1
MYCOSES
35, 301-303 (1992)
ACCEPTED: JULY 10, 1992
CASEREPORT
Trichoderrna viride infection in a liver transplant recipient Infektion eines Lebertransplantierten durch Trichoderma viride F. Jacobs', B. By]], N. Bourgeois', J. Coremans-Pelseneer3, S. Florquin4, G. Depri', J. Van de Stadt2, M. Adler', M. Gelin' and J. P. Thys' Key words. Trichoderma viride, intra-abdominal infection, liver transplantation. Schliisselworter. Trichoderma viride, intraabdominale Infektion, Lebertransplantation.
Summary. A liver transplant recipient developed infection of a perihepatic haematoma due to Trichoderma uiride. Before the infection was diagnosed, the patient received intense immunosuppressive and prolonged an tibacterial and antifungal therapies. Although the death of the patient was not directly related to the fungal infection, abundant quantities of this pathogen were recovered in the haematoma at post-mortem examination, despite previous surgical removal and treatment with amphotericin B and fluconazole. Zusammenfassung. Der Empfanger eines Lebertransplantats entwickelte eine Infektion eines perihepatischen Hamatoms durch Trichoderma uiride. Bevor der Befund erstellt war, erhielt der Patient immunsuppressive Medikation in hoher Dosis und iiber einen langen Zeitraum antibakterielle und antimykotische Behandlung. Auch wenn der Tod des Patienten nicht in direktem Zusammenhang mit der Pilzinfektion stand, wurde der Erreger trotz vorheriger chirurgischer Drainage und intensiver Behandlung durch Amphotericin B und Fluconazol bei der Autopsie in groRer Menge im perihepatischen Hamatom vorgefunden. 'Infectious Diseases Clinic, 'Gastroenterology and Digestive Surgery Department, *Pathology Department, and 'Microbiology Department, Erasme University Hospital, and 3Laboratory of Parasitology, Free University of Brussels, Brussels, Belgium. Correspondence: Dr F. Jacobs, Infectious Diseases Clinic, HBpital Erasme, Route de Lennik 808, B-1070 Brussels, Belgium.
Introduction
During recent years, a n increasing number of fungal infections due to usually harmless microorganisms have been reported, occurring mainly in immunocompromised hosts. Infections due to colourless, septate, filamentous moulds adopting a hyphal form in human and animal tissues were named hyalohyphomycosis [ 1, 21. The number of organisms responsible for these infections is increasing. These include the genera Acremonium, Fusarium and Penicillium in most of the cases but many other fungi, most of which are abundant in the environment (mainly in soil), have been reported. Until now, only one case of Trichoderma uiride infection has been reported: a 44-year-old man on continuous ambulatory peritoneal dialysis died from T. viride peritonitis despite amphotericin B therapy [3]. We report here another case of invasive infection due to this pathogen in a liver transplant recipient. Case report
A 44-year-old woman underwent a liver transplantation (LTX) because of terminal alcoholic cirrhosis. Perioperative antimicrobial prophylaxis included cefotaxime and ampicillin for 48 h. Selective digestive decontamination by nonresorbable antibiotics (polymyxin, gen tamycin and nystatin) was given for 21 days. Immunosuppressive therapy consisted of cyclosporin A, azathioprine and steroids. A perihepatic haematoma was removed by surgery on day 2. In the
302
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ET AL.
month after LTX, broad-spectrum antibiotics (vancomycin and ciprofloxacin, followed by imipenem and gentamycin) were given for bacterial pneumonia and acute cholangitis. On day 31, a second LTX was performed because of hepatic artery thrombosis of the first graft. The same digestive decontamination was given for 21 days combined with antifungal prophylaxis by intravenous amphotericin B (25 mg every other day). A few days after surgery, the patient developed fever and her general clinical status worsened. Pancytopenia appeared. Perihepatic collections and lung infiltrates were found. Liver biopsy disclosed signs of rejection of the graft and the presence of giant cells, suggesting viral infection. The patient was treated with a combination of vancomycin, ciprofloxacin and gancyclovir, and higher doses of amphotericin B (50 mg daily for several days, then every other day) were added later. The rejection episode was treated with high-dose corticosteroids for 3 days. Blood cultures yielded Herpes simplex virus type 11. No other pathogen was found in the various fluid or tissue cultures. Gancyclovir was replaced by acyclovir, and only this last drug and amphotericin B were continued. From day 50, Trichoderma viride grew poorly on culture from the abdominal drainage fluid. The clinical status of the patient initially improved but from day 52, high fever and chills reappeared. Abdominal ultrasonography confirmed large perihepatic and perirenal collections. These collections were surgically removed. Direct examination for bacteria and fungi was negative, but culture yielded T. viride in moderate growth from all the intraabdominal specimens (Fig. 1). Amphotericin B was then continued at 50mg every other day. Clinical status improved and fever disappeared but T. viride was regularly found in fluids collected through abdominal drains. Amphotericin
Figure 1. Subcapsular haernatorna of the liver infected by hyphae of Trichodmna uiride (PAS staining, ~ 5 0 0 ) .
