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Indian Journal of Nephrology
Indian J Nephrol 2004;14: 22-24
CASEREPORT
Subcutaneous abscess caused by coelomycetous fungus Pleurophomopsis lignicola in a renal transplant recipient S Verghese*, P Ravichandran ** *Institute of Cardio-vascular Diseases, Mogappair, **Institute of Orthopeadics & Traumatology, Chennai
Abstract We report an unusual case of phaeohyphomycosis caused by Pleurophomopsis lignicola in a renal transplant recipient which presented as a subcutaneous cystic lesion on the foot. Key Words: Pleurophomopsis lignicola , phaeohyphomycotic cyst
Introduction Agents that cause subcutaneous phaeohyphomycotic infection are primarily soil saprophytes and plant pathogens. Of these, the common agents causing human infections belong to the genera Bipolaris , Alternaria, Curvularia and Exerohilum. Coelomycetous fungi are rare agents involved in subcutaneous disease in man.
Case History A 54 year old male patient from Bihar (India) was referred for kidney transplantation for renal failure following chronic glomerulonephtritis. His investigations revealed anaemia and raised hepatic enzymes. He was positive for HbsAg and Hbe Ag. He had a BP of 160/100 and was a non diabetic, with no history of joint pains or fever. He had no past history of tuberculosis or diabetes. His chest X Ray and ECG were normal, ECHO showed left ventricular hypertrophy with diastolic dysfunction. The patient was continued on haemo-dialysis and after evaluation a liver biopsy was done which showed signs of chronic active hepatitis. After the liver enzymes came to normal, a renal transplantation was performed. Post transplant he was maintained on steroids and cyclosporine. His immediate post- operative period was uneventful. Two weeks after discharge he was admitted for giddiness and poor vision. On evaluation he was found to be a Address for Correspondence: Dr S. Verghese, Institute of Cardio-vascular Diseases, Madras Medical Mission, R 30C Ambattur Industrial Estate Road, Chennai – 600 101 E.mail :
[email protected] Copyright © 2004 by The Indian Society of Nephrology
diabetic with a blood sugar of 600mg/ dl and a diagnosis of post transplant diabetes was made. His diabetes was brought under control using human insulin. He was on regular follow up. Six months after transplantation he came with a history of swelling on the foot that was not painful and was fluctuant with a history of low grade fever of one month‘s duration. Excision of the whole cyst was done and he was started on Amphotericin B for the fungal infection and antituberculous treatment as he was diagnosed as pulmonary tuberculosis also. The diagnosis of pulmonary tuberculosis was based on sputum positivity for acid fast bacilli and chest X ray findings. He received a total of 275mgs of Amphotericin B after which he discontinued the Amphotericin B due to worsening liver functions. He died within in six months due to sepsis secondary to pneumonia at his native place .The exact cause of death was not known. Microbiological culture The cystic lesion was incised and it had a thick purulent material. KOH mounts revealed branched phaeoid septate hyphae amidst numerous pus cells . It also stained partially on Gram stain.(Fig:1) It was cultured on all routine media , like blood agar, Mac Conkey agar, Sabourard‘s dextrose agar, at 37oC and room temperature and all broth media such as nutrient broth ,thioglycollate broth, and Sabourard‘s dextrose broth at two temperatures(37oC& room temperature). It produced a slow growing greyish black pigmented mycelial colony after 72 hours of incubation which did not sporulate on any routine media. There
Indian J Nephrol 2004;14: 22-24
Subcutaneous coelomycetous Fungul abscess in RT
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Figure 1: Gram Stain shows pigmented septate hyphae with round cells seen along with pus cells X1000.
was no growth of any bacterial agent from the pus. It was also cultured for M tuberculosis on LJ medium and there was no growth at the end of 8 weeks. Slide cultures done on SDA and corn meal agar did not show any sporulation even after 2 to 4 weeks. The culture was sent to Dr Padhye, Center for Disease Control and Prevention , Atlanta, Georgia, for further identification. It was identified as Pleurophomopsis lignicola .
Discussion Agents that cause subcutaneous phaeohyphomycotic infections are primarily soil saprophytes, and plant pathogens or environmental contaminants . More than 130 species belonging to over 70 diverse genera are known to be agents of phaeohyphomycosis. 1 At present 25 species belonging to 12 Coelomycetous genera are known to cause opportunistic infections. 2,3.These coelomycetous fungi cause a variety of human infections including onychomycosis, sinusitis , osteomyelitis , fungemia and eumycotic black grain mycetomas.1 The majority of systemic infections occur in immunocompromised patients frequently through traumatic implantation. Coelomycetous fungi are rare agents involved in subcutaneous disease in man. They belong to the genera Phoma, Phomopsis, Pleurophoma, Pleurophomopsis and Pyrenocheta. At present the genus Pleurophomopsis includes seven species which are all known plant pathogens. Only P lignicola is known to cause infections in humans. They are introduced persumably through traumatic implantation into the subcutaneous tissue. Our patients‘s immuno-suppression due to diabetes and anti-rejection drugs after transplantation were the likely risk factors for this opportunistic fungal infection.
Pleurophomopsis lignicola produce velvety olivaceous grey to black mycelial colony at 37oC and 25oC.They do not sporulate on any routine laboratory media. The pycnidial formation needs special growth conditions such as selective medium like oat meal agar and exposure to ultraviolet light ( black light) alternating with equal periods of darkness. Conidiophores and conidia are produced inside pycnidia . These pycnidia are scattered on the surface and some were partially immersed in the agar. They are reddish brown, subglobose and chiefly uninucleate. These pycnidia measure 200 to 250m wide and 300 to 600m in length. The conidia are hyaline , cylindrical and aseptate. During the last five years , P lignicola has been reported as a causal agent of a subcutaneous cyst on the left leg of a patient from France , who was treated with corticosteroids for asthma.4 The second infection was reported from Italy in a kidney transplant recipient who developed a soft tissue abscess and subcutaneous tibiofibular fistula on his left leg.5 In United States , P lignicola was reported to cause allergic , non invasive , maxillary sinusitis in an immuno-competent 59 year old male patient after cutting down a rotten maple tree.6 Other similar agents which are known to cause human infections belong to the genus Phomopsis and several species of Phoma.7,8,9. The treatment for phaeohypomycotic infection is complete excision and antifungal therapy. Our patient was started on amphotericin B. He died within 6 months due to sepsis associated with pulmonary infection. The effects of azoles against subcutaneous phaeohyphomycotic infection has not been fully established. But in-vitro data suggests that Itraconazole may be an effective drug for treatment of coeleomycetous fungi4 Copyright © 2004 by The Indian Society of Nephrology
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Indian Journal of Nephrology
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This unusual case is being reported as it is possible that many of these infections may go undiagnosed as these fungi are difficult to identify by routine laboratory procedures.
Acknowledgement The authors are deeply grateful to Dr. AA Padhye, PhD, Chief, Fungus Reference Laboratory, Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, for identification of the fungus.
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Copyright © 2004 by The Indian Society of Nephrology
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