Successful treatment of cutaneous protothecosis with fluconazole: A case report and epidemiology study of Prototheca infection in China.

BACKGROUND: Protothecosis is an infection of humans and animals caused by a rare conditionally pathogenic fungus (prototheca). It can occur in immunocompromised or normal patients. AIMS: To describe the epidemiology of prototheca infection in China. METHODS: We report a case of successful treatment of cutaneous protothecosis with fluconazole and analyzed the epidemiological characteristics, risk factors, clinical manifestations, diagnosis, treatment and prognosis of prototheca infections in China. RESULTS: We describe this case and 29 cases of prototheca infections in China. At present, Prototheca wickerhamii (Pw) infection is the most common infection in China, and single or combined itraconazole is the preferred treatment. CONCLUSIONS: These results provide detailed information and relevant clinical treatment strategies for the diagnosis and treatment of protothecosis in China.

Protothecosis in the mucosa of the pharynx mimicking pharyngeal cancer in an immunocompetent individual: a case report.

BACKGROUND: Protothecosis is a rare infection in humans and animals caused by the achlorophyllic algae Prototheca species. More than half of the protothecosis cases are cutaneous infections, and most cases are observed in immunocompromised individuals. CASE PRESENTATION: We report a case of Prototheca wickerhamii infection in the mucosa of the pharynx in a 53-year-old immunocompetent woman with an incidentally found mass lesion at the left tongue base. Histopathological findings of the mass lesion suggested cryptococcosis, but P. wickerhamii was identified from the oropharynx scrape culture based on DNA sequencing. After surgical resection, fosfluconazole treatment was initiated, and subsequently, treatment was switched to topical amphotericin B. The residual mass lesion did not deteriorate during the 4-month antifungal treatment and 1-year observational period. CONCLUSIONS: Prototheca species can be easily misdiagnosed as yeasts because of their morphological and pathological similarities. Prototheca, in addition to Cryptococcus should be considered if slow-growing, large Gram-positive organisms are encountered. Lactophenol cotton blue staining of the colony helps distinguish these organisms. Further study is needed to determine the appropriate treatment according to the infection focus.

Prototheca bovis, a unicellular achlorophyllous trebouxiophyte green alga in the healthy human intestine.

Introduction. Prototheca species are non-photosynthetic trebouxiophyte algae ubiquitously distributed in nature and can be found in sewage and soil. This microbial eukaryote causes human protothecosis in immunocompromised individuals. Thus, Prototheca presence in the stool of individuals without gastrointestinal symptoms has been reported only rarely.Hypothesis/Gap statement. There is an absence of detailed characterization of human Prototheca isolates.Aim. The aim of this study was to perform morphological and molecular characterization of Prototheca isolates obtained from human stool.Methodology. Prototheca was isolated from faecal samples of four individuals living in a rural area in Thailand. A combination of bioimaging along with molecular and bioinformatics tools was used to characterize the four strains. The growth rate was tested using four media and three temperature conditions. Phylogenetic analysis using the small subunit ribosomal RNA (SSU rRNA) and cytochrome b (cytb) was also performed.Results. Static and live microscopy demonstrated the various life stages of Prototheca and its major defining cellular characteristics. An optimized DNA extraction methodology that improves DNA yield is provided. Partial fragments of the SSU rRNA and cytb genes were obtained. Phylogenetic analysis placed all four strains in the clade with Prototheca bovis. More broadly, Prototheca was not monophyletic but split into at least two distinct clades instead.Conclusion. The results represent the first molecular characterization of Prototheca in Thailand. The study provides insight into transmission dynamics of the organism and potential caveats in estimating the global prevalence of Prototheca. These will spearhead further investigations on Prototheca occurrence in rural areas of both industrialized and developing nations.

A novel TaqMan qPCR assay for rapid detection and quantification of pro-inflammatory microalgae Prototheca spp. in milk samples.

