A case of Acremonium strictum peritonitis

ASLI GAMZE SENER*, MINE YUCESOY$, SECKIN SENTURKUN%, ILHAN AFSAR*, SUREYYA GUL YURTSEVER* &

MERAL TURK*

*Ataturk Training and Research Hospital Clinical Microbiology Department, $Dokuzeylul University Medical FacultyMicrobiology and Clinical Microbiology Department, and %Ataturk Training and Research Hospital Nephrology Department,Izmir, Turkey

During the past two decades opportunistic fungal infections have emerged as

important causes of morbidity and mortality in patients with severe underlying

illnesses. A few cases of Acremonium spp. infections have been described in

immunocompromised patients, but they have on occasion been reported as the

cause invasive disease in immunocompetent individuals. Peritonitis is a common

clinical problem that occurs in patients with end-stage renal disease treated by

continous ambulatory peritoneal dialysis (CAPD). Yeasts, or rarely molds, may

also cause peritonitis in patients on CAPD and we present here a case caused by

Acremonium strictum.

Keywords Acremonium strictum, opportunistic fungal infection, peritonitis

Introduction

Hyaline filamentous fungi which were previously un-

common as disease agents are increasingly encountered

as the cause of life threatening invasive infections thatare often refractory to conventional therapies [1].

Infections with fungi such as Acremonium species

have become significant problems in the treatment of

immunocompromised hosts [2]. Acremonium species

have been reported to be the cause of localized or

disseminated infections in patients with predisposing

conditions such as Addison’s disease, neutropenia,

immune suppression and intravenous drug abuse [3�5]. We present a case of a fungal peritonitis caused by

Acremonium strictum in patient undergoing continuous

ambulatory peritoneal dialysis (CAPD).

Case report

A 47-year-old woman with diabetes mellitus and

chronic renal failure was admitted to the nephrology

service of Ataturk Training and Research Hospital with

dimness in peritoneal dialysis fluid. The patient’s

primary diagnosis was hypertensive nephropathy of

eight years duration and she had been treated by

CAPD for five years. Abdominal pain was the main

complaint of the patient. Physical examination revealed

eudema in the pretibial region. Tension arterial and

pulses were normal. Biochemical findings were as

follows: hematocrit 29%; leucocyte count 10000/ml;

neutrophil count 7800/ml; eritrocyt sedimentation rate

109 mm/h; glucose 155 mg/dl; urea 92 mg/dl; and

transaminases ALT and AST of 8 and 6 U/l, respec-

tively. Leucocyte count was detected as 1,200/ml in

peritoneal dialysis fluid.

Cultures were inoculated with blood, nasal, perito-

neal dialysis fluid and catheter samples. Staphylococcus

aureus was recovered from the nasal specimens. In

addition leucocytes (1,200/ml) were detected in perito-

neal dialysis fluid. Nasal mupirocin and systemic

antibacterial therapy (cefazolin and ciprofloxacine)

were started. Fungal colonies were isolated in cultures

inoculated with peritoneal dialysis fluid.

Isolation and identification of Acremonium spp. were

performed in the laboratory of the Department of

Microbiology, Ataturk Training and Research Hospital.

Direct examination of the specimen of the peritoneal

dialysis fluid revealed hyphae and leucocytes. The

peritoneal fluid was cultured on sheep blood agar,

eosin-methylene-blue agar and Sabouraud dextrose

agar. After 4 days of incubation at 378C, mold colonies

were observed on all agar plates. Downy, pale-salmon

Correspondence: Asli Gamze Sener, Ataturk Training and Research

Hospital Microbiology and Clinical Microbiology Laboratory, Izmir,

35340 Turkey. E-mail: agsener@gmail.com

Received 25 September 2007; Accepted 7 December 2007

– 2008 ISHAM DOI: 10.1080/13693780701851729

Medical Mycology August 2008, 46, 495�497

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(orange/white) colored colonies were observed on Sa-

bouroud dextrose agar (SDA). On microscopic exam-

ination with lactophenol cotton blue, septate hyphae,

conidiogenous cells and needle-shaped awl phialides

were seen.This fungus was identified as Acremonium spp.

on the basis of its colony morphology and its morphol-ogy on microscopic observation of the lactophenol

cotton blue preparations (Figs. 1�3) and further identi-

fied as Acremonium strictum by Centers for Disease

Control and Prevention Fungus Reference Unit. Mole-

cular analysis was not performed. Oral fluconazole

(100 mg/day) and removal of the catheter resulted in

microbiologic and clinical cure.

