Rasamsonia argillacea Pulmonary and Aortic Graft Infection in an Immune-Competent Patient

Abstract

Rasamsonia argillacea (formerly known as Geosmithia argillacea) is a fungus recently recognized as a pathogen of immunocompromised patients. