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  Table of Contents    
CASE REPORT  
Year : 2013  |  Volume : 56  |  Issue : 3  |  Page : 312-314
Perinephric abscess caused by fusarium chlamydosporum in an immunocompetent child: Case report and identification of the morphologically atypical fungal strain


Department of Microbiology, Govt. Medical College and Hospital, Sector-32, Chandigarh, India

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Date of Web Publication24-Oct-2013
 

   Abstract 

Fusarium infections are important problem worldwide, cause a broad spectrum of infections in human including superficial infections as well as locally invasive and disseminated infections. We report a rare case of perinephric abscess caused by Fusarium chlamydosporum in a child who had a recent episode of pyelonephritis. This case illustrates the ever increasing spectrum of rare but offending pathogenic fungi in an immunocompetent host. Fungal infections should always be suspected in patients having one or the other underlying risk factor or who are unresponding to antibacterial therapy. Early diagnosis of infection with a specific pathogen may lead to changes in antifungal therapy and may be critical for an improved outcome

Keywords: Fusarium, immunocompetent, perinephric abscess

How to cite this article:
Sidhu S, Chander J, Singh K. Perinephric abscess caused by fusarium chlamydosporum in an immunocompetent child: Case report and identification of the morphologically atypical fungal strain . Indian J Pathol Microbiol 2013;56:312-4

How to cite this URL:
Sidhu S, Chander J, Singh K. Perinephric abscess caused by fusarium chlamydosporum in an immunocompetent child: Case report and identification of the morphologically atypical fungal strain . Indian J Pathol Microbiol [serial online] 2013 [cited 2020 Jun 1];56:312-4. Available from: http://www.ijpmonline.org/text.asp?2013/56/3/312/120409



   Introduction Top


Fusarium species cause a broad spectrum of infections in humans, including superficial infections, as well as locally invasive and disseminated infections. [1] Fusarium has been recognized as a second most frequent mold causing invasive infections in immunocompromised patients and is associated with high morbidity and mortality.­[2] Most cases of invasive fusariosis are caused by Fusarium solani, F. oxysporum, and F. moniliforme but in one-third the species are not identified. [3] The clinical form of fusariosis depends largely on the immune status of the host and the portal of entry, with superficial and localized disease occurring mostly in immunocompetent patients and disseminated disease affecting immunocompromised patients. [4],[5] Prevention of Fusarium infection among high-risk patients should be considered and these infections may be clinically suspected on the basis of a constellation of clinical and laboratory findings, which should lead to prompt therapy. A rare case of fusariosis presenting as perinephric abscess in an immunocompetent child is being reported here with clinical, cytological, and mycological findings.


   Case Report Top


A 12-year-old boy was hospitalized with fever, dysuria, nausea, vomiting and left sided flank pain. On physical examination he had fever (39.5°C) with rigors and chills, pallor, tachycardia (110 per minute), tachypnoea (32 pm), and blood pressure of 90/60 mmHg. There were no signs of dehydration. He had undergone previous antibiotic therapy to treat urinary tract infections 2 months prior to admission. On abdo­minal examination, he had bilateral tenderness at the costovertebral angles with percussion while the other systemic examination was essentially normal. Initial laboratory investigations demons­trated pyuria on urine complete examination, hemoglobin of 11 gm/dl, white cell count of 16 200/mm 3 (65% neutrophils, 32% lymphocytes), platelet count of 350 000/mm 3 and 10-fold rise in C-reactive protein. Serum creatinine and blood urea level were 0. and 17 mg%, respectively. An ultrasonography (USG) of the ab­domen revealed an enlarged left kidney with evidence of a hypoechoic collection measuring 4.6 × 3.2 × 2.9 cm 3 in the mid pole. Computed tomography (CT) scan confirmed these findings. No abnormality was detected on Chest X-ray. Ultrasound guided percutaneous drainage was done. Sero-purulent material was aspirated and sent for bacteriological and fungal culture. Blood and urine cultures were also sent and intravenous ceftriaxone and amikacin were started.

Aspirated pus sent to microbiology laboratory was cultured using standard techniques for the isolation of aerobic and anaerobic bacteria and on Emmons' modified Sabouraud glucose agar supplemented with gentamicin and chloramphenicol (SGA, Difco) for fungi. Fungal cultures were incubated at 25 and 37°C. On direct microscopic examination, KOH wet mount showed multiple septate, branched, and irregular hyaline hyphae [Figure 1]. Gram stained smears of the aspirate revealed numerous pus cells, no bacteria. Leishman stained smear of aspirate showed large septate branched, fungal hyphae mixed with lymphocytes, polymorphs and macrophages.

Cultures of blood, urine and pus were negative for bacteria while those for fungi were positive after 4-5 days of incubation. On SGA, the isolate produced intensely pinkish red, floccose colonies 6-7 cm in diameter with abundant arial mycelia both at 25 and 37°C [Figure 2]. On lactophenol cotton blue preparation, branched septate hyaline hyphae with sessile conidiophores and numerous fusiform microconidia in long chains were seen [Figure 3]a. The isolate produced numerous one to two celled clavate, oblong to fusiform microconidia (2.5-4 8-12 mm) round at the apex and tapered toward base directly on the short and narrow phialides on sympodially proliferating conidiophores on cornmeal agar slide culture. No macroconidia were seen. Numerous globose brown walled chlamydospores (6-15 mm in diameter) were formed singly or in short chains [Figure 3]b. The reverse of the colony was faintly brown in the beginning but became dark brown as the culture aged due to the increasingly abundant darkly pigmented chlamydospores. Thus, the isolate was identified as Fusarium chlamydosporum on the basis of intensely pink red colonies, sympodially proliferating conidiophores, clavate to fusiform microconidia born directly on phialides and numerous intercalary brown walled chlamydospores and rare formation of macroconidia on agar media.
Figure 1: KOH wet mount shows multiple septate, branched and irregular hyaline hyphae(40x)

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Figure 2: Intensely pinkish red, floccose colonies with abundant arial mycelia on SGA

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Figure 3: LCB mount shows (a) branched hyaline hyphae and numerous fusiform microconidia (b) multiple globose chlamydospores

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When the microbiology lab reported the growth of fungal species, antifungal treatment was started. On the basis of efficacy and safety considerations; oral voriconazole (200 mg orally every 24 h) was started. Clinical improvement already occurred in the patient after the drainage of abscess and antifungal treatment was continued for 4 weeks. On follow-up after 2 months, the child showed weight gain and USG revealed complete resolution of the renal abscess.


   Discussion Top


Fusarium spp. are molds that have worldwide distribution, mainly soil saprophytes and plant pathogens which are commonly associated with superficial infections. [4] However, from the last one decade, more than 100 cases of invasive infections caused by Fusarium spp. have been reported. [6] It is the second most common mold causing localized infection, deep seated skin infection and disseminated diseases and results in mortality ranging from 50-80%. Most cases of invasive fusariosis are caused by F. solani, F. oxysporum, and F. moniliforme but various other atypical strains are emerging as an important cause of infection especially in patients having one or the other underlying risk factors like immunosupression, tissue damage and neutropenia etc. [7],[8]

We report a rare case of perinephric abscess caused by Fusarium chlamydosporum in a patient who had a recent episode of pyelonephritis that was treated with antibiotics. To the best of our knowledge, this is the first case described in the literature in which renal abscess was present in a child with urinary tract infection. Renal and perinephric abscesses are serious infections that are commonly caused by one or several different kinds of bacteria. Fungal renal abscesses are very rare amongst intra-­abdominal abscesses and the risk factors that are identified include the presence of renal stone, structural abnormality of the urinary tract, and his­tory of urologic surgery, trauma and diabetes mellitus. [9] No such risk factor was present in our case other than pyelonephritis. This case demonstrates the importance of identifying the rare but offending pathogenic fungi in an immunocompetent host. Reports of fusarial infection in immunocompetent patients are sparse and these include mostly infection of the eyes, skin, nails, peritoneum or lungs. [10],[11] Another study has reported fusarial infections in 76% of immunocompetent patients with disseminated disease and locally invasive disease in 8 and 38% patients, respectively. [2]

Some fungal species, including F. chlamydosporum rarely cause disease but are considered emerging fungal pathogens. [12] Since many of the data concerning such infections are gathered from small series or individual cases, it is difficult to evaluate the predisposing factors, natural history, clinical course, treatment, and prognosis of these patients. [2] The number of patients with fusariosis is likely to increase in the future as more patients receive intensive immunosuppressive therapy. Our purpose here is to report probably the first known case of renal abscess caused by F. chlamydosporum and to alert the clinicians as well as the microbiologists. Fungal infections should always be suspected in patients having one or the other underlying risk factor or who are unresponsive to antibacterial therapy. These infections may be clinically suspected on the basis of a constellation of clinical and laboratory findings and imaging, which would lead to prompt therapy.