B was then replaced by intravenous fluconazole, 200 mg daily for the first 4 days, then reduced to 200 mg. every other day because of renal insufficiency (creatinine clearance 30 ml/min) . A new rejection episode was treated with high doses of steroids and by OKT3 monoclonal antibody for 14 days. On day 77, the patient was admitted to the intensive care unit because of acute respiratory distress due to a large necrotic mass of the larynx, ultimately diagnosed as laryngeal neoplasia. The general status of the patient did not allow any curative therapy of her malignant tumour. The patient died on day 91. Post-mortem examination confirmed a poorly differentiated epidermoid laryngeal carcinoma with metastatic cervical lymph nodes. Abdominal examination showed a persistent perihepatic haematoma in which abundant quantities of hyphae of T. viride were found (Fig. 1). Cultures of the haematoma were positive for this fungus. T. viride was not documented either by pathological examination or by culture from any other site. In vitro sensitivities of the different antimycotic drugs were performed later with the strain obtained a few days after laparotomy (day 62)) before treatment with fluconazole. The minimum inhibitory concentrations (MIC) were determined by broth dilution test: 1.2 x lo3 spores/ml were incubated at 28°C for 2 days with various concentrations of dissolved antimycotic drugs (50 to 0.2 pg/ml). The MIC for fluconazole, ketoconazole, itraconazole, amphotericin B and 5-fluorocytosine were respectively 25,0.8, 1.6, 3.1 and > 50 pg/ml. This in vitro resistance of the fungus to fluconazole and 5-fluorocytosine and the sensitivity to the other antimycotics tested was confirmed by agar dilution and agar diffusion tests.
Discussion Trichoderma is a fungus with worldwide distribution. It has been isolated mainly from plant material but also from different fomites. It is characterized by very fast growth. The strain isolated from the patient described grew at 25 "C, 37 "C and even slowly at 45 "C. Colonies are first hyaline, becoming green when spores are formed. Microscopically, conidiophores are repeatedly branched in divergent tufts, characteristic of the genus Trichoderma. Conidiophores may end in sterile appendages. Phialides are ninepin-shaped (8-14 pm x 2.5-3 pm) (Fig. 2). Conidia are green, ovoid and slightly rough (4.5-5 pm x 2.5-3 pm) . Chlamydospores are terminal or intercalate and smooth-walled (8-10 pm). These sizes, as well as the slightly rough phialospores,
mycoses 35, 30 1-303 ( 1992)
TRICHODERMA VIRIDE INFECTION
Figure 2.
Trichodcrma viridc in culture. Ninepin-shaped phialides with spore “aggregates” and sterile appendages.