Animal or human protothecosis belongs to rather rare, endemic, pro-inflammatory infections. It is caused by achlorophyllous algae of the genus Prototheca. Especially, P. bovis (formerly P. zopfii genotype 2) is often inflected as a non-bacterial causative agent of dairy cattle mastitis. In this study, we present a multiplex real-time PCR (qPCR) system for rapid and exact Prototheca spp. detection and quantification. Limit of detection, diagnostic sensitivity, and specificity were determined. For the first time, specific sequences of AccD (encoding acetyl CoA reductase) for P. bovis, cox1 (encoding cytochrome C oxidase subunit 1) for P. wickerhamii, cytB (encoding cytochrome B) for P. blashkeae and atp6 (encoding transporting ATPase F0 subunit 6) for P. ciferrii (formerly P. zopfii genotype 1) were used for species identification and quantification together with 28S rRNA sequence detecting genus Prototheca. The developed qPCR assay was applied to 55 individual cow milk samples from a herd suspected of protothecosis, 41 bulk milk samples from different Czech farms, 16 boxed milk samples purchased in supermarkets and 21 environmental samples originating from a farm suspected of protothecosis. Our work thus offers the possibility to diagnose protothecosis in the samples, where bacterial mastitis is the most commonly presumed and thereby assisting adequate corrective measures to be taken.

Molecular characterization of Prototheca in 11 symptomatic dogs.

Protothecosis is an uncommon disease caused by algae of the genus Prototheca. In dogs, the infection is usually first localized to the colon but has the propensity to later disseminate hematogenously to many other organs, with marked tropism for the eyes and central nervous system. Diagnosis is established by culture and/or evidence of Prototheca organisms in cytologic or histologic preparations. Species characterization, however, requires molecular investigations. Our laboratory set up a real-time PCR targeting portion D1/D2 of the 28S rRNA for identification of Prototheca species from both positive cultures (of rectal swabs and urine) and formalin-fixed, paraffin-embedded tissue. Prototheca bovis, P. ciferrii, and P. wickerhamii were characterized in 11 dogs with systemic or cutaneous protothecosis. Prototheca identifications were phylogenetically consistent with the new taxonomy proposed for this genus based on the mitochondrial cytochrome b gene. As a pilot study, we screened feces and rectal scrapes from 200 asymptomatic dogs, using 2 cohorts of stray and owned animals, to determine the prevalence of intestinal carriage of Prototheca spp. The Prototheca-negative results from both cohorts of healthy dogs suggest that predisposing factors related to the host probably contribute more to the acquisition of clinical disease than exposure to contaminated environments.

Prototheca from bovine milk and associated minimal algaecide concentration of chlorhexidine and povidone-iodine in Taiwan.

OBJECTIVE: Protothecal mastitis has emerged and affected the dairy industries globally in last decades; however, little is known about the occurrence of Prototheca in Taiwan. The present study identified the Prototheca isolated from bovine milk and revealed the algaecide efficacy of 2 disinfectants. MATERIAL AND METHODS: From 2011 to 2014, a total of 176 Prototheca isolates were obtained from 10 625 milk samples collected from dairy cows in 24 Taiwanese dairy farms. Of these, 149 isolates were identified by biochemical tests and genotype differentiation with a specific PCR protocol. Minimal algaecide concentration (MAC) of chlorhexidine and povidone-iodine were obtained from 16 isolates by microdilution method. RESULTS: Almost all (n = 147) isolates were P. zopfii, and remaining 2 isolates were P. wickerhamii and unidentified, respectively. Based on molecular genotyping, all P. zopfii isolates belonged to genotype 2. The MAC of 2 commonly used disinfectants, chlorhexidine and povidone-iodine, against 16 P. zopfii isolates was 1.56-3.13 and 48.83-390.63 µg/ml, respectively. CONCLUSION: This report revealed for the first time the prevalence and the predominant P. zopfii genotype 2 of bovine protothecal infection in Taiwan. In vitro algaecide efficacy indicated that both tested disinfectants were effective against P. zopfii.

