JOHNS HOPKINS
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Department of Pathology
600 N. Wolfe Street / Baltimore MD 21287-7093
(410) 955-5077 / FAX (410) 614-8087
Division of Medical Microbiology
THE JOHNS HOPKINS MICROBIOLOGY NEWSLETTER Vol. 25, No. 17
Tuesday, September 5, 2006
A. Provided by Sharon Wallace, Division of Outbreak Investigation, Maryland Department of
Health and Mental Hygiene.
There is no information available at this time.
B. The Johns Hopkins Hospital, Department of Pathology, Information provided by,
Aaron Tobian, M.D., Ph.D.
Clinical Presentation: A 57 y.o. women with a history of severe COPD who underwent right lung
transplant (three months prior) had a complicated post-operative course including a left pneumothorax,
right hemothorax that required surgical evacuation, pulmonary embolus, cardiac arrest, atrial fibrillation,
vancomycin-resistant Enterococcus (VRE) bacteremia, resistant Klebsiella oxytoca bacteremia, and
Stenotrophomonas pneumonia. The patient was on broad spectrum antibiotics, and in the MICU when
she subsequently spiked a fever with an increased white blood cell count of 11,490. She was started on
Colistin for empiric treatment of ESBL Klebieilla pneumonia. Blood cultures grew filamentous fungi
and it was confirmed to be Paecilomyces variotii.
Organism: Paecilomyces is a filamentous fungus that can be found in the soil, decaying plants, and
food. Some species of Paecilomyces can also be isolated in insects. Paecilomyces, similar to Penicillium
and Aspergillus, is an asexual saprophyte. The genus Paecilomyces is composed of 31 species, but only
two species, P. variotii and P. lilacinus, cause the vast majority of human infections (1).
Clinical Significance: Paecilomyces species are usually considered to be a contaminant, but this genus
of organisms can cause infections in both humans and animals (1). Infection with Paecilomyces is
referred to as paecilomycosis. Most infections with Paecilomyces involve either soft tissues, lungs,
sinuses or bone (2). Paccilomyces may also cause fungemia due to their ability to sporulate during tissue
invasion (2). Specifically, Paecilomyces may cause corneal ulcers, keratitis, and endopthalmitis after
prolonged contact lens use or ocular surgery (1). Infection may also lead to cellulitis, onychomycosis,
otitis media, endocarditis, pneumonia, cerebral spinal shunt infections, and osteomyelitis (1, 3).
Paceilomyces may cause allergic disorders, such as allergic alveolitis (1). P. variotii most often causes
peritonitis, sinusitis, and dermatitis.
Epidemiology: Paecilomyces species rarely cause infection. Immunosuppression (e.g., neutropenia,
depressed cellular immunity, corticosteroid use, diabetes mellitus) is the critical risk factor for infection
with Paecilomyces species. (1 - 4). There is one previously reported case in the literature of P. lilacinus
fungemia in an adult bone marrow transplant patient at Johns Hopkins Hospital (4). There five reported
cases in the literature of paecilomycosis in children with chronic granulomatous disease (3). Many
infections, however, are also associated with the presence of biomedical devices such as central venous
or peritoneal catheters, prosthetic cardiac valves, cerebrospinal fluid shunts, and breast implants (2). This
is likely due to the fact that Paecilomyces has been shown to grow well on fabrics and plastics (5).
Due to the limited number of infections by Paecilomyces and just single case reports representing the
majority of the literature on paecilomycosis, there is not good data on the epidemiology of these organisms.
Laboratory Diagnosis: Paecilomyces is detected by standard culture techniques on Sabouraud’s dextrose
agar. Paecilomyces grow rapidly and mature within three days (1). With older cultures, a sweet aromatic
odor may also be found (1). Paecilomyces is closely related morphologically to Penicillium; thus, careful
assessment (both microscopic and macroscopic) evaluation must be performed (2). Paecilomyces can be
distinguished by their long and tapered phialides terminating in a point and the elliptical, irregularly sized
conidia with uneven staining produced in chains (2, 6). Penicillium has phialides with blunt ends, and
usually round conidia produced in chains.
Colony characteristics and the microscopic features help distinguish the different species. P.
variotii morphologically appears as large, powdery yellow to olive brown colonies with a velvety center up
to 30 mm in diameter (2, 3). Microscopically, P. variotii consists of irregular branched conidiophores that
arise directly and bear large swollen phialides in a loose verticullate group (2, 3). The conidia appear
fusiform and ellipsoid (2). On the other hand, P. lilacinus morphologically appears as white cottony
colonies that gradually become lilac (2). P. variotii and P. crustaceus can also be distinguished from the
other species within the genus by their thermophilic nature (growing well at temperatures as high as
between 50 and 60 oC). The distinction between P. variotii and P. lilacinus is clinically relevant since these
two species have quite distinct anti-fugal agent susceptibilities. P. lilacinus and P. marquandii are usually
resistant to amphotericin B (2, 3).
Treatment: Due to the limited availability of data for infection with P. variotii, treatment guidelines are
not well established. P. variotii, however, is universally susceptible to amphotericien B, which is
considered the medication of choice (2). Except for fluconazole, P. variotii is susceptible to almost the
entire azole class of antifungal agents (2). Caspofungin and terbinafine also appear to be active in vitro to
P. variotii (1). Due to the substantial morbidity of paecilomycosis, P. variotii should be treated with
aggressive anti-fungal therapy and close observation for complications.
References:
1. Salle, V., E. Lecuyer, T. Chouaki, F.X. Lescure, A. Smail, A. Vaidie, C. Dayen, J.L. Schmit, J.P.
Ducroix, and Y. Douadi. Paecilomyces variotii fungemia in a patient with multiple myeloma: case
report and literature review. J. Infection. 2005; 51: e93-e95.
2. Chamilos, G., D.P. Kontoyiannis. Voriconazole-resistant disseminated Paecilomyces variotii infection
in a neutropenic patient with leukaemia on voriconazole prophylaxis. J. Infection. 2005; 51: e225e228.
3. Wang, S.M., C.C. Shieh, and C. C. Liu. Successful treatment of Paecilomyces variotii splenic abscesses:
a rare complication in a previously unrecognized chronic granulmatous disease child. Diagnostic
Micro. Infect. Dis. 2005; 53: 149-152.
4. Chan-Tack, K.M., C.L. Thio, N.S. Miller, C.L. Karp, C. Ho, and W.G. Merz. Paecilomyces lilacinus
fungemia in an adult bone marrow transplant recipient. Med. Mycol. 1999; 37: 57-60.
5. Martin, C.A., S. Roberts, R.N. Greenberg. Voriconazole treatment of disseminated Paecilomyces
infection in a patient with acquired immunodeficiency syndrome. Clin. Infect. Dis. 2002; 35: e78-e81.
6. Winn, W. S. Allen, W. Janda, E. Koneman, G. Procop, P. Schreckenberger, G. Woods. Koneman’s
color atlas and textbook of diagnostic microbiology. 6th ed. Baltimore; Lippincott Williams & Wilkins,
2006.