Disseminated Trichosporon asahii infection in a combined liver-kidney transplant recipient successfully treated with voriconazole.

INTRODUCTION: Trichosporon asahii is an emerging cause of systemic fungal infection in an immunocompromised host. Several life threatening disseminated T. asahii infection in single solid organ (liver or kidney) transplant recipients, in neutropenic and hematological malignancy patients have been reported. CASE PRESENTATION (METHODS AND RESULTS): A 49-year old gentleman who underwent simultaneous living-donor liver transplantation (donor sister) and kidney transplant (donor wife) developed fever and subsegmental patchy consolidation with right sided pleural effusion on fourth postoperative day. Central line blood stream infection was suspected. Blood culture grew creamy white colonies of T. asahii on blood agar with characteristic dirty-green colonies on CHROMagar. Laboratory analysis of pleural fluid also revealed budding yeast cells identified as T. asahii. Microscopy of the isolates showed hyphae, arthroconidia, and blastospores. The isolates were identified as T. asahii by VITEK MS which uses matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) technology. Initially liposomal amphotericin B and micafungin was initiated, but due to lack of clinical and microbiological response, patient was switched to voriconazole. Simultaneously, tacrolimus doses were reduced to one-third in view of interaction with voriconazole. Subsequently, patient improved with resolution of fever and microbiological cure. CONCLUSION: This is the first case report of disseminated T. asahii infection in a combined liver-kidney transplant recipient successfully treated with voriconazole. Azole antifungal are the promising drug of choice for systemic T. asahii infection. Drug interactions should be considered while using these antifungal agents.

Clinical manifestations of nocardiosis: Study of risk factors and outcomes in a tertiary care hospital.

PURPOSE: The aim of this study is to evaluate the predisposing risk factors, clinical presentations, laboratory parameters, and treatments taken and outcomes in patients of nocardiosis in the span of 5 years in a tertiary care hospital. MATERIALS AND METHODS: The patients whose specimens showed Nocardia like organism in Gram-staining, Kinyoun staining and characteristic colonies in culture were included in the retrospective analysis study. Retrospective analysis of associated risk factors, clinical presentations, and radiological findings was performed. RESULTS: Of the thirteen patients, 11 (76.9%) had immunosuppressive pathologies including solid organ transplantation, autoimmune disease, use of steroids, and immunosuppressive drugs as important risk factors. Four types of clinical manifestations were observed, pulmonary (46.1%), cutaneous (23.07%), cerebral (15.3%), and bacteremia (15.3%). The most common presentation was pulmonary with steroid therapy as a significant risk factor. Consolidation and pleural effusion were the common radiological findings in these cases. In eight of the nine patients anti-nocrdial drugs were given. Cotrimoxazole as monotherapy was given in four cases (44.44%), cotrimoxazole in combination with meropenem in two cases (22.22%); minocycline and linezolid were given in one case each. The overall mortality was 36.36% and was seen in patients with pulmonary nocardiosis. CONCLUSIONS: The study indicates that Nocardial infections are re-emerging on account of an increase in numbers of immunocompromised patients due to increased organ transplants, autoimmune diseases, malignancies, and use of immunosuppressive drugs and steroids. The diagnosis is often missed/not suspected and delayed because of the clinical resemblance to many other infections. Nocardial infection should be suspected and assessed particularly in immunocompromised patients not responding to treatment/improving clinically.