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LETTER TO EDITOR Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 2  |  Page : 387-388
Successful management of Trichosporon asahii urinary tract infection with fluconazole in a diabetic patient


Dr Lal Path Labs, 54, Hanuman Road, New Delhi - 110 001, India

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Date of Web Publication12-Jun-2010
 

How to cite this article:
Sabharwal E R. Successful management of Trichosporon asahii urinary tract infection with fluconazole in a diabetic patient. Indian J Pathol Microbiol 2010;53:387-8

How to cite this URL:
Sabharwal E R. Successful management of Trichosporon asahii urinary tract infection with fluconazole in a diabetic patient. Indian J Pathol Microbiol [serial online] 2010 [cited 2014 Jul 31];53:387-8. Available from: http://www.ijpmonline.org/text.asp?2010/53/2/387/64320


Sir,

In the past few decades, a worldwide increase in the incidence of fungal infections has been observed. The emergence of less common, but medically important opportunistic fungal pathogens has contributed to an increase in the rate of morbidity and mortality. [1],[2] Among them, deep-seated trichosporonosis is a lethal opportunistic infection occasionally found in immunocompromised patients, particularly those who are neutropenic due to cytotoxic therapy for hematological malignancies. [1],[2]

Trichosporon asahii is a basidiomycetous yeast, which causes white piedra and onychomycosis in immunocompetent hosts as well as various localized and disseminated invasive infections in immunodeficient hosts. There are only sporadic reports of infections caused by Trichosporon asahii reported from India. [3],[4] We hereby report a case of successful management of T. asahii infection with orally administered fluconazole in a patient of urinary tract infection (UTI).

A 60-year old man presented to the casualty of a medical center, Eastern Delhi with acute renal failure and shock. As per the medical records he was a diabetic and hypertensive, not on any sort of immunosuppressive medication and was HIV nonreactive. The patient was catheterized immediately and started on intravenous ceftriaxone. After seven days of stay in the intensive care unit, he developed UTI. His general condition was poor. He had pyrexia of 102 o F. His blood parameters were as follows: Hemoglobin 6.4 g/dL, total leucocyte count 13,400/mL (neutrophil 80%, lymphocyte 10%, monocyte 9%, and eosinophil 1%), serum urea 52 mg/dL, serum creatinine 2.3 mg/dL and serum electrolytes were also deranged. The patient's urine sample was sent for routine examination and aerobic culture and sensitivity testing. The sample was inoculated on CLED (Cystine Lactose Electrolyte deficient) agar plate and incubated overnight at 37 o C. Routine examination revealed field with numerous pus cells and leukocyte esterase was positive. Tiny, creamy- white, dry, wrinkled colonies were seen on CLED agar. The Gram's stain of the colony revealed the presence of septate hyaline hyphae with arthrospores and few budding yeast cells. The colony was sub-cultured on a set of Sabouraud Dextrose Agar (SDA) slants (with and without supplementation of antibiotics). These were incubated at 28 o C and 37 o C. At both these temperatures, colonies of yeast-like fungus were obtained in pure culture, within 24 h. A repeat sample from the patient revealed a similar picture.

The yeast was finally identified with ID 32C strip and sensitivity tested by ATB TM FUNGUS 3 strip, miniAPI, BioMerieux, France. ID 32C is a standardized system for the identification of yeasts, which uses 32 miniaturized assimilation tests and a database. ATB Fungus 3 strip enables the determination of the susceptibility of yeast isolates to antifungal agents in a semisolid medium under conditions similar to the reference method for micro-dilution, according to CLSI (Clinical Laboratory Standards Institute) guidelines.

On the basis of the culture report, antifungal therapy with fluconazole was initiated and the condition of the patient improved dramatically. Within four days of therapy, the urinary complaints were resolved. After four weeks of antifungal treatment, urine sample was sent for repeat fungal culture and it was found to be negative for the fungus.

Isolation of the same yeast in two consecutive urine samples with a significant number of pus cells (40-75/HPF) and absence of any bacteria isolated establishes T. asahii as an etiological agent of UTI in the patient. Also the fact that there was clearance of the fungus from the urinary tract with recovery of the patient following catheter removal and antifungal therapy further confirms the yeast as the cause of UTI. Our patient also exhibited risk factors such as presence of an indwelling catheter, use of broad spectrum antibiotics and presence of comorbid conditions such as diabetes, hypertension and anemia. It is possible that the organism colonized the catheter from the human flora during catheterization and subsequently caused UTI.

Despite the increasing frequency and severity of trichosporonosis, data on its antifungal susceptibility are limited. While amphotericin B (AMB) has been shown to have a limited in vitro effect, there is growing evidence that azole drugs have good activity against the fungus [5],[6] The isolate in our case study also showed resistance to AMB and was found sensitive to flucytosine and azoles (fluconazole, itraconazole and voriconazole). With concerns about the emergence of antifungal resistance, it is essential that prophylactic and empiric antifungal therapy be based on appropriately designed clinical studies, particularly in high-risk patients. Further studies are needed to define optimal approaches to facilitate earlier treatment, which will improve patient outcomes.

 
   References Top

1.Anaissie EJ. Opportunistic mycoses in the immunocompromised host: experience at a cancer center and review. Clin Infect Dis 1992;14:43-53.  Back to cited text no. 1      
2.Girmenia C, Pagano L, Martino B, D'Antonio D, Fancir Specchia G, Melillo L, et al. Gimema Infection Program. Invasive infections caused by Trichosporon species and Geotrichum capitatum in patients with hematological malignancies: A retrospective multicenter study from Italy and review of the literature. J Clin Microbiol 2005;43:1818-28.   Back to cited text no. 2      
3.Sood S, Pathak D, Sharma R, Rishi S. Urinary tract infection by Trichosporon asahii. Indian J Med Microbiol 2006;24:294-6.  Back to cited text no. 3  [PUBMED]  Medknow Journal  
4.Chowdhary A, Ahmad S, Khan ZU, Doval DC, Randhawa HS. Trichosporon asahii as an emerging etiologic agent of disseminated trichosporonosis: A case report and an update. Indian J Med Microbiol 2004;22:16-22.  Back to cited text no. 4  [PUBMED]  Medknow Journal  
5.Walsh TJ, Melcher GP, Rinaldi MG, Lecciones J, McGough DA, Kelly P, et al. Trichosporon beigelii: an emerging pathogen resistant to amphotericin B. J Clin Microbiol 1990;28:1616-22.   Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.McGinnis MR, Pasarell L, Sutton DA, Fothergill AW, Cooper Jr CR, Rinaldi MG. In vitro activity of voriconazole against selected fungi. Med Mycol 1998;36:239-42.  Back to cited text no. 6      

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Correspondence Address:
E Rajni Sabharwal
D-22 Rose Apartments, Sec 14 - Extension, Rohini, Delhi - 110 085
India
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DOI: 10.4103/0377-4929.64320

PMID: 20551575

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