highly suggest the fungus to be Trichoderma viride [4,51. Immunosuppression is a major risk factor for the development of usually non-pathogenic fungi. Our patient had been aggressively immunosuppressed because of many acute rejection episodes of her liver graft, treated with high-dose corticosteroids and OKT3 monoclonal antibody. Prolonged treatments with antibacterial agents including broad-spectrum parenteral and nonresorbable antibiotics increased the risk for fungal infection. In this setting, particular attention is warranted when unusual pathogens are found, even in specimens in which contamination by a ubiquitous agent is frequent (as in fluids obtained from abdominal drainage). The route of contamination in our patient is not known. No other case of T. viride infection occurred in our hospital. Contamination of the second liver graft before transplantation or operative contamination of the surgical field are both possible hypotheses. Contamination of the haematoma by ascending colonization of the abdominal drain seems less likely, since only a few colonies were found in culture of the abdominal fluid, contrasting with more abundant culture in the haematoma. In our patient, death was not directly related to fungal infection. However,
mycoses 35, 301-303 (1992)
303
T. viride was still abundantly found at postmortem examination. A failure was observed with amphotericin B despite in vitro sensitivity. The poor response observed at the beginning of the treatment by this drug might be explained by the absence of drainage of the infected haematoma. However, after the surgical procedure, T. viride was recovered more abundantly despite complete removal of infected tissues and adequate treatment with amphotericin B. The poor results observed with fluconazole may, by contrast, be correlated with the in uitro resistance to this drug. In conclusion, clinicians should. be aware of the possible clinical role of usually nonpathogenic fungi, mainly in immunocompromised hosts. The persistence of T. viride in our patient, in vitro sensitive to amphotericin B, despite treatment with this drug and surgical removal of the infected haematoma must be noted. Acknowledgements The authors wish to thank Professor A. Wildfeuer, Illertissen, Germany, for performing the sensitivity tests.
References Ajello, L. ( 1986) Hyalohyphomycosis and phaehyphomycosis: two global disease entities of public health importance. Eur. 3. Epidemiol. 2, 243-25 1. Loeppky, C. B., Sprouse, R . F., Carlson, J. V. & Everett, E. D. (1983) ‘Trichodermn viride peritonitis. South Med. 3. 76, 789-799. Warnock, D. W. & Johnson, E. M. (1991) Clinical manifestations and management of hyalohyphomycosis, phaehyphomycosis and other uncommon forms of fungal infection in the compromised patient. In: Warnock, D. W. & Richardson, M. D. (eds) Fungal Infection in the Compromised Patient. Chichester: John Wiley & Sons Ltd, pp. 248-310. Domsch, K. H., Gams, W. & Anderson, T. H. (1980) Compendium of Soil Fungi. London: Academic Press, pp. 794-809. Rifai, M. A. (1969) A Revision of the Genus Trichoderma. MyCol. PUP. 116, 1-56.
MYCOSES
35, 301-303 (1992)
ACCEPTED: JULY 10, 1992
CASEREPORT
Trichoderrna viride infection in a liver transplant recipient Infektion eines Lebertransplantierten durch Trichoderma viride F. Jacobs', B. By]], N. Bourgeois', J. Coremans-Pelseneer3, S. Florquin4, G. Depri', J. Van de Stadt2, M. Adler', M. Gelin' and J. P. Thys' Key words. Trichoderma viride, intra-abdominal infection, liver transplantation. Schliisselworter. Trichoderma viride, intraabdominale Infektion, Lebertransplantation.
Summary. A liver transplant recipient developed infection of a perihepatic haematoma due to Trichoderma uiride. Before the infection was diagnosed, the patient received intense immunosuppressive and prolonged an tibacterial and antifungal therapies. Although the death of the patient was not directly related to the fungal infection, abundant quantities of this pathogen were recovered in the haematoma at post-mortem examination, despite previous surgical removal and treatment with amphotericin B and fluconazole. Zusammenfassung. Der Empfanger eines Lebertransplantats entwickelte eine Infektion eines perihepatischen Hamatoms durch Trichoderma uiride. Bevor der Befund erstellt war, erhielt der Patient immunsuppressive Medikation in hoher Dosis und iiber einen langen Zeitraum antibakterielle und antimykotische Behandlung. Auch wenn der Tod des Patienten nicht in direktem Zusammenhang mit der Pilzinfektion stand, wurde der Erreger trotz vorheriger chirurgischer Drainage und intensiver Behandlung durch Amphotericin B und Fluconazol bei der Autopsie in groRer Menge im perihepatischen Hamatom vorgefunden. 'Infectious Diseases Clinic, 'Gastroenterology and Digestive Surgery Department, *Pathology Department, and 'Microbiology Department, Erasme University Hospital, and 3Laboratory of Parasitology, Free University of Brussels, Brussels, Belgium. Correspondence: Dr F. Jacobs, Infectious Diseases Clinic, HBpital Erasme, Route de Lennik 808, B-1070 Brussels, Belgium.