[Disseminated protothecosis with ulcerative granulomatous colitis in a Rhodesian Ridgeback from Germany]. / Ulzerative granulomatöse Kolitis durch Prototheca spp. bei einem Rhodesian Ridgeback in Deutschland.

A 10-month-old male Rhodesian Ridgeback was presented to the Clinic of Small Animal Medicine, LMU, Germany, with a 6-month history of chronic diarrhea and hematochezia. The dog lived in Germany and had never traveled abroad. Complete blood count and serum biochemistry performed by the referring veterinarian revealed neutrophilia, hyperkalemia, and hyponatremia, with a basal cortisol of 4.3 µg/dl, which excluded hypoadrenocorticism. Since antibiotic treatment had not resulted in any improvement, a 2 week course of prednisolone administration had been initiated, leading to a marked deterioration of intestinal signs and a significant weight loss of 6 kg. At the time of referral, the patient was markedly emaciated, dehydrated, hypovolemic and had a rectal temperature of 39.6 °C. Abdominal ultrasound showed a thickened and irregular colonic wall. On colonoscopy, an irregular colonic mucosa with ulcerations was observed. Histopathologic examination revealed an ulcerative granulomatous colitis, and on Periodic acid-Schiff reaction (PAS) numerous organisms consistent with Prototheca spp. were identified. Prototheca zopfii infection was confirmed by culture and MALDI-TOF MS. In order to test for an underlying immunodeficiency, immunoglobulin levels in serum were determined. IgM was decreased, while IgG and IgA levels were within the reference interval. Due to deterioration of general condition, grave prognosis and costs of a treatment trial, the patient was euthanized one week later, and necropsy was performed. Prototheca spp. were detected on histopathologic examination in the lymphnodes, however not in the eyes or the central nervous system. Protothecosis should be considered an differential diagnosis in dogs with chronic diarrhea and ulcerative granulomatous colitis even in dogs living in Germany. Histopathologic examination of colonic biopsies with special stains such as PAS is recommended in every dog with signs of chronic large bowel disease in order to avoid missing this rare infectious disease.

Multiple cutaneous infections caused by Prototheca wickerhamii.

BACKGROUND: Prototheca species are a group of organisms ubiquitously existing in nature but have become a pathogenic threat to public health, which has aroused wide attention. Species identification and antifungal susceptibility have essential and valuable meanings to clinical diagnosis and treatment. METHODS: A case of an 84-year-old patient who had suffered from multiple cutaneous infections was reported. Tissue samples of the damaged skin were collected from the patient and used for microscopic examination and tissue culture. Staining methods, the VITEK system with YSD card and the molecular identification method based on partial mitochondrion-encoded cytochrome b (cytb) gene amplification and sequencing were used for species identification. Antifungal susceptibility testing was completed by using YeastOne plate. RESULTS: The patient had type II diabetes mellitus. Round, grape-like, and scattered morula forms were observed under the microscope in bright blue with lactophenol cotton blue staining and in green fluorescence with fungus fluorescence staining. Yeast-like colonies were grown on both the blood plates and the Sabouraud agar. P wichehamii was identified and presented resistance to three echinocandins, fluconazole, and 5-fluorocytosine, while was susceptible to amphotericin B, posaconazole, itraconazole, and voriconazole. CONCLUSION: Our result revealed that an old patient with diabetes mellitus might be a dangerous population of cutaneous protothecosis. It also highlighted the contribution to microbial methodology on the diagnosis and treatment of such rare fungus infection.

Cytologic, histologic, microbiologic, and electron microscopic characterization of a canine Prototheca wickerhamii infection.

