An Unusual Cause of Fungemia

March 30, 2009

The case and slide were submitted by Pradeep K. Agarwal, MD, a cardiologist at the Arizona Medical Clinic in Sun City West; Sunati Sahoo, MD, assistant professor and director of cytopathology in the department of pathology and laboratory medicine at the University of Louisville in Kentucky; and Rupa J. Panchal, MD, an internist in Hackensack, NJ.

A 70-year-old man was admitted with a change in mental status and shortness of breath. He had a history of carcinoma of the colon and status postcolectomy with ileostomy. He was receiving long-term total parenteral nutrition, including lipid emulsion, for short-gut syndrome. Other pertinent findings in the medical history included type 2 diabetes mellitus and enterocutaneous fistula.

On examination, the patient was tachypneic, with a respiration rate of 28 breaths per minute; his heart rate was 104 beats per minute; his blood pressure was 118/62 mm Hg; and his temperature was 37.2°C (99°F). Auscultation of his chest revealed scattered rhonchi. The Hickman catheter site was not erythematous or tender to palpation. A chest radiograph did not show infiltrates. Arterial blood gas values on forced inspiratory oxygen of 30% included a pH of 7.41, Pco₂ of 35.2 mm Hg, Po₂ of 111.6 mm Hg, and bicarbonate level of 22.5 mEq/L. The total white blood cell count was 15,800/µL, with 74% segmented neutrophils and 10% bands. A peripheral blood smear demonstrated numerous budding yeasts (Figure, Wright stain, original magnification ×100).

A catheter-related fungemia was considered, and the Hickman catheter was removed. Therapy was started with amphotericin B(Drug information on amphotericin b). Blood cultures drawn from the Hickman catheter grew Malassezia furfur. Amphotericin B therapy was continued for 10 days, with the patient making an uneventful recovery. Three months later, the patient died of unrelated surgical complications.

Discussion
M furfur is a lipophilic yeast that colonizes human skin and causes superficial infections such as tinea versicolor. Rarely, it is the cause of catheter-related sepsis. Most reported cases have been in patients who were receiving parenteral lipids via a central vascular catheter.¹ Most patients were either neonates or adults with malignancy or immunosuppression.² The symptoms are indistinguishable from those of sepsis from any other cause.

M furfur does not grow readily on standard fungal media; it requires fatty acid for growth. Blood cultures from a central catheter source have a better yield than those from peripheral sites.³ A positive peripheral blood smear, as seen in this case, is rare.⁴ Malassezia fungemia should be considered in the workup of sepsis in patients with a central catheter who are receiving hyperalimentation with lipids, and the laboratory should be alerted so that oil-rich media can be used.

Treatment consists of removal of the catheter and discontinuation of lipids, along with administration of amphotericin B or imidazoles for persistent or invasive infections.⁵

REFERENCES
1. Dankner WM, Spector SA, Fierer J, Davis CE. Malassezia fungemia in neonates and adults: complication of hyperalimentation. Rev Infect Dis. 1987;9:743-753.
2. Barber GR, Brown AE, Kiehn TE, et al. Catheter-related Malassezia furfur fungemia in immunocompromised patients. Am J Med. 1993;95:365-370.
3. Marcon MJ, Powell DA. Human infections due to Malassezia spp. Clin Microbiol Rev. 1992;5:101-119.
4. Brooks R, Brown L. Systemic infection with Malassezia furfur in an adult receiving long-term hyperalimentation therapy. J Infect Dis. 1987;156:410-411.
5. Weisse ME. Malassezia furfur. In: Behrman RE, Kliegman R, Janson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia: WB Saunders; 2000:937.

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An Unusual Cause of Fungemia

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