
Photo Quiz
Journal of Clinical Microbiology
REFERENCES
October 2017 Volume 55 Issue 10
6. Gil-Lamaignere C, Roilides E, Maloukou A, Georgopoulou I, Petrikkos G, Walsh TJ. 2002. Amphotericin B lipid complex exerts additive antifungal activity in combination with polymorphonuclear leukocytes against Scedosporium prolificans and Scedosporium apiospermum. J Antimicrob Chemother 50:1027–1030. https://doi.org/10.1093/jac/ dkf198. 7. Gil-Lamaignere C, Roilides E, Mosquera J, Maloukou A, Walsh TJ. 2002. Antifungal triazoles and polymorphonuclear leukocytes synergize to cause increased hyphal damage to Scedosporium prolificans and Scedosporium apiospermum. Antimicrob Agents Chemother 46:2234 –2237. https://doi.org/10.1128/AAC.46.7.2234-2237.2002. 8. Meletiadis J, Mouton JW, Meis JF, Verweij PE. 2003. In vitro drug interaction modeling of combinations of azoles with terbinafine against clinical Scedosporium prolificans isolates. Antimicrob Agents Chemother 47: 106 –117. https://doi.org/10.1128/AAC.47.1.106-117.2003. 9. Howden BP, Slavin MA, Schwarer AP, Mijch AM. 2003. Successful control of disseminated Scedosporium prolificans infection with a combination of voriconazole and terbinafine. Eur J Clin Microbiol Infect Dis 22:111–113. https://doi.org/10.1007/s10096-002-0877-z.
jcm.asm.org 3150
Downloaded from http://jcm.asm.org/ on September 25, 2017 by King's College London
1. Hennebert GL, Dessai BG. 1974. Lomentospora prolificans, a new hyphomycete from greenhouse soil. Mycotaxon 1:50. 2. Rodriguez-Tudela JL, Berenguer J, Guarro J, Kantarcioglu AS, Horre R, De Hoog GS, Cuenca-Estrella M. 2009. Epidemiology and outcome of Scedosporium prolificans infection, a review of 162 cases. Med Mycol 47: 359 –370. https://doi.org/10.1080/13693780802524506. 3. Idigoras P, Pérez-Trallero E, Piñeiro L, Larruskain J, López-Lopategui MC, Rodríguez N, González JM. 2001. Disseminated infection and colonization by Scedosporium prolificans: a review of 18 cases, 1990 –1999. Clin Infect Dis 32:E158 –E165. https://doi.org/10.1086/320521. 4. Revankar SG, Patterson JE, Sutton DA, Pullen R, Rinaldi MG. 2002. Disseminated phaeohyphomycosis: review of an emerging mycosis. Clin Infect Dis 34:467– 476. https://doi.org/10.1086/338636. 5. Vetter E, Torgerson C, Feuker A, Hughes J, Harmsen S, Schleck C, Horstmeier C, Roberts G, Cockerill F. 2001. Comparison of the BACTEC MYCO/F Lytic bottle to the Isolator tube, BACTEC Plus Aerobic F/bottle, and BACTEC Anaerobic Lytic/10 bottle and comparison of the BACTEC Plus Aerobic F/bottle to the Isolator tube for recovery of bacteria, mycobacteria, and fungi from blood. J Clin Microbiol 39:4380 – 4386. https://doi .org/10.1128/JCM.39.12.4380-4386.2001.
crossm Answer to Photo Quiz: Scedosporium prolificans Infectious Diseases, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USAa; Department of Pathology Anatomy and Cell Biology, Clinical Microbiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USAb; Department of Infectious Diseases, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USAc
KEYWORDS Scedosporium prolificans, fungal infections, lymphoma, febrile neutropenia, antifungal therapy, fungemia
S
cedosporium prolificans is a filamentous fungus that was discovered in greenhouse soil in 1974 (1). Scedosporium species are ubiquitous saprophytic fungi found in soil and polluted water. Infection is acquired following traumatic implantation or aspiration of contaminated water. The most common clinical presentations are disseminated infection, pulmonary mycosis, and osteomyelitis/arthritis; in rare cases, cutaneous, ocular, sinus, ear, or cerebral infections occur (2). Disseminated S. prolificans infection occurs mainly in immunocompromised patients and has a mortality rate as high as 87% (2). Positive blood cultures are reported for approximately 80% of the patients with disseminated scedosporiosis (2–4). However, most of the blood cultures become positive close to the time of death, limiting their diagnostic utility (2). Two common methods for fungal detection in blood are the Isolator system (Wampole Laboratories) and the Bactec Myco/F Lytic bottle. The two systems are similar in the recovery of most yeasts and molds, with the exception of some dimorphic fungi. The dimorphic fungus Histoplasma was recovered more often from the Isolator system (5). In this patient presentation, Scedosporium was detected by the BD Bactec FX system. Two separate blood cultures were collected the same day in two BD Bactec Plus Aerobic/F bottles and in Lytic/10 Anaerobic/F culture vials. Both aerobic bottles were positive after 48 h and were subcultured to both routine and fungal media. Gram staining showed