An adult dog was presented for chronic cough and a recent development of ulcerated, erythematous nares with nasal discharge. Cytology of enlarged peripheral lymph nodes revealed many intracellular and extracellular organisms. These round or rarely oval organisms measured approximately 5-9 µm in diameter and frequently contained several globular structures, ranging from deeply basophilic to magenta. A thin, clear halo was present. Smaller 1-2 µm, magenta forms were also observed. Fungal culture yielded small, wet, raised, irregularly shaped, white to pale tan colonies. Microbiologic staining of cultured material revealed features suggestive of algae. Histopathology of the lymph nodes revealed marked granulomatous inflammation with intralesional algal organisms suggestive of Prototheca. Electron microscopic findings were also consistent with protothecosis. Polymerase chain reaction, followed by direct DNA sequencing, identified the organism as Prototheca wickerhamii. A brief literature review discussing protothecosis in veterinary medicine is included.

In vitro algicidal effect of polypyrrole on Prototheca species isolates from bovine mastitisAlgicidal activity of polypyrrole on Prototheca spp.

Algae of the genus Prototheca are microorganisms involved in the occurrence of diseases in humans and animals. In bovine species, Prototheca spp. cause environmental mastitis, productive losses in dairy herds, mainly leading to the discard of infected cows. Currently, there are no effective anti-Prototheca spp. drugs to combat this infection. Thus, the search for an efficacious therapy for Prototheca spp. infections have become essential. Highly soluble polypyrrole (Ppy) is a molecule with known antimicrobial activity. This study aimed to characterize Prototheca spp. isolates from bovine mastitis as well as to evaluate the susceptibility profile and to verify the morphological alterations on Prototheca spp. isolates treated with Ppy. In this research, 36 Brazilian isolates of Prototheca spp. were characterized by restriction fragment length polymorphism polymerase chain reaction (RFLP-PCR) assay for the mitochondrial cytB gene. Additionally, Ppy algicidal activity against these isolates of Prototheca spp. was assessed by minimal microbicidal concentration method in microplates. Further, scanning electron microscopy (SEM) was performed in order to verify the morphological alterations on Prototheca spp. isolates in response to Ppy. The isolates were characterized as belonging to Prototheca zopfii genotype 2 (35/36) and Prototheca blaschkeae (1/36). Ppy had an algicidal effect on all isolates tested at concentrations ranging from 15.625 µg ml-1 to 62.5 µg ml-1. SEM showed changes on planktonic and sessile P. zopfii, including a decrease of the number of cells with the presence of an amorphous substance involving the cells. The algicidal activity of Ppy suggests the therapeutic potential of this molecule in the prevention and treatment of Prototheca spp. in bovine mastitis.

Emergence of Fungal-Like Organisms: Prototheca.

The genus Prototheca consists of achlorophyllic algae that are ubiquitous in the environment and animal intestines. However, this organism has forfeited its photosynthetic ability and switched to parasitism. In 1894, Krüger described two microorganisms isolated in Germany from mucous flux of Tilia and Ulmus spp., namely Prototheca moriformis and P. zopfii. Based on their yeast-like colony morphology, Krüger classified these organisms as fungi. The genus is now included within the class Trebouxiophyceae, order Chlorellales, and family Chlorellaceae. Historically, protothecosis and infections caused by green algae have been studied in the field of medical mycology. Prototheca spp. have been found to colonize human skin, fingernails, the respiratory tract, and digestive system. Although human infection by Prototheca is considered rare, an increase in infections has been noted among immunosuppressed patients, those on corticosteroid treatment, or both. Moreover, the first human outbreak of protothecal algaemia and sepsis was recently reported in a tertiary care chemotherapy oncology unit in 2018. Prototheca is also a causative pathogen of bovine disease. Prototheca zopfii and P. blaschkeae are associated with bovine mastitis, which causes a reduction in milk production and secretion of thin, watery milk containing white flakes. Economic losses are incurred either directly via reduced milk production and premature culling of affected animals or indirectly as a result of treatment and veterinary care expenses. Thus, knowledge of this fungal-like pathogen is essential in human and veterinary medicine. In this mini-review, I briefly introduce human and animal protothecoses.

Prevalence of Prototheca spp. on dairy farms in Poland - a cross-country study.

The Prototheca algae have recently emerged as an important cause of bovine mastitis globally. Here, we present results of a first large-scale, cross-country survey on the prevalence of Prototheca spp. in dairy cows, and their environment in Poland. A total of 1211 samples were collected and microbiologically analysed. Included within this number were milk (n = 638), body swabs (n = 374) and environmental samples (n = 199), originating from 400 dairy cows and their surroundings, on 16 dairy farms, based in all major provinces of the country. Prototheca spp. were the third, after Streptococcus and Staphylococcus spp., most common mastitis pathogens. The overall prevalence of protothecal mastitis was 8.3% (33/400), with the majority (75.8%) of cases having a subclinical course, and all but one attributable to P. zopfii genotype 2. Prototheca spp. were cultured from body swabs of both healthy and mastitic cows, yet the isolation rate among the latter was conspicuously lower (12.3% vs. 17.8%). Forty-two (21.2%) environmental samples yielded growth of Prototheca spp. However, no clear association between Prototheca mastitis in dairy cows and the algal isolation from the herd environment was found. Nor was there any association between the environmental recovery of the algae and farm management practices.

Short communication: Occurrence and persistence of Prototheca zopfii in dairy herds of Korea.

Bovine mastitis caused by Prototheca has been reported globally, and its incidence is increasing in dairy herds. The present study aimed to investigate the occurrence of Prototheca and persistence of Prototheca zopfii strains in Korean dairy herds. A total of 187 (7.5%) P. zopfii strains were isolated from 2,508 quarter milk samples collected from 50 dairy farms throughout Korea from 2015 to 2017. Prototheca zopfii was isolated from one farm among the 50 farms over the 3-yr period. The P. zopfii isolates belonged to genotype 2. Overall, Prototheca-positive quarter milk samples showed high somatic cell counts with an average value of log 6.48 ± 6.54 cells/mL. Prototheca zopfii was found to be persistent in an infected farm over a 2-yr period. To the best of our knowledge, this is the first report on the presence and persistence of protothecal mastitis caused by P. zopfii genotype 2 in a Korean dairy herd. This disease leads to a significant increase in somatic cell counts in milk, which persists for more than 1 yr in the affected cow udder. These results suggest that P. zopfii could pose a serious risk to dairy herds. Thus, strict surveillance for protothecal mastitis is urgently needed and sanitary conditions regarding the environment and milk collection are essential because of the lack of effective treatment options.

Thermotherapy in calcaneal infection due to Prototheca wickerhamii / Termoterapia en infección calcánea debida a Prototheca wickerhamii

No disponible

A survey on the incidence of Prototheca mastitis in dairy herds in Lublin province, Poland.

Prototheca mastitis has recently become an emerging disease; although its incidence is increasing steadily, its epidemiology remains largely understudied. The aim of this work was to investigate the prevalence of Prototheca spp. in dairy cows and their environment in Lublin province, covering most of southeastern Poland. Between December 2015 and July 2016, a total of 172 milking cows from 10 dairy farms were inspected for mastitis using clinical examination and the California Mastitis Test (CMT). Quarter milk samples (QMS, n = 179) and body site swabs (n = 151) from CMT-positive cows were collected for microbiological culture. In addition, we evaluated QMS and body site swabs from 23 healthy cows, along with 91 environmental samples. Of 100 CMT-positive cows, 71 had at least one QMS positive for microbial growth. In 8 (11.3%) of these cows, originating from 7 dairy farms, Prototheca spp. were cultured. The average somatic cell count of the Prototheca-containing milk was 4.02 × 106 cells/mL compared with 0.13 × 106 cells/mL of the Prototheca-free milk (collected from control animals). No significant differences were observed between mastitis and control cows with respect to counts of total white blood cells, lymphocytes, neutrophils, and eosinophils. Half of the cows with Prototheca spp. in their milk did not yield the algae from other anatomical sites. Eight cows were negative for the presence of Prototheca spp. in their milk but positive for the algae in swabs from anatomical sites. Among the environmental sources that were positive for Prototheca growth were watering troughs, manure, feed, and mud. All (45) Prototheca isolates recovered in this study were subjected to species- and genotype-level molecular identification. All QMS and most of the animal swabs (90%) yielded Prototheca zopfii genotype (gen.) 2. Of the animal samples, P. zopfii gen. 1 and Prototheca blaschkeae were isolated only from feces and rectum. Environmental samples grew either P. zopfii gen. 2 (67%) or P. zopfii gen. 1 (33%). This study demonstrates that P. zopfii gen. 2 is the third most common pathogen of mastitis in cattle in southeast Poland, with an overall incidence of 4.6%. Finding Prototheca spp., including P. zopfii gen. 1 and 2 and P. blaschkeae, in stool and rectal swabs from healthy animals may suggest their role as nonpathogenic microflora of bovine gut.