The optimal selection of antifungal therapy for fusariosis is not well defined in the literature. Despite the variable response, high dose amphotericin B (1-2 mg/kg/day) or a lipid formulation of amphotericin B is considered standard therapy. [7] Fusarium spp. generally exhibit high MICs to echinocandins, flucytosine, and azoles, although they may exhibit intermediate susceptibility to voriconazole (MIC, 1-8 μg/ml) and posaconazole. [13] Correlation between in vitro drug susceptibility and a successful clinical response is unknown, and data on combination antifungal therapy are lacking. Host immune system is the most important factor predicting outcome, [1] with high mortality observed in immunocompromised patients.

F. chlamydosporum is an emerging pathogen and only few cases of human infection caused by this pathogen are reported in the literature. [6],[12] Rapid and reliable diagnostic methods for mold identification from various specimens would increase our diagnostic precision and should be adopted in routine microbiology laboratory. Moreover, effective antifungal therapy and reliable fungal susceptibility testing methods are urgently needed to prevent the further dissemination of Fusarium infection. One should have a high index of suspicion for emerging fungal pathogens, even in immunocompetent patients.

 
   References Top

1.Nucci M, Annaissie E. Fusarium infections in immunocompromised patients. Clin Microbiol Rev 2007;20:695-704.  Back to cited text no. 1
    
2.Nir-Paz R, Strahilevitz J, Shapiro M, Block N, Polacheck I. Clinical and epidemiological aspects of infections caused by Fusarium species: Collaborative study from Israel. J Clin Microbiol 2004;42:456-61.  Back to cited text no. 2
    
3.Guarro J, Gene J. Opportunistic Fusarial infections in humans. Eur J Clin Microbiol Infect Dis 1995;14:741-54.  Back to cited text no. 3
    
4.Nelson PE, Dignani MC, Annaissie EJ. Taxonomy, biology and clinical aspects of Fusarium species. Clin Microbiol Rev 1994;7:479-504.  Back to cited text no. 4
    
5.Boutati EI, Annaissie EJ. Fusarium, a significant emerging pathogen in patients with hematologic malignancy: Ten years experience at cancer cemtre and implications for management. Blood 1997;90:999-1008.  Back to cited text no. 5
    
6.Segal BH, Walsh TJ, Liu JM, Wilson JD, Kyung-Chung KJ. Invasive infection with Fusarium chlamydosporum in a patient with aplastic anaemia. J Clin Microbiol 1998;36:1772-6.  Back to cited text no. 6
    
7.Fleming RV, Walsh TJ, Annaissie EJ. Emerging and less common fungal pathogens. Infect Dis Clin North Am 2002;16:915-33.  Back to cited text no. 7
    
8.Raad I, Tarrand J, Hanna H, Albitar M, Janssen E, Boktour M, et al. Epidemiology, molecular mycology and environmental sources of Fusarium infection in patients with cancer. Infect Control Hosp Epidemiol 2002;23:532-7.  Back to cited text no. 8
    
9.Dembry LM, Andriole VT. Renal and perirenal abscesses. Infect Dis Clin North Am 1997;11:663-80.  Back to cited text no. 9
    
10.Nucci M, Anaissie E. Cutaneous infection by Fusarium species in healthy and immunocompromised hosts: Implications for diagnosis and management. Clin Infect Dis 2002;35:909-20.  Back to cited text no. 10
    
11.Pushker N, Chra M, Bajaj S, Ghose S, Naik N, Kashyap S, et al. Necrotizing periorbital Fusarium infection: An emerging pathogen in immunocompetent individuals. J Infect 2002;44:236-9.  Back to cited text no. 11
    
12.Kiehn TE, Nelson PE, Bernard EM, Edwards FF, Koziner B, Armstrong D. Catheter associated fungemia caused by Fusarium chlamydosporum in a patient with lymphocytic lymphoma. J Clin Microbiol 1985;21:501-4.  Back to cited text no. 12
    
13.Alastruey-Izquierdo A, Cuenca-Estrella M, Monzon A, Mellado E, RodríguezTudela JL. Antifungal susceptibility profile of clinical Fusarium species isolated identified by molecular methods. J Antimicrob Chemother 2008;61:805-9.  Back to cited text no. 13
    

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Correspondence Address:
Shailpreet Sidhu
Department of Microbiology, Govt. Medical College and Hospital, Sector - 32, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.120409

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