Cryptococcus laurentii fungaemia in a cervical cancer patient

braz j infect dis.2015;19(6):660–663

www .e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Case

report

Cryptococcus

laurentii

fungaemia

in

a

cervical

cancer

patient

Rejane

Pereira

Neves

_,

_Reginaldo

_Gonc¸alves

_de

_Lima

_Neto

_,

_Melyna

_Chaves

_Leite

_,

Vanessa

Karina

Alves

da

Silva

_,

_Franz

_de

_Assis

_Graciano

_dos

_Santos

_,

Danielle

Patrícia

Cerqueira

Macêdo

a_{DepartamentodeMicologia,UniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil} b_{DepartamentodeMedicinaTropical,UniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil} c_{DepartamentodeCiênciasFarmacêuticas,UniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil}

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Received18March2015 Accepted23June2015

Availableonline9September2015

Keywords:

Cryptococcuslaurentii

Fungaemia Cancer

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InfectionscausedbyemergingCryptococcusnon-neoformansspeciesarebeingreported withincreasinglyfrequency. Here,wepresentacase offungaemiabyCryptococcus lau-rentiiinawomanreceivingaggressiveimmunosuppressivetherapyforcervicalneoplasia. ThreevenousbloodsampleswereasepticallycollectedonconsecutivedaysandC. lauren-tiiwasisolatedandidentifiedthroughphenotypicandmolecularmethods.Aftercentral venouscatheterremovalandappropriateantifungaltherapy,thepatientshowedsignificant improvementandbloodculturebecamenegative.Thus,patientsfollowing immunosup-pressive therapies and using invasive medical devices are at riskof C. laurentii blood infections.

©2015ElsevierEditoraLtda.Allrightsreserved.

Introduction

Cervicalcancerisanimportantmalignancycondition world-wide,withasignificantmortalityrateindevelopingcountries, which corresponds to annual incidence of approximately 132,000 cases. According to the Brazilian National Cancer Institute(INCA),thereare18,430newlyreportedcasesperyear andthiscanceristhefourthleadingcauseofdeathinfemale populationrepresentedby4800caseswithfataloutcome.

∗ _{Correspondingauthorat:UniversidadeFederaldePernambuco,Av.AvenidaProfessorNelsonChaves,s/n,CidadeUniversitária,50670-420}

Recife,PE,Brazil.

E-mailaddress:daniellemacedo28@gmail.com(D.P.C.Macêdo).

Thetherapiesofchoiceandtheunderlyingconditionsof cancerhadledtoanincreasingnumberofsevere opportunis-ticfungalinfectionssuchascryptococcosis.1_{Commonly,itis}

causedbyCryptococcusneoformansandCryptococcusgattii,with recent reports bynon-neoformans Cryptococcusspeciesas C. laurentiiwhichisabasidiomycetousencapsulatedyeast,also foundinthedroppingsandcloacalsamplesofpigeons.2

Cryptococcus laurentii generally cause superficial to deep seated infections inimmunosuppressed patients. The fun-gal infection may be acquired by inhalation leading to

http://dx.doi.org/10.1016/j.bjid.2015.06.014

brazj infect dis.2015;19(6):660–663

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asymptomatic pulmonary infection or through the use of contaminatedinvasivemedicaldevices.Also,otherrisk fac-torsinclude:priorsteroidandimmunosuppressantexposure, azolesprophylaxis,lowCD4count,andneutropenia.2

Case

report

Theproceduresdescribedhereinareinaccordancewith ethi-calstandardsoftheEthicsCommitteeonresearchesinvolving humansfromtheUniversidadeFederaldePernambuco/Brazil.

A42-year-oldBrazilianwomanwasadmittedin Decem-ber2012totheHospitaldasClínicas,apublictertiaryhospital locatedinRecife,Brazil.Shehadhadfeverforoneweekand diffuseabdominalpainanddiscomfortduringintercourse.A complete bloodcountrevealed no abnormalitiesand blood andurinecultureswerealsonegativeforbacteriaandfungiin thisoccasion.Colposcopyproceduresexhibitedanabnormal areainthecervix,andthePapanicolaoutestshowedabnormal cells. Cervical colposcopic biopsies, endocervical curettage andconebiopsydiagnosedcervicalintraepithelialneoplasia(CIN) grade3(squamouscellcarcinoma).Chemotherapyand radio-therapyelicitedgoodresponsesandultimatelyafullclinical recovery.Subsequentlythepatientwasdischargedhome.