Case Report: Olecranon Bursitis due to Prototheca wickerhamii in an Immunocompromised Patient.

Human protothecosis is a rare algal infection caused by Prototheca; it is a ubiquitous achlorophyllic alga, which rarely causes human disease. Currently, the pathogenesis remains unclear and no treatment options have been elucidated. We present a case of olecranon bursitis caused by Prototheca wickerhamii in an immunocompromised patient. A 45-year-old man presented with left elbow pain after scraping his elbow on a tree. He reported significant pain and swelling of the elbow after injury, which resolved without intervention. He was diagnosed with HIV/AIDS infection and started on antiretroviral therapy. Afterward, he experienced recurrent elbow swelling and pain; an incision and drainage was performed and cultures demonstrated P. wickerhamii. Unsuccessful treatment with oral voriconazole led to an attempt at therapy with parental amphotericin and oral doxycycline; however the patient left against medical advice. He presented to our facility and both parental amphotericin and doxycycline were initiated with planned outpatient bursectomy. He clinically improved on that regimen but left against medical advice before completing his recommended course of IV amphotericin and oral doxycycline. Patients diagnosed with disseminated protothecosis can have a mortality rate upward of 67%. Given the rarity of this pathogen, no official treatment guidelines exist and there are few studies analyzing the antimicrobial susceptibility of Prototheca. Management is challenging because of slow-growing nature of the algae, paucity of research studies, and limited susceptibility of this pathogen. This case adds to the limited body of literature by demonstrating the clinical presentation of protothecosis and highlighting the pathology and current treatment options.

[Next-generation Sequencing Analysis of Bacterial Flora in Bovine Prototheca Mastitic Milk].

Prototheca zopfii is an achlorophyllic algae that causes bovine mastitis, resulting in a reduction in milk production and the secretion of thin, watery milk with white flakes. The aim of the present study was to evaluate the bacterial flora in the udder environment in protothecal mastitis. We used metagenomic next-generation sequencing (NGS) analysis to identify 16S rRNA genes from bacterial flora present in milk samples from protothecal mastitic dairy cows.Seven clinical strains of P. zopfii genotype 2 were isolated from 7 milk samples from 7 cases (Holstein cow) of protothecal mastitis; another 9 milk samples were obtained from 9 normal Holstein cows. The samples were collected in 2017 from cows in one dairy located in the Kushiro region in Hokkaido, Japan, which had a history of protothecal mastitis infection.The NGS produced 10,000 to 15,000 sequences in each DNA sample. To facilitate comparison, we grouped the sequencing results according to the culture-based protothecal mastitis diagnosis; sequences derived from the milk samples obtained from healthy cows were grouped separately.Sequences classified as Streptococcus spp., Pseudomonas spp. and Sphingomonas spp., Caulobacter segnis, Macrococcus caseolyticus, Methylobacterium tarhaniae, and Sphingomonas leidyi were the main sequences detected in the groups of samples from cows characterized by culture as having protothecal mastitis. Notably, Calothrix desertica (a cyanobacterium) sequences showed higher prevalence in these samples.To our knowledge, this is the first study to report that C. desertica sequences, effectively absent in the samples derived from healthy cows, are detected at high prevalence in samples from protothecal mastitic animals.