Mycetoma

INTRODUCTION: Paecilomyces is a saprophytic fungus implicated in sporadic reports of serious infections involving almost all organ systems. Mycetoma, empyema and pneumonias have been described. This case report describes an immunocompetent patient with a progressive lung infection found at autopsy to have Paecilomyces variotii.

CASE PRESENTATION: A forty nine year old woman who had been followed in our pulmonary clinic for emphysema presented in January 2004 with fatigue, fevers, sinus drainage and weight loss. She had undergone right upper and middle lobectomies for a non-resolving pneumonia in 1993; pathology report from that operation revealed the absence of neoplasm or infection. She was a baker by trade but had not worked over the past two years. Radiographs revealed multiple cavitary lesions in her right lower lobe with one cavity that had an air fluid level. She was admitted to the hospital, where bronchoscopy was performed and she was started on broad spectrum antibiotics. Several weeks after her discharge two colonies of paecilomyces grew from bronchoscopy culture--felt to be a contaminant as her symptoms and radiographs improved while on a six week intravenous antibiotic course. Symptoms of pneumonia returned in June 2004. Radiographs revealed increasing cavitary lesions in her right lung, and airspace disease in her left upper lobe. Bronchoalveolar lavage returned clear fluid which was sent for culture. The patient was admitted to the hospital after the bronchoscopy for increased work of breathing. On the second hospital day hypoxic respiratory failure and shock developed. Mechanical ventilation and resuscitative measures were initiated; high dose vasopressor was required, broad spectrum antibiotics and amphotericin B were started. Care was withdrawn by family request on intensive care unit day three after progressive escalation of support and multiple organ system failure. Autopsy was performed. Cultures of her cavitary lung lesions, and her liver grew paecilomyces variotii. The amount of fungal forms seen on tissues Prom was overwhelming--but bronchoalveolar lavage cultures from her remained sterile.

DISCUSSIONS: Paecilomyces are soil saprophytes which are increasingly cited in cases of serious infections. This fungus is known to survive on a variety of surfaces/environments including plastics, saline, water damaged wood, and decaying food matter. Paecilomyces is also found as an airborne contaminant in graineries, sawmills, and water damaged houses. Outbreaks of paecilomyces have been noted in dialysis units from dialysate bags stored on water damaged wood, operating rooms from contaminated air exhaust systems, and in a bone marrow transplant unit from sharing contaminated skin lotion. Paecilomyces has been also found to contaminate prosthetic devices including lens and breast implants. Prior reviews have noted this fungus to be resistant to some commercial sterilizing techniques, burgeoned by the fungus" ability to thrive in a saline environment and the p. variotti species being able to withstand very high temperatures. The clinical risk factors for invasive paecilomyces infection are similar to that described for other fungal infections and center around immune compromise. Prosthetic devices also seem to carry risk. Several Paecilomyces species are known to produce human infections but by far the two most common are lilacinus and variotii. Antifungal susceptibilites reported vary significantly in the literature; susceptibility testing for each isolate found is supported by the literature.

CONCLUSION: Although bronchoscopy performed five months prior to our patient's death grew two colonies of paecilomyces the resolution of symptoms on antibiotics for pneumonia during that period would favor colonization. The patient reported in this case was likely exposed to paecilomyces from her occupational history as a baker. Factors that may nave led our patient to be at increased risk for infection were supplemental steroids for treatment of symptoms attributable to obstructive lung disease.

DISCLOSURE: Catherine Grossman, None.

[ILLUSTRATION OMITTED]

Catherine E. Grossman MD * Alpha Fowler MD Medical College of Virginia, Richmond, VA

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group