Pleuritis caused by Acremonium strictum in a patient with metastatic testicular teratocarcinoma

Dear Editor,

A 23-year-old boy was hospitalized for dyspnea with mild fever. Chest x-ray documented left pleural effusion. Cultures from thoracentesis grew out Acremonium strictum and intravenous liposomal amphotericin B was given at a dose of 200 mg daily. On treatment, fever subsided but dyspnea worsened. Whole-body CT scan showed multiple bilateral lung nodules, systemic lymphadenopathies and a mass over the left testis. Biopsies from an enlarged supraclavicular lymph node revealed metastatic testicular teratocarcinoma. Chemotherapy with PEB was started but, at day 70 from admission, the patient died of acute respiratory distress syndrome.

Acremonium (formerly Cephalosporium) species are filamentous fungi commonly found in soil and plants.¹Of note, cephalosporins were isolated from this class of hyphomycetes in 1951. In humans, they are rare opportunistic pathogens, mainly causing in immunocompetent individuals superficial infections such as foot mycetoma, keratitis and onychomycosis. Invasive infections are exceptional since only a dozen reports exist in the pertinent literature: such conditions usually occur in severely immunocompromised patients with hematologic diseases or solid tumors and include fungemia, meningitis, brain abscess, peritonitis and pyomyositis.^1-5 Pro-tracted neutropenia, corticosteroid therapy and the presence of a central venous catheter represent the principal predisposing factors.² As for the respiratory system, Acremonium strictum has been associated with two types of lesions: multiple bilateral nodules with no halo sign (4 cases) and pleuritis (2 cases including ours).^1-5 The prognosis of invasive infection from Acremonium spp. is usually unfavorable with a mortality rate of 30%.3 The reasons of such a poor outcome are related to the delay in diagnosis and specific therapy, lack of standard treatment because of the rarity of such infections, and the little susceptibility to the common antifungal agents such as fluconazole and flucytosine. Liposomal amphotericin B and the newer azoles such as posoconazole are the most effective drugs.²

REFERENCES

• ¹
  Nedret Koç A, Mutlu Sarigüzel F, Artis¸ T. Isolation of Acremonium strictum from pleural fluid of a patient with colon adenocarcinoma. Mycoses. 2009;52:190-2.
• ²
  Herbrecht R, Letscher-Bru V, Fohrer C, et al. Acremonium strictum pulmonary infection in a leukemic patient successfully treated with posaconazole after failure of amphotericin B. Eur J Clin Microbiol Infect Dis. 2002;21:814-7.
• ³
  Foell JL, Fischer M, Seibold M, et al. Lethal double infection with Acremonium strictum and Aspergillus fumigatus during induction chemotherapy in a child with ALL. Pediatr Blood Cancer. 2007;49:858-61.
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  López-Ruiz A, Queipo De Llano MP, Arana C, Palacios R. Acremonium spp. Pneumonia in a patient with acute myelogenous leukemia. Rev Clin Esp. 2012;212:326-7.
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  Boltansky H, Kwon-Chung KJ, Macher AM, Gallin JI. Acremonium strictum-related pulmonary infection in a patient with chronic granulomatous disease. J Infect Dis. 1984;149:653.

Publication Dates

• Publication in this collection
  May-Jun 2015

History

• Received
  25 Feb 2015
• Accepted
  02 Mar 2015