704
Meningitis Due to Prototheca wickerhamii in a Patient with AIDS
z. C. Kaminski, R. Kapila, L. R. Sharer, P. Kloser, and L. Kaufman
From the Departments ofLaboratory Medicine and Pathology, Medicine. and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School. University Hospital, Newark, New Jersey; and Division of Bacterial and Mycotic Diseases. National Center for Infectious Diseases. Centers for Disease Control. Public Health Service, Department ofHealth and Human Services. Atlanta, Georgia
u.s.
The first documented case of algal meningitis due to Prototheca wickerhamii is reported in a patient with AIDS. The initial CSF culture yielded only Cryptococcus neoformans. P. wickerhamii was isolated on four subsequent lumbar punctures. The patient died, and at autopsy the alga was isolated from leptomeninges over the brain and about the spinal cord. Histologic sections from numerous locations of the brain revealed masses of cryptococci and protothecae.
Received 20 February 1992; revised 16 April 1992. Reprints or correspondence: Dr. Zigmund C. Kaminski, Department of Laboratory Medicine and Pathology. New Jersey Medical School, University of Medicine and Dentistry of New Jersey, 185 South Orange Avenue, Newark. New Jersey 07103-2425. Clinical Infectious Diseases 1992;15:704-6 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1504-0022$02.00
glucose, 26 mg/dL; protein, 94 mg/dL; and lactate, 6.9 mEq/L. An India ink preparation of the CSF was positive for encapsulated yeast, and C. neoformans subsequently was isolated from the fluid. The CSF cryptococcal antigen titer was I: I,024 by a latex agglutination test. On the third day of admission, the patient started to receive therapy with intravenous amphotericin Band 5-fluorocytosine. An episode of seizures I week later prompted phenytoin therapy, and pneumonia believed to be secondary to aspiration required tobramycin and clindamycin for I week. Herpetic lesions on the face and oral mucosa were treated with intravenous acyclovir for I week, with good results. An ELISA for antibody to human immunodeficiency virus type 1 (HIV-I) was positive, and results were confirmed by western blot. The patient began to receive intravenous hyperalimentation. Seven weeks after admission, a second spinal tap was performed. An India ink preparation of the CSF showed encapsulated, budding yeast forms as well as nonbudding, nonencapsulated yeast-like cells. Fungal cultures on Sabouraud dextrose agar yielded yeast-like colonies of spherical organisms measuring 8-12 ~m in diameter, subsequently identified as P. wickerhamii by API 20C (Analytab Products, Plainview, NY). Identification was confirmed by the New Jersey State Health Laboratories, Trenton, New Jersey, and by the Division of Bacterial and Mycotic Diseases, Centers for Disease Control, Atlanta, Georgia. C. neoformans was not isolated from this CSF sample. Three subsequent CSF examinations, each 1 month apart, yielded results similar to those for the second specimen, with isolation of P. wickerhamii only. All results of subsequent India ink preparations were identical to those for the second CSF sample, with budding, encapsulated yeasts and nonbudding, nonencapsulated cells. Urine, cervix, nose, throat, and blood cultures were all negative for both P. wickerhamii and C. neoformans. Fluorescent antibody studies performed on the third CSF specimen, with use of the techniques described by Sudman and Kaplan [8], revealed single and endosporulating cells
Downloaded from http://cid.oxfordjournals.org/ at University of Sussex on October 17, 2012
Prototheca wickerhamii is a unicellular, achlorophyllic alga [I]. Six cases ofsystemic infection have been reported in which the organism was isolated from various sources, including blood and a peritoneal abscess [2], peritoneal fluid [3, 4], liver [5], synovial tissue [6], and blood related to an indwelling catheter [7]. The patient reported herein has the first documented human case of prototheca meningitis. This is also the first patient with AIDS in whom both Cryptococcus neoformans and P. wickerhamii were isolated from the CSF. A 25-year-old woman was admitted to University Hospital (Newark, NJ) complaining of headache, stiff neck, and a 6month history of fever, chills, anorexia, weight loss, epistaxis, and upper respiratory ailments. The patient was a heavy drinker and an intravenous drug user. On admission she had a temperature of 38°C; pulse, 96/ min; respirations, 20/min; and blood pressure, 150/120 mm Hg. She was cachectic and lethargic, and she had lymphadenopathy and oral lesions consistent with candidiasis. There was evidence of muscle wasting as well as numerous needle tracks on the extremities from intravenous drug use. Laboratory values on admission included a white blood cell count of 6,700 cells/mm 3 (82% polymorphonuclear leukocytes, 8% lymphocytes, 9% monocytes, 1% eosinophils); hemoglobin, 11.8 g/dL; hematocrit, 34%; and platelets, 342,000/mm 3 • Serum albumin was 2.5 g/dL; alkaline phosphatase, 244 U/L; and aspartate aminotransferase, 94 U /L. On lumbar puncture, opening pressure was 480 mm of fluid, with 13 white blood cells/mm 3 (85% lymphocytes, 15% polymorphonuclear leukocytes) and 1,233 red blood cells/mm 3 ;
