Disseminated Saprochaete capitata in a patient with Diabetes mellitus and HCV Hepatitis; A Case Report

Saprochaete capitata is yeast rarely causes human infections; nonetheless the vast majority of infections were reported in patients with hematological malignancy. Here, we report one of the unusually rare presentations of disseminated Saprochaete capitata in a patient without hematological malignancy, but the patient had a prolonged history of chronic active hepatitis C, diabetes mellitus, prolonged ICU stay on mechanical ventilation, and exposure to several antimicrobials. The currently isolated Saprochaete capitata showed resistance to amphotericin B, triazoles and ecchinocandins, but susceptible to 5-fluocytocine with MIC ≤1 mg/dl.


Introduction
Saprochaete capitata formerly called Geotrichum capitatum and Blastoschizomyces capitatus is related to fungi that rarely cause invasive human infections; when it does, usually in the immunocompromised individuals. Saprochaete capitata is widely spread in nature and can be isolated from soil, plants, water, and air. It can also be found in the digestive tract in humans and other mammals, and it may be found in food but never reported to cause disease through this route. The number of recorded Saprochaete capitata cases in English literature and related species so far are around 104 cases [1,2]. Disseminated Saprochaete capitata was reported in few case reports of single and five-case series, causing blood stream infection with severe sepsis syndrome, multi-organ failure, and mortality. Occasionally Saprochaete capitata is easily missed as Candida species for that they share the same epidemiology, the same predisposed host,and morphologically somehow not apparently different [3,4,5]. Uncommonly, a related species i.e.Geotrichum clavatum was also reported to cause disseminated infections in few patients with acute myeloid leukemia [6]. Saprochaete capitata breakthrough was also reported in patients suffering from hematological malignancy while being treated with echinocandin therapy; caspofungin was the agent used in those reports [7,8,9]. As knowledge regarding this fungus piles up, both fluconazole and ecchinocandins are recognized for being inadequate strategy as prophylactic or empirical antifungal treatment in patient with hematological malignancy when cases of Saprochaete capitata were found colonizing hematology unit and a potential threat to patients. Moreover, there is no consensus on the best antifungal regimen to prescribe in disseminated disease as it is resistant to most antifungal agents in clinical use [4].

Case report
A 78 years old female patient, she was admitted on 3 December 2014 to Al khalidi Hospital and Medical Centre, with the diagnoses of dementia, diabetes mellitus, and previously treated chronic HCV hepatitis. Eighteen months earlier she finished her pegylated interferon and ribavirin treatment. Her acute history dates back to five weeks when she was admitted to another general hospital not feeling well with decreased appetite, she developed sudden onset of nausea and vomiting, few hours later she lost her consciousness and was intubated for respiratory difficulty. She was diagnosed as having had an episode of diabetic ketoacidosis, spent more than two weeks in ICU and was managed to be extubated later. During her ICU stay she was treated as sepsis; suspected ventilator-associated pneumonia (VAP) due to Acinetobacter baummanni, and she was started on meropenem and colistin for 14 days. Blood culture grew yeast which was not characterized then.
On arrival to our hospital she was in deep coma with breathing difficulty, no spontaneous movements, puffy face, and mechanical ventilation was resumed; septic work up including blood cultures was commenced, she had pulmonary infiltrates that was progressively improving on daily radiological evaluation, with no stigmata of infective endocarditis. Initial laboratory finding upon admission showed: WBC: 19.7K HB: 7.6, Platelets 60K, INR: 2.18. Blood film showed normochromic anisocytosis with mild rouleaux formation, WBC's showed leucocytosis with neutrophilia, no immature cells seen, reduced platelets without clumps. Normal liver enzymes (ALT = 10 U/L and AST = 26 U/L), and normal liver ultrasound, abdominal CT scan showed "heterogeneous liver with spots of calcifications, no definite liver masses were detected". 2D-echocardiography was normal. Brain CT showed no focal brain changes, but wide spread brain atrophy and de-pneumatized sphenoid sinus filled with fluid and mucosal swelling. She was started on intravenous meropenem, four days later treatment with micafungin 100 mg/ day was added (weight = 75 Kg) when her aerobic blood cultures grew yeast, and it was evident from direct smear and gram-stained (Figure 1). After 43 hours of incubation in BacT-ALERT (Biomerieux S.A. Chemin de I'Orme 69280. Marcy I'Etoile, FRANCE) the yeast was identified as Saprochaete capitata, then meropenem was discontinued. Subculture on Sabouraud dextrose agar plate grew in 24 hours, and was processed in VITEK II (Biomerieux S.A. Chemin de I'Orme,69280. Marcy I'Etoile, FRANCE) using identification card. Susceptibility patterns showed resistance to the tested antifungals; amphotericinB (MIC ≥16 mg/dl), ecchinocandins (caspofungin MIC ≥ 4 mg/dl, micafungin MIC ≥ 4 mg/dl), fluconazole (MIC ≥ 4 mg/dl) and voriconazole (MIC = 4 mg/dl) but 5-fluocytosine was susceptible (MIC ≤1 mg/dl). The patient died eleven days after her admission, and seven days of micafungin treatment.

Discussion
Mazzocato and his coworkers reported in July 2014, their literature review between 1977 and August 2013, they identified 104 cases of Saprochaete capitata including their reported cases.They found that the patients' median age was 56 years, 56% were males, and half of them had acute myeloid leukemia, 22% with acute lymphoid leukemia, and 22% with other malignancies. The majority of patients (82%) were neutropenic at the time of diagnosis, and 75% of Saprochaete capitatawere isolated from blood. Mortality was about 60% and amphotericin was the mostly prescribed antifungal [2]. After their report, two cases were reported by other investigators as well as our current case [5,7]. Our patient did not have hematological malignancy like earlier reports, rather diabetes mellitus and HCV hepatitis as comorbidities. Initially, elsewhere the fungus was described as yeast, possibly Candida, which may have not been an uncommon occurrence in many microbiological laboratories; in our hospital automated processing revealed the true nature of the yeast as Saprochaete capitata [4].
The patient presented to us in coma and looking severely ill, next day she needed ventilator support and vasopressors. She met her demise suffering from multiorgans dysfunction and failure. Here, Saprochaete capitata isolate was resistant to the tested antifungals, this agrees with the previously published literature from different authors that disseminated infection with Saprochaete capitata is usually difficult to treat and carries high mortality [2,7,8]. This is one of the rare cases of disseminated Saprochaete capitata in a patient without hematological malignancy; however the patient had a prolonged ICU stay, mechanical ventilation, and was exposed to several antibacterials, which are known risk factors for acquiring invasive candidiasis [10,11]. Saprochaete capitata seemed to have smilar risk factors like invasive candidiasis. The patient was started on micafungin soon after blood culture revealed yeast; however it was too late for that she had previous untreated and persistent 'yeast' blood. infection [12]. It showed that starting antifungal therapy did not alter her expected poor prognosis though a repeat blood culture few days after antifungal therapy showed no growth of Saprochaete capitata or any other microorganism. Where Doctors exchange clinical experiences, review their cases and share clinical knowledge. You can also access lots of medical publications for free. Join Now! http://medicalia.org/

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