Fatima and Shailaja: Trichosporon asahii as an emerging panresistant agent of urinary tract infection: A case report


Introduction

  1. Trichosporon asahii (T. asahii) formerly called T.bigelli is an emerging fungal pathogen seen particularly in immunocompromised patients.

  2. Trichosporon asahii causes white piedra, a superficial infection of hair shafts mainly restricted to tropical regions and less commonly onychomycosis in immunocompetent humans.

  3. In immunodeficient hosts it has been isolated from blood, skin and viscera causing various localized or disseminated deep infections.1

  4. Trichosporonosis has been recognized with increased frequency during the past 10-15 years

Aims & Objective

Identification & Determination of antifungal susceptibility of the yeast Trichosporon asahii.

Case Report

  1. A 65 years male patient k/c/o diabetes and hypertension since 5 years was admitted with the complaints of decreased urine output and burning micturition since 15 days. After the relevant investigations he was clinically diagnosed as Acute kidney injury (AKI) on Chronic kidney disease (CKD).

  2. Empirical treatment was started with antibiotic Monocef

  3. He has undergone dialysis outside our hospital for 4 times before admission and additional 4 dialysis therapy in our hospital.

  4. Complete urine examination (CUE showed many pus cells.

Materials and Methods

  1. Urine sample sent to our laboratory was examined microscopically as wet mount and Inoculated onto Blood agar and SDA plates and incubated overnight at 37oC.

  2. SDA plate was futher incubated for upto 7 days.

  3. The Gram stain of the colonies from both BA and SDA plates were done.

  4. LPCB mount was also done from both BA and SDA plates.

  5. Automated VITEK2 system and MALDI-TOF was done for confirmation of identification.

  6. Antifungal susceptibility done by VITEK2 system.

  7. Repeat two consecutive samples were collected and processed similarly to confirm pathogenicity.

Results

Figure 1

Wet mountof urine - lateral budding yeast cells and hyphae.

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Figure 2

Blood Agar – colonies are tiny, white to cream colored smooth which later on become dry folded.

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Figure 3

SDA plate -cream colored, smooth colonies by 24 hours of incubation.

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Figure 4

SDA plate -dry wrinkled appearance of the colonies on further incubation.

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Figure 5

LPCB mount –arthroconidia and budding yeast cells.

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Figure 6

Gram stain (of isolate) -gram positive yeast cells with lateral budding and septate hyphae.

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  1. Isolate was confirmed as T. asahii by automated VITEK2 system and MALDI-TOF (matrix assisted laser desorption ionization-time of flight mass spectrometry).

  2. All the three consecutive samples gave similar results which confirmed the pathogenicity

  3. Antifungal susceptibility by VITEK2 system revealed multi resistance to all antifungal drugs tested with preserved susceptibility only to Voriconazole.

Discussion

  1. Trichosporon infections present diagnostic and therapeutic challenges.2 Although Trichosporon is ubiquitous and colonizes many areas, it is a known opportunistic pathogen causing emergent and invasive infections in tertiary care hospitals worldwide.3

  2. Invasive Trichosporonosis is documented mostly in patients with hematological malignancies and other medical conditions associated with immunosuppression.3

  3. Asahii is the predominant causative species and is associated with a poor prognosis

  4. A review of more recent English language literature revealed additional cases of disseminated trichosporonosis among patients with AIDS, malignancy, extensive burns, intravenous catheters, treatment with corticosteroids and heart valve surgery reported from the United states, Europe and Japan.4 Multiple comorbidities such as diabetes and kidney disease may be contributory to the establishment of this infection in our case.

  5. MALDI-TOF appears to be a valuable tool for identifying clinical Trichosporon isolates at the species level.5

  6. Therapeutic management of these infections may also be challenging, since Trichosporon spp. exhibit an intrinsic resistance to the Echinocandins and a poor susceptibility to the Polyenes.6

  7. When assessed by MIC and MFC determinations, Voriconazole is the most active and fluconazole is the least active triazole tested against T. asahii,7 and many other articles are suggestive of Voriconazole as the treatment of choice.

  8. In our case we have advised voriconazole to the patient and the patient showed clinical improvement.

Conclusions

  1. We need to have an increased awareness of disseminated infections due to Trichosporon spp.Such infections require early diagnosis and treatment for fast recovery of the patient.

  2. Due to the natural resistance to echinocandins and polyenes of Trichosporon, breakthrough infections are common.

  3. T. asahii is the predominant causative species and is associated with a poor prognosis, possibly linked to its reduce sensitivity to some azole drugs.

  4. First line therapy should rely on Azole derivatives and particularly Voriconazole, which exhibits the best in vitro activity against Trichosporon sps and significantly leads to a better outcome in patients.6

Conflicts of Interest

All contributing authors declare no conflicts of interest.

Source of Funding

None.

References

1 

VP Baradkar S Mathur S Kumar Urinary Tract Infection Due to Trichosporon asahii in a Diabetic PatientBombay Hospital J20085046546

2 

ID Khan AK Sahni A Basu S Haleem Trichosporon asahii urinary tract infection in immunocompetent patientsMed J Armed Forces India2015714373610.1016/j.mjafi.2014.08.013

3 

A. L. Colombo A. C. B. Padovan G. M. Chaves Current Knowledge of Trichosporon spp. and TrichosporonosisClin Microbiol Rev201124468270010.1128/cmr.00003-11

4 

A Chowdhary S Ahmad Z U Khan D C Doval H S Randhawa Trichosporon asahii as an emerging etiologic agent of disseminated trichosporonosis: A case report and an updateIndian J Med Microbiol2004221622

5 

J.N. de Almeida Júnior D.S.Y. Figueiredo D. Toubas G.M.B. Del Negro A.L. Motta F. Rossi Usefulness of matrix-assisted laser desorption ionisation–time-of-flight mass spectrometry for identifying clinical Trichosporon isolatesClin Microbiol Infect20142087849010.1111/1469-0691.12502

6 

JN de Almeida Júnior C Hennequin Invasive Trichosporon Infection: a Systematic Review on a Re-emerging Fungal PathogenFront Microbiol20167162910.3389/fmicb.2016.01629

7 

G Hazirolan E Canton S Sahin S Arikan-Akdagli Head-to-head comparison of inhibitory and cidal activities of fluconazole, itraconazole, voriconazole, posaconazole and isavuconazole against clinical isolates of Trichosporon asahii determined by three methods: MIC, minimum fungicidal concentration and time-kill curvesAntimicrob Agents Chemother20135748417



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