CID 1992; 15 (October)
Prototheca Meningitis in a Patient with AIDS
705
that stained intensely with fluorescein-conjugated specific P. wickerhamii immunoglobulin. The isolate was sensitive to amphotericin B (MIC, 0.05 ILgjmL) and resistant to 5-fluorocytosine (MIC, > 100 JlgjmL). The patient was treated for cryptococcal and prototheca meningitis with intravenous amphotericin B (35 mg daily for 2 months followed by 40 mg for 2 months and then by 45 mg for 2.5 months) and with 5-fluorocytosine (1,250 mg orally every 6 hours, beginning on the same day as amphotericin B) for 4 months. Despite this therapy, the patient died 5 months after the diagnosis of prototheca meningitis had been made. At autopsy, the base of the brain, including the brain stem, was surrounded by thick yellow exudate. On the coronal sections of the forebrain, large gelatinous cystic masses were noted in the basal ganglia and thalamus. Histologic sections from numerous locations in the CNS exhibited discrete, separate masses ofcryptococci and P. wickerhamii within the subarachnoid space, with some mixing of the two (figure 1). The perivascular Virchow-Robin spaces were filled and distended by cryptococci, with focal invasion of the surrounding parenchyma. By contrast, there was no evidence ofextension by P.
wickerhamii into the CNS tissue. The media and adventitia of several large arteries within the subarachnoid space were invaded by masses of Prototheca organisms, with evidence of intimal proliferation. In addition, a few inflammatory cell infiltrates containing multinucleated giant cells, changes typical of HIV-I encephalitis [9], were observed in both gray and white matter. The cells of P. wickerhamii exhibited variable staining with hematoxylin and eosin; those that stained well contained clumps of chromatin. The Prototheca organisms were well demonstrated with the Gridley and periodic acid-Schiff techniques, with autospores visible within occasional P. wickerhamii cells (figure I), and confirmed by electron microscopy. The Grocott-Gomori methenamine-silver nitrate technique stained both the Prototheca and Cryptococcus organisms, but only the cryptococci were stained well by mucicarmine. Cultures at autopsy of specimens obtained from leptomeninges in the right parietal cortex, base of the pons, and thoracic spinal cord yielded P. wickerhamii. No other microorganisms were isolated from the CNS. Neither P. wickerhamii
Downloaded from http://cid.oxfordjournals.org/ at University of Sussex on October 17, 2012
Figure 1. Masses of small Prototheca wickerhamii organisms (upper part of photograph) and enlarged cryptococci (lower part and right edge) in the subarachnoid space of a cerebral sulcus. A Prototheca cell in the center (arrow) contains autospores within it (bar = 10 ILm; periodic acid-Schiff stain, original magnification, X1,260).
706
Kaminski et al.
peeted in any immunocompromised and debilitated patient when a nonbudding yeast-like organism is isolated. Another class of microorganisms (the algae) can now be added to the list of numerous opportunistic infections that occur in patients with AIDS.
References I. Arnold P, Ahearn DG. The systematics of the genus Prototheca with a description of a new species. P. filamenta. Mycologia 1972;64:26575. 2. Cox GE. Wilson JD, Brown P. Protothecosis: a case of disseminated algal infection. Lancet 1974;2:379-82. 3. O'Connor JP, Nimm GR, Rigby RJ, Petrie JJB, Hardie IR, Strong RW. Algal peritonitis complicating ambulatory peritoneal dialysis. Am J Kidney Dis 1986;8: 122-3. 4. Sands M, Poppel D, Brown R. Peritonitis due to Prototheca wickerhamii in a patient undergoing chronic ambulatory peritoneal dialysis. Rev Infect Dis 1991; 13:376-8. 5. Chan JC, Jeffers U, Gould EW, et al. Visceral protothecosis mimicking sclerosing cholangitis in an immunocompetent host: successful antifungal therapy. Rev Infect Dis 1990;12:802-7. 6. Moyer RA, Bush DC, Dennehy JJ. Prototheca wickerhamii tenosynovitis. J RheumatoI1990;17:701-4. 7. Heney C, Greef M, Davis V. Hickman catheter-related protothecal algaemia in an immunocompromised child [letter]. J Infect Dis 1991;163:930-1. 8. Sudman MS, Kaplan W. Identification of the Prototheca species by immunofluorescence. Appl Microbial 1973;25:981-90. 9. Sharer LR. Pathology of HI V-I infection of the central nervous system (review). J Neuropathol Exp Neurol 1992;51 :3-1 I. 10. Segal E, Padhl AA, Ajello L. Susceptibility of protothecal species to antifungal agents. Antimicrob Agents Chemother 1976; 10:75-9.
