Introduction Trichosporon asahii infection in very low birth weight neonates is unusual, and few cases are found in the literature. We report a case of a neonate with trichosporonosis emphasizing the need to be aware of this rare cause of fungemia with a high mortality rate in spite of therapy.
Case Report A 517 g male infant was born at 23 weeks and 6 days of gestation to a gravida 2 para 1 woman via an emergent cesarean section due to prolonged rupture of membranes and cord prolapse. Apgar scores were 2, 5, and 8 at 1, 5, and 10 minutes, respectively. The baby was intubated, given surfactant, and admitted to the NICU. Umbilical venous and arterial catheters were placed. Ampicillin and cefotaxime were begun for suspected sepsis. He remained critically ill, requiring pressor therapy and blood products, and was placed on an oscillator on day 2 of life. On day 9, he was noted to have peeling skin lesions on his upper and lower extremities and abdomen with moderate mucoid exudate. On day 13, a swab obtained from the abdominal exudates grew T. asahii. Cultures from blood and urine were obtained and amphotericin B was started at 1 mg/kg. Urine and blood cultures were positive for T. asahii. Blood cultures on days 18 and 22 continued to be positive, and amphotericin dose was increased to 1.5 mg/kg. The blood culture on day 18 also grew Staphylococcus epidermidis, and vancomycin was begun. On day 25, 5-flucytosine (5-FC) by mouth was added. Blood cultures from days 25 and 29 remained positive for T. asahii and S. epidermidis. The umbilical venous catheter was removed on day 29. Subsequently, fluconazole and rifampin were added. 5-FC was stopped after 3 days due to presumed necrotizing enterocolitis. MICs (μg/mL) of the patient's isolate at 24/48 hours were AMB 0.25/0.5, 5-FC 2/8, FLU 2/2. The infant did not respond to therapy and died on day 36 due to respiratory failure and overwhelming sepsis.
Discussion T. asahii (previously known as T. beigelii) is a basidiomyceteous yeast found naturally in soil, vegetation, and water. It can cause superficial infection of the hair shaft (white piedra), onychomycosis, and otomycosis in an immunocompetent host and deep infection (trichosporonosis) in an immunocompromised patient. Of the 10 cases of disseminated T. asahii infection in neonates described in literature, 6 had positive blood cultures, 2 of these infants had cutaneous lesions, and 4 had kidney involvement. The mortality rate was 90%. Cultures from cutaneous lesions, when present, can be useful in diagnosing infection in neonates, as it was in our case. Unfortunately, trichosporonosis is difficult to treat with standard antifungal agents and is almost uniformly fatal in these immunocompromised neonatal hosts.
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