However,oneyearthereafterthepatientwashospitalized withdiabetesmellitus,abdominaldistension,appetiteloss, hypoalbuminemia,andintestinalsubocclusion,characteristic ofanactinicstenosis.Bowelresectionandjejunostomywere requiredtocorrecttheintestinalstenosis,withconcomitant administrationofparenteralnutritionandantibiotictherapy. InJanuary 2014,due toadhesionsbetween bowel loops associated with stenosis and presence of mucous fis-tula, anothercorrective enterectomywas performedwhich revealedthepresenceoffecalcontent,intestinalevisceration andaponeuroticdehiscence.Postoperatively,asurgicalwound infectioncausedbyPseudomonasaeruginosa,Citrobactersp.and

Acinetobactersp.,aggravatedbysepsisandagenerally wors-eningclinicalconditionrequiredlong-termantibiotictherapy involvingintravenousvancomycin,followedbyimipenemand metronidazole.However,threemonthslatershewas readmit-tedtotheintensivecareunitpresentingfeverepisodes,severe abdominal pain, weakness and respiratory distress. Labo-ratory investigations showed elevatedurea (207mg/dl) and creatinine(4.0mg/dl)levels, leukopenia(WBC3.60×103_/␮l),

lowhemoglobin(8.0g/dl)andplatelets(8500/␮l)levels. Duplicatevenousbloodsampleswereasepticallycollected intoVACUTAINER®_{tubesusingEDTAanticoagulantandblood}

cultures(BACTEC860system;BectonDickinson,Inc.,Sparks, MD)onthreeconsecutivedays.Sampleswereprocessedby standardmethods(directexaminationandculture)for myco-logicaldiagnosisattheMedicalMycologyLaboratory,Federal UniversityofPernambuco.Directexaminationwasperformed withandwithoutIndiaink.Collectedmaterialwasculturedon SabouraudDextroseAgarmedium(DifcoLaboratories) supple-mentedwithchloramphenicol,incubated at25◦Cand 37◦C inanaerobicatmospherefor10days.Thetaxonomic iden-tificationwascarriedoutwithpureculturesandalsousing moleculartechniquesbycomparingD1/D2sequencesofthe isolatedyeaststrainswiththetypestrainCBS139/Genbank AF075469.3

Fig.1–Buddingencapsulatedsphericalandellipsoidal yeastcellsofCryptococcuslaurentiifrombloodspecimenat directexaminationandcontrastedwithIndiaink.

Buddingcapsulatedyeastcellswerevisualizeddirectlyin wetfilmswithcontrastmicroscopy(Indiaink)andallblood cultureswerepositiveafterfivedaysofgrowth(Fig.1). Macro-scopically,50–100white-creamcoloniesgrew,withmucoidto butyrousconsistence,whichdarkenedwithage.Thereverse wascolorless.Microscopically,contrastedbudding encapsu-lated spherical andellipsoidal yeast cells ofapproximately 5␮mindiameterwereobserved,whichwasmorphologically consistentwiththeiridentificationasCryptococcusspecies.

Nonfermentative colonies, absence of KNO3

utiliza-tion, caffeic acid negative, and urease positive reactions were observed through standard identification techniques. The assimilation profile showed utilization of lactose, d-glucuronate, d-gluconate,andmelibiose,whichindicatesC.

laurentiiastheagentofthebloodstreaminfection.The iden-tification of the microorganism was also confirmed using moleculartechniques.

Inaddition,bronchoalveolarlavageandcerebrospinalfluid wereanalyzedthroughdirectexam,culture,andcryptococcal latexagglutination.However,nofungiweredetected.

Theminimalinhibitoryconcentrations(MICs)ofthe etio-logicalagentisolatedfrombloodsamplesagainstfluconazole andamphotericinBweredeterminedusingthebroth micro-dilution method according to the M27-A3 document from theClinicalandLaboratoriesStandardsInstitute-CLSI.4_The

isolatesweresensitivetoamphotericinB(1.0␮g/ml)and flu-conazole(4␮g/ml).

Duetopersistentelevatedlevelsofureaandcreatinine, flu-conazolewasthedrugofchoiceandthepatientwastreated intravenously (400mg) for 22 weeks. After central venous catheter removalsheshowed significantimprovement and wasdischargedhome.