Downloaded from http://cid.oxfordjournals.org/ at University of Sussex on October 17, 2012
nor C. neoformans was isolated from either postmortem blood or the systemic organs. The route ofinfection with P. wickerhamii in our patient is unknown. In the case ofvisceral protothecosis [5], the organism was also isolated from the feces. Although a fecal source is a possibility, culture of the feces from our patient was not performed. The possibility that the organism was introduced by the first lumbar puncture cannot be excluded, since the organism was not isolated from that CSF sample. However, the large number ofcolonies of C. neoformans on the Sabouraud agar plate in the first specimen may have masked the presence of P. wickerhamii. On all subsequent isolations from CSF, the genus and species of the P. wickerhamii cells were identified on the basis of carbohydrate and alcohol assimilation studies and immunofluorescent staining. It should be noted that a diagnosis of protothecosis is not always readily accomplished. Single cells and small clumps of cells are occasionally seen in vivo, and they may resemble nonencapsulated pathogenic yeasts, an appearance that we observed in all but the first of our India ink preparations. There is no standard regimen for the treatment ofprotothecosis. Clinical isolates are generally susceptible to amphotericin B but resistant to 5-fluorocytosine [10]. Amphotericin B has been used successfully on a number ofoccasions, but the patients were not as severely immunocompromised as ours. We describe, to our knowledge, the first patient for whom a diagnosis of algal meningitis was made successfully. In addition, this is the first case of protothecosis in a patient with AIDS. Although obviously rare, this disease should be sus-
CID 1992; 15 (October)
Meningitis Due to Prototheca wickerhamii in a Patient with AIDS
z. C. Kaminski, R. Kapila, L. R. Sharer, P. Kloser, and L. Kaufman
From the Departments ofLaboratory Medicine and Pathology, Medicine. and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School. University Hospital, Newark, New Jersey; and Division of Bacterial and Mycotic Diseases. National Center for Infectious Diseases. Centers for Disease Control. Public Health Service, Department ofHealth and Human Services. Atlanta, Georgia
u.s.
The first documented case of algal meningitis due to Prototheca wickerhamii is reported in a patient with AIDS. The initial CSF culture yielded only Cryptococcus neoformans. P. wickerhamii was isolated on four subsequent lumbar punctures. The patient died, and at autopsy the alga was isolated from leptomeninges over the brain and about the spinal cord. Histologic sections from numerous locations of the brain revealed masses of cryptococci and protothecae.