Discussion

In the last few years there has been an increase in

mycoses caused by opportunistic fungal pathogens [6].

Species of the genus Acremonium are widespread soil

saprophytes which on rare occasions can be opportu-

nistic pathogens in immunosuppressed individuals [7�12]. Wang et al. [8] reported Ochroconis gallopavum

infection and Acremonium spp. peritonitis in a 13-year-

old renal transplant recipient. The patient failed to

respond to high dose amphotericin B therapy and died.

Chang et al. [9] reported a patient with leukemia who

developed pyomyositis due to Acremonium spp. They

successfully treated the patient with amphotericin B,

granulocyte colony-stimulating factor (G-CSF) and

surgical drainage. Disseminated Acremonium strictum

infection in a neutropenic patient was reported by

Schell and Perfect [10]. There are only a few reports for

disseminated Acremonium infections. Foell et al. [11]

presented a case of double fungal infection with

disseminated Acremonium strictum and pulmonary

Aspergillus fumigatus. They reported that the infections

were rapidly fatal despite neutrophil recovery and early

antifungal combination therapy with amphotericin B

and caspofungin. In another study, fungal infections of

dialysis fistulae were presented in two patients with

recurrent infections were presented. Staphylococcus

aureus and Acremonium species were isolated from the

thromboses of their grafts [12]. The authors suggested

amphotericin B therapy for fungal infections of dialysis

fistulae. However Mattei et al. [13] reported two cases

of Acremonium fungemia which were succesfully treated

with voriconazole with very mild toxicity. Peritonitis is

a frequent complication in patients with chronic renal

failure on continuous ambulatory peritoneal dialysis

(CAPD) treatment. Manzano-Gayosso et al. [14]

investigated the prevalence of fungal peritonitis on

patients undergoing CAPD. Specimens of the perito-

neal dialysis fluid from 165 patients on CAPD treat-

ment with peritonitis manifestations were submitted for

Fig. 1 Micromorphology of a colony of Acremonium strictum

(lactophenol cotton blue preparation).

Fig. 2 Micromorphology of a colony of Acremonium strictum

(lactophenol cotton blue preparation).

Fig. 3 Microscopic appearance of Acremonium strictum (colorless).

– 2008 ISHAM, Medical Mycology, 46, 495�497

496 Sener et al.

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mycological studies and Acremonium spp. were isolated

in two of the cases.Because reported cases are limited, optimal treat-

ment of Acremonium species infections is not well-

defined. In addition, conflicting results have been

obtained in different studies [3�5,15]. Early catheter

removal and prophylaxis have been suggested for

peritoneal dialysis patients with fungal peritonitis [16].

Chan et al. [17] have studied 290 patients on CAPD

and recommended that oral fluconazole was used asinitial therapy in all patients, which was followed by

catheter removal if peritonitis failed to improve. The

cure rate with fluconazole therapy alone without

catheter removal was 9.5% but when combined with

catheter removal, the cure rate increased to 66.7%.

They concluded that oral fluconazole can be safely

used as initial therapy in patients with fungal peritonitis

complicating CAPD. Warris et al. [18] reported a7-year-old boy with relapsed acute lymphatic leukae-

mia who developed fungaemia caused by Acremonium

strictum and amphotericin B and fluconazole were used

to treat the patient. General resistance to most

antifungals, excluding amphotericin B and ketocona-

zole has been reported [5]. Hence, amphotericin B

therapy, in combination with ketoconazole or another

new azole or allylamine, is advocated for Acremonium

infections [3�5,16,19].

Although Acremonium infection is rare in humans,

cases have been increased recently. This is due to recent

advances in medical technology that have led to

increased numbers of immunosuppressed patients,

receiving broad-spectrum antibiotics or having indwel-

ling medical devices [20].

We emphasize the importance of an active search forunusual organisms like Acremonium strictum in immu-

nodeficient patients and early specific treatment against

such microoganisms for the reduction of their morbid-

ity and mortality.

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This paper was first published online on iFirst on 5 March 2008.

– 2008 ISHAM, Medical Mycology, 46, 495�497

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