Introduction
During recent years, a n increasing number of fungal infections due to usually harmless microorganisms have been reported, occurring mainly in immunocompromised hosts. Infections due to colourless, septate, filamentous moulds adopting a hyphal form in human and animal tissues were named hyalohyphomycosis [ 1, 21. The number of organisms responsible for these infections is increasing. These include the genera Acremonium, Fusarium and Penicillium in most of the cases but many other fungi, most of which are abundant in the environment (mainly in soil), have been reported. Until now, only one case of Trichoderma uiride infection has been reported: a 44-year-old man on continuous ambulatory peritoneal dialysis died from T. viride peritonitis despite amphotericin B therapy [3]. We report here another case of invasive infection due to this pathogen in a liver transplant recipient. Case report
A 44-year-old woman underwent a liver transplantation (LTX) because of terminal alcoholic cirrhosis. Perioperative antimicrobial prophylaxis included cefotaxime and ampicillin for 48 h. Selective digestive decontamination by nonresorbable antibiotics (polymyxin, gen tamycin and nystatin) was given for 21 days. Immunosuppressive therapy consisted of cyclosporin A, azathioprine and steroids. A perihepatic haematoma was removed by surgery on day 2. In the
302
F. JACOBS
ET AL.
month after LTX, broad-spectrum antibiotics (vancomycin and ciprofloxacin, followed by imipenem and gentamycin) were given for bacterial pneumonia and acute cholangitis. On day 31, a second LTX was performed because of hepatic artery thrombosis of the first graft. The same digestive decontamination was given for 21 days combined with antifungal prophylaxis by intravenous amphotericin B (25 mg every other day). A few days after surgery, the patient developed fever and her general clinical status worsened. Pancytopenia appeared. Perihepatic collections and lung infiltrates were found. Liver biopsy disclosed signs of rejection of the graft and the presence of giant cells, suggesting viral infection. The patient was treated with a combination of vancomycin, ciprofloxacin and gancyclovir, and higher doses of amphotericin B (50 mg daily for several days, then every other day) were added later. The rejection episode was treated with high-dose corticosteroids for 3 days. Blood cultures yielded Herpes simplex virus type 11. No other pathogen was found in the various fluid or tissue cultures. Gancyclovir was replaced by acyclovir, and only this last drug and amphotericin B were continued. From day 50, Trichoderma viride grew poorly on culture from the abdominal drainage fluid. The clinical status of the patient initially improved but from day 52, high fever and chills reappeared. Abdominal ultrasonography confirmed large perihepatic and perirenal collections. These collections were surgically removed. Direct examination for bacteria and fungi was negative, but culture yielded T. viride in moderate growth from all the intraabdominal specimens (Fig. 1). Amphotericin B was then continued at 50mg every other day. Clinical status improved and fever disappeared but T. viride was regularly found in fluids collected through abdominal drains. Amphotericin
Figure 1. Subcapsular haernatorna of the liver infected by hyphae of Trichodmna uiride (PAS staining, ~ 5 0 0 ) .
B was then replaced by intravenous fluconazole, 200 mg daily for the first 4 days, then reduced to 200 mg. every other day because of renal insufficiency (creatinine clearance 30 ml/min) . A new rejection episode was treated with high doses of steroids and by OKT3 monoclonal antibody for 14 days. On day 77, the patient was admitted to the intensive care unit because of acute respiratory distress due to a large necrotic mass of the larynx, ultimately diagnosed as laryngeal neoplasia. The general status of the patient did not allow any curative therapy of her malignant tumour. The patient died on day 91. Post-mortem examination confirmed a poorly differentiated epidermoid laryngeal carcinoma with metastatic cervical lymph nodes. Abdominal examination showed a persistent perihepatic haematoma in which abundant quantities of hyphae of T. viride were found (Fig. 1). Cultures of the haematoma were positive for this fungus. T. viride was not documented either by pathological examination or by culture from any other site. In vitro sensitivities of the different antimycotic drugs were performed later with the strain obtained a few days after laparotomy (day 62)) before treatment with fluconazole. The minimum inhibitory concentrations (MIC) were determined by broth dilution test: 1.2 x lo3 spores/ml were incubated at 28°C for 2 days with various concentrations of dissolved antimycotic drugs (50 to 0.2 pg/ml). The MIC for fluconazole, ketoconazole, itraconazole, amphotericin B and 5-fluorocytosine were respectively 25,0.8, 1.6, 3.1 and > 50 pg/ml. This in vitro resistance of the fungus to fluconazole and 5-fluorocytosine and the sensitivity to the other antimycotics tested was confirmed by agar dilution and agar diffusion tests.