Received 20 February 1992; revised 16 April 1992. Reprints or correspondence: Dr. Zigmund C. Kaminski, Department of Laboratory Medicine and Pathology. New Jersey Medical School, University of Medicine and Dentistry of New Jersey, 185 South Orange Avenue, Newark. New Jersey 07103-2425. Clinical Infectious Diseases 1992;15:704-6 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1504-0022$02.00
glucose, 26 mg/dL; protein, 94 mg/dL; and lactate, 6.9 mEq/L. An India ink preparation of the CSF was positive for encapsulated yeast, and C. neoformans subsequently was isolated from the fluid. The CSF cryptococcal antigen titer was I: I,024 by a latex agglutination test. On the third day of admission, the patient started to receive therapy with intravenous amphotericin Band 5-fluorocytosine. An episode of seizures I week later prompted phenytoin therapy, and pneumonia believed to be secondary to aspiration required tobramycin and clindamycin for I week. Herpetic lesions on the face and oral mucosa were treated with intravenous acyclovir for I week, with good results. An ELISA for antibody to human immunodeficiency virus type 1 (HIV-I) was positive, and results were confirmed by western blot. The patient began to receive intravenous hyperalimentation. Seven weeks after admission, a second spinal tap was performed. An India ink preparation of the CSF showed encapsulated, budding yeast forms as well as nonbudding, nonencapsulated yeast-like cells. Fungal cultures on Sabouraud dextrose agar yielded yeast-like colonies of spherical organisms measuring 8-12 ~m in diameter, subsequently identified as P. wickerhamii by API 20C (Analytab Products, Plainview, NY). Identification was confirmed by the New Jersey State Health Laboratories, Trenton, New Jersey, and by the Division of Bacterial and Mycotic Diseases, Centers for Disease Control, Atlanta, Georgia. C. neoformans was not isolated from this CSF sample. Three subsequent CSF examinations, each 1 month apart, yielded results similar to those for the second specimen, with isolation of P. wickerhamii only. All results of subsequent India ink preparations were identical to those for the second CSF sample, with budding, encapsulated yeasts and nonbudding, nonencapsulated cells. Urine, cervix, nose, throat, and blood cultures were all negative for both P. wickerhamii and C. neoformans. Fluorescent antibody studies performed on the third CSF specimen, with use of the techniques described by Sudman and Kaplan [8], revealed single and endosporulating cells
Downloaded from http://cid.oxfordjournals.org/ at University of Sussex on October 17, 2012
Prototheca wickerhamii is a unicellular, achlorophyllic alga [I]. Six cases ofsystemic infection have been reported in which the organism was isolated from various sources, including blood and a peritoneal abscess [2], peritoneal fluid [3, 4], liver [5], synovial tissue [6], and blood related to an indwelling catheter [7]. The patient reported herein has the first documented human case of prototheca meningitis. This is also the first patient with AIDS in whom both Cryptococcus neoformans and P. wickerhamii were isolated from the CSF. A 25-year-old woman was admitted to University Hospital (Newark, NJ) complaining of headache, stiff neck, and a 6month history of fever, chills, anorexia, weight loss, epistaxis, and upper respiratory ailments. The patient was a heavy drinker and an intravenous drug user. On admission she had a temperature of 38°C; pulse, 96/ min; respirations, 20/min; and blood pressure, 150/120 mm Hg. She was cachectic and lethargic, and she had lymphadenopathy and oral lesions consistent with candidiasis. There was evidence of muscle wasting as well as numerous needle tracks on the extremities from intravenous drug use. Laboratory values on admission included a white blood cell count of 6,700 cells/mm 3 (82% polymorphonuclear leukocytes, 8% lymphocytes, 9% monocytes, 1% eosinophils); hemoglobin, 11.8 g/dL; hematocrit, 34%; and platelets, 342,000/mm 3 • Serum albumin was 2.5 g/dL; alkaline phosphatase, 244 U/L; and aspartate aminotransferase, 94 U /L. On lumbar puncture, opening pressure was 480 mm of fluid, with 13 white blood cells/mm 3 (85% lymphocytes, 15% polymorphonuclear leukocytes) and 1,233 red blood cells/mm 3 ;
CID 1992; 15 (October)
Prototheca Meningitis in a Patient with AIDS
705
that stained intensely with fluorescein-conjugated specific P. wickerhamii immunoglobulin. The isolate was sensitive to amphotericin B (MIC, 0.05 ILgjmL) and resistant to 5-fluorocytosine (MIC, > 100 JlgjmL). The patient was treated for cryptococcal and prototheca meningitis with intravenous amphotericin B (35 mg daily for 2 months followed by 40 mg for 2 months and then by 45 mg for 2.5 months) and with 5-fluorocytosine (1,250 mg orally every 6 hours, beginning on the same day as amphotericin B) for 4 months. Despite this therapy, the patient died 5 months after the diagnosis of prototheca meningitis had been made. At autopsy, the base of the brain, including the brain stem, was surrounded by thick yellow exudate. On the coronal sections of the forebrain, large gelatinous cystic masses were noted in the basal ganglia and thalamus. Histologic sections from numerous locations in the CNS exhibited discrete, separate masses ofcryptococci and P. wickerhamii within the subarachnoid space, with some mixing of the two (figure 1). The perivascular Virchow-Robin spaces were filled and distended by cryptococci, with focal invasion of the surrounding parenchyma. By contrast, there was no evidence ofextension by P.