hyphal elements in both bottles. Upon subculture, the mold grew in 1 day and was identified morphologically by a touch preparation stained with Myco Perm Blue mounting medium. S. prolificans typically grows rapidly within 5 days. Colonies on Sabouraud dextrose agar are flat, suede-like in texture, and olive-gray in color, with a lighter peripheral edge. Microscopically, S. prolificans forms septate hyphae and conidiogenous annellides, producing oval or slightly truncate conidia. The annellides have swollen bases with a narrowing tip, which differentiates this species from other Scedosporium species. Molecular tools for diagnosis are currently investigational. The in vitro resistance of S. prolificans to most antifungals makes treatment challenging. The currently available antifungals are typically ineffective in treating these infections. Synergistic effects between amphotericin B, triazoles, terbinafine, and polymorphonuclear leukocytes have been observed (6–8). Successful control of infection with voriconazole in combination with terbinafine or an echinocandin has been described (9). Infections with S. prolificans seldom respond to medical therapy alone. Reversal of immunosuppression, surgery, and possibly additive antifungal therapy are the only potential therapeutic options currently available. October 2017 Volume 55 Issue 10
Journal of Clinical Microbiology
Citation Nambiar PH, Tokarczyk M, DeSimone JA, Jr. 2017. Answer to Photo Quiz: Scedosporium prolificans. J Clin Microbiol 55:3149 –3150. https://doi.org/10.1128/JCM .02488-15. Editor P. Bourbeau Copyright © 2017 American Society for Microbiology. All Rights Reserved. Address correspondence to Puja H. Nambiar, [email protected]. See page 2877 in this issue (https://doi.org/10 .1128/JCM.02485-15) for photo quiz case presentation.
jcm.asm.org 3149
Downloaded from http://jcm.asm.org/ on September 25, 2017 by King's College London
Puja H. Nambiar,a Mindy Tokarczyk,b Joseph A. DeSimone, Jr.c
Photo Quiz
Journal of Clinical Microbiology
REFERENCES
October 2017 Volume 55 Issue 10
6. Gil-Lamaignere C, Roilides E, Maloukou A, Georgopoulou I, Petrikkos G, Walsh TJ. 2002. Amphotericin B lipid complex exerts additive antifungal activity in combination with polymorphonuclear leukocytes against Scedosporium prolificans and Scedosporium apiospermum. J Antimicrob Chemother 50:1027–1030. https://doi.org/10.1093/jac/ dkf198. 7. Gil-Lamaignere C, Roilides E, Mosquera J, Maloukou A, Walsh TJ. 2002. Antifungal triazoles and polymorphonuclear leukocytes synergize to cause increased hyphal damage to Scedosporium prolificans and Scedosporium apiospermum. Antimicrob Agents Chemother 46:2234 –2237. https://doi.org/10.1128/AAC.46.7.2234-2237.2002. 8. Meletiadis J, Mouton JW, Meis JF, Verweij PE. 2003. In vitro drug interaction modeling of combinations of azoles with terbinafine against clinical Scedosporium prolificans isolates. Antimicrob Agents Chemother 47: 106 –117. https://doi.org/10.1128/AAC.47.1.106-117.2003. 9. Howden BP, Slavin MA, Schwarer AP, Mijch AM. 2003. Successful control of disseminated Scedosporium prolificans infection with a combination of voriconazole and terbinafine. Eur J Clin Microbiol Infect Dis 22:111–113. https://doi.org/10.1007/s10096-002-0877-z.
jcm.asm.org 3150
Downloaded from http://jcm.asm.org/ on September 25, 2017 by King's College London
1. Hennebert GL, Dessai BG. 1974. Lomentospora prolificans, a new hyphomycete from greenhouse soil. Mycotaxon 1:50. 2. Rodriguez-Tudela JL, Berenguer J, Guarro J, Kantarcioglu AS, Horre R, De Hoog GS, Cuenca-Estrella M. 2009. Epidemiology and outcome of Scedosporium prolificans infection, a review of 162 cases. Med Mycol 47: 359 –370. https://doi.org/10.1080/13693780802524506. 3. Idigoras P, Pérez-Trallero E, Piñeiro L, Larruskain J, López-Lopategui MC, Rodríguez N, González JM. 2001. Disseminated infection and colonization by Scedosporium prolificans: a review of 18 cases, 1990 –1999. Clin Infect Dis 32:E158 –E165. https://doi.org/10.1086/320521. 4. Revankar SG, Patterson JE, Sutton DA, Pullen R, Rinaldi MG. 2002. Disseminated phaeohyphomycosis: review of an emerging mycosis. Clin Infect Dis 34:467– 476. https://doi.org/10.1086/338636. 5. Vetter E, Torgerson C, Feuker A, Hughes J, Harmsen S, Schleck C, Horstmeier C, Roberts G, Cockerill F. 2001. Comparison of the BACTEC MYCO/F Lytic bottle to the Isolator tube, BACTEC Plus Aerobic F/bottle, and BACTEC Anaerobic Lytic/10 bottle and comparison of the BACTEC Plus Aerobic F/bottle to the Isolator tube for recovery of bacteria, mycobacteria, and fungi from blood. J Clin Microbiol 39:4380 – 4386. https://doi .org/10.1128/JCM.39.12.4380-4386.2001.