Discussion

In the caseherein described awoman with anunderlying malignancy was severelyimmunocompromised due to the

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Table1–ReportedcasesofCryptococcuslaurentiifungaemiainhumans.

Year/Reference Age/Sex Underlyingconditions Treatment Outcome

1995/6 _{Non-informed Acutemyelogenousleukemia Itraconazole Resolved}

1995/6 _{Non-informed Acutemyelogenousleukemia Ketoconazole Resolved}

1997/7 _{17/M Neutropenia(bonemarrow}

transplantation)

Fluconazole Resolved

1997/8 _{27d/M Prematurebirth AmphotericinB,flucytosine Resolved}

1997/8 _{27/F Bacterialendocarditis(catheter}

use)

Fluconazole Resolved

1998/9 _{26/M Solidtumor Fluconazole Resolved}

1998/9 _{50/M Non-Hodgkin’slymphoma AmphotericinB Fatal}

1999/9 _{57/M Acutemyelogenousleukemia AmphotericinB Resolved}

2000/10 _{74d/F Prematurebirth AmphotericinB Resolved}

2002/11 _{Non-informed Solidtumor AmphotericinB Resolved}

2009/12 _{39/M Glomerulonephritison}

immunosuppressivetherapy

Itraconazole Resolved

2013/2 _{76/M Cardiovasculardisease AmphotericinB/Fluconazole Resolved}

2015/(presentreport) 42/F Cervicalneoplasia Fluconazole Resolved

M,male;F,female;d,days.

immunosuppressiveeffectsofradioandchemotherapycycles and due toher long-standing diabetic status. Additionally, thepatienthadapredispositionduetotheuseofmultiple cathetersandinvasivemedicaldevices,whichwere consid-ered the possible sourceof fungaemia, although catheters cultureswerenotevaluatedduringhospitalization.

Cryptococcus commonly invades the human body after inhalation,throughthealimentarytractorinjuredskin.From the portal of entry, the encapsulated yeast cells are eas-ily transportedvia bloodstream toother parts ofthe body. Thepresenceofinvasivedevicesisconsideredasignificant risk factor associated with C. laurentii infections.2,5 _{In our}

case, the catheter tip was only removed during the anti-fungaltreatmentandhasnotbeensentformicrobiological analysis.

Furthermore,whatmakesthiscaserelevantisthefactthat fungaemiawascausedbyaratheruncommonmicroorganism,

C.laurentii,forwhichthereisstillapaucityofdatainthe lit-erature.Forinstance,therearefewpublishedcasesforboth superficialanddeep-seatedinfections,including fungaemia (Table1).

Areviewofthemedicalliteratureindicatedthatthisreport representsthefirstisolationofC.laurentiifromthebloodof apatientwithcervicalneoplasiaunderradioand chemother-apy.AsystematicreviewbyKhawcharoenpornetal.5_showed

that non-neoformans and non-gattii cryptococcal infections occursporadically,withC.neoformansandCryptococcusalbidus

accountingfor80%ofthereportedcases.

DuetotherarityofcasesinvolvingC.laurentii,astandard treatmenthasnotyetbeenestablished.Commonly, ampho-tericinB withflucytosine isrecommended. However, azole derivatives havebeen used successfully insomecases5 _as

verifiedinthepresentcase.

Susceptible patients, especially those at risk due to immunosuppressivetherapies,mightinadvertentlycomeinto contact with such species and develop nosocomial infec-tions. Interestingly, it appears that C. laurentii, a non-C.

neoformansspecies,hasmanaged toexpandbeyondits nor-mal environmental niche to become a recognized human pathogen.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Authors’

contribution

RPNandDPCMconceivedthemanuscript,participatedinthe collection ofclinical data,molecular tests, andmanuscript writing;RGLNandVKASparticipatedinthecollectionof clin-icaldataandmanuscriptrevision;MCLandFAGSparticipated intheLaboratorialtechnicalsupportandmoleculartests.All authorsreadandapprovedthefinalmanuscript.

Acknowledgements

TheauthorswouldliketothankDepartmentofMycologyfrom

UniversidadeFederaldePernambuco,fortheirtechnicalsupport andkindassistance.Thisworkwassupportedbythe Coordi-nationofImprovementofHigherEducationPersonnel(CAPES) andNationalCouncilforScientificandTechnological Develop-ment(CNPq)/Brazil.

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