wickerhamii into the CNS tissue. The media and adventitia of several large arteries within the subarachnoid space were invaded by masses of Prototheca organisms, with evidence of intimal proliferation. In addition, a few inflammatory cell infiltrates containing multinucleated giant cells, changes typical of HIV-I encephalitis [9], were observed in both gray and white matter. The cells of P. wickerhamii exhibited variable staining with hematoxylin and eosin; those that stained well contained clumps of chromatin. The Prototheca organisms were well demonstrated with the Gridley and periodic acid-Schiff techniques, with autospores visible within occasional P. wickerhamii cells (figure I), and confirmed by electron microscopy. The Grocott-Gomori methenamine-silver nitrate technique stained both the Prototheca and Cryptococcus organisms, but only the cryptococci were stained well by mucicarmine. Cultures at autopsy of specimens obtained from leptomeninges in the right parietal cortex, base of the pons, and thoracic spinal cord yielded P. wickerhamii. No other microorganisms were isolated from the CNS. Neither P. wickerhamii
Downloaded from http://cid.oxfordjournals.org/ at University of Sussex on October 17, 2012
Figure 1. Masses of small Prototheca wickerhamii organisms (upper part of photograph) and enlarged cryptococci (lower part and right edge) in the subarachnoid space of a cerebral sulcus. A Prototheca cell in the center (arrow) contains autospores within it (bar = 10 ILm; periodic acid-Schiff stain, original magnification, X1,260).
706
Kaminski et al.
peeted in any immunocompromised and debilitated patient when a nonbudding yeast-like organism is isolated. Another class of microorganisms (the algae) can now be added to the list of numerous opportunistic infections that occur in patients with AIDS.
References I. Arnold P, Ahearn DG. The systematics of the genus Prototheca with a description of a new species. P. filamenta. Mycologia 1972;64:26575. 2. Cox GE. Wilson JD, Brown P. Protothecosis: a case of disseminated algal infection. Lancet 1974;2:379-82. 3. O'Connor JP, Nimm GR, Rigby RJ, Petrie JJB, Hardie IR, Strong RW. Algal peritonitis complicating ambulatory peritoneal dialysis. Am J Kidney Dis 1986;8: 122-3. 4. Sands M, Poppel D, Brown R. Peritonitis due to Prototheca wickerhamii in a patient undergoing chronic ambulatory peritoneal dialysis. Rev Infect Dis 1991; 13:376-8. 5. Chan JC, Jeffers U, Gould EW, et al. Visceral protothecosis mimicking sclerosing cholangitis in an immunocompetent host: successful antifungal therapy. Rev Infect Dis 1990;12:802-7. 6. Moyer RA, Bush DC, Dennehy JJ. Prototheca wickerhamii tenosynovitis. J RheumatoI1990;17:701-4. 7. Heney C, Greef M, Davis V. Hickman catheter-related protothecal algaemia in an immunocompromised child [letter]. J Infect Dis 1991;163:930-1. 8. Sudman MS, Kaplan W. Identification of the Prototheca species by immunofluorescence. Appl Microbial 1973;25:981-90. 9. Sharer LR. Pathology of HI V-I infection of the central nervous system (review). J Neuropathol Exp Neurol 1992;51 :3-1 I. 10. Segal E, Padhl AA, Ajello L. Susceptibility of protothecal species to antifungal agents. Antimicrob Agents Chemother 1976; 10:75-9.
Downloaded from http://cid.oxfordjournals.org/ at University of Sussex on October 17, 2012
nor C. neoformans was isolated from either postmortem blood or the systemic organs. The route ofinfection with P. wickerhamii in our patient is unknown. In the case ofvisceral protothecosis [5], the organism was also isolated from the feces. Although a fecal source is a possibility, culture of the feces from our patient was not performed. The possibility that the organism was introduced by the first lumbar puncture cannot be excluded, since the organism was not isolated from that CSF sample. However, the large number ofcolonies of C. neoformans on the Sabouraud agar plate in the first specimen may have masked the presence of P. wickerhamii. On all subsequent isolations from CSF, the genus and species of the P. wickerhamii cells were identified on the basis of carbohydrate and alcohol assimilation studies and immunofluorescent staining. It should be noted that a diagnosis of protothecosis is not always readily accomplished. Single cells and small clumps of cells are occasionally seen in vivo, and they may resemble nonencapsulated pathogenic yeasts, an appearance that we observed in all but the first of our India ink preparations. There is no standard regimen for the treatment ofprotothecosis. Clinical isolates are generally susceptible to amphotericin B but resistant to 5-fluorocytosine [10]. Amphotericin B has been used successfully on a number ofoccasions, but the patients were not as severely immunocompromised as ours. We describe, to our knowledge, the first patient for whom a diagnosis of algal meningitis was made successfully. In addition, this is the first case of protothecosis in a patient with AIDS. Although obviously rare, this disease should be sus-
CID 1992; 15 (October)