Discussion Trichoderma is a fungus with worldwide distribution. It has been isolated mainly from plant material but also from different fomites. It is characterized by very fast growth. The strain isolated from the patient described grew at 25 "C, 37 "C and even slowly at 45 "C. Colonies are first hyaline, becoming green when spores are formed. Microscopically, conidiophores are repeatedly branched in divergent tufts, characteristic of the genus Trichoderma. Conidiophores may end in sterile appendages. Phialides are ninepin-shaped (8-14 pm x 2.5-3 pm) (Fig. 2). Conidia are green, ovoid and slightly rough (4.5-5 pm x 2.5-3 pm) . Chlamydospores are terminal or intercalate and smooth-walled (8-10 pm). These sizes, as well as the slightly rough phialospores,
mycoses 35, 30 1-303 ( 1992)
TRICHODERMA VIRIDE INFECTION
Figure 2.
Trichodcrma viridc in culture. Ninepin-shaped phialides with spore “aggregates” and sterile appendages.
highly suggest the fungus to be Trichoderma viride [4,51. Immunosuppression is a major risk factor for the development of usually non-pathogenic fungi. Our patient had been aggressively immunosuppressed because of many acute rejection episodes of her liver graft, treated with high-dose corticosteroids and OKT3 monoclonal antibody. Prolonged treatments with antibacterial agents including broad-spectrum parenteral and nonresorbable antibiotics increased the risk for fungal infection. In this setting, particular attention is warranted when unusual pathogens are found, even in specimens in which contamination by a ubiquitous agent is frequent (as in fluids obtained from abdominal drainage). The route of contamination in our patient is not known. No other case of T. viride infection occurred in our hospital. Contamination of the second liver graft before transplantation or operative contamination of the surgical field are both possible hypotheses. Contamination of the haematoma by ascending colonization of the abdominal drain seems less likely, since only a few colonies were found in culture of the abdominal fluid, contrasting with more abundant culture in the haematoma. In our patient, death was not directly related to fungal infection. However,
mycoses 35, 301-303 (1992)
303
T. viride was still abundantly found at postmortem examination. A failure was observed with amphotericin B despite in vitro sensitivity. The poor response observed at the beginning of the treatment by this drug might be explained by the absence of drainage of the infected haematoma. However, after the surgical procedure, T. viride was recovered more abundantly despite complete removal of infected tissues and adequate treatment with amphotericin B. The poor results observed with fluconazole may, by contrast, be correlated with the in uitro resistance to this drug. In conclusion, clinicians should. be aware of the possible clinical role of usually nonpathogenic fungi, mainly in immunocompromised hosts. The persistence of T. viride in our patient, in vitro sensitive to amphotericin B, despite treatment with this drug and surgical removal of the infected haematoma must be noted. Acknowledgements The authors wish to thank Professor A. Wildfeuer, Illertissen, Germany, for performing the sensitivity tests.
References Ajello, L. ( 1986) Hyalohyphomycosis and phaehyphomycosis: two global disease entities of public health importance. Eur. 3. Epidemiol. 2, 243-25 1. Loeppky, C. B., Sprouse, R . F., Carlson, J. V. & Everett, E. D. (1983) ‘Trichodermn viride peritonitis. South Med. 3. 76, 789-799. Warnock, D. W. & Johnson, E. M. (1991) Clinical manifestations and management of hyalohyphomycosis, phaehyphomycosis and other uncommon forms of fungal infection in the compromised patient. In: Warnock, D. W. & Richardson, M. D. (eds) Fungal Infection in the Compromised Patient. Chichester: John Wiley & Sons Ltd, pp. 248-310. Domsch, K. H., Gams, W. & Anderson, T. H. (1980) Compendium of Soil Fungi. London: Academic Press, pp. 794-809. Rifai, M. A. (1969) A Revision of the Genus Trichoderma. MyCol. PUP. 116, 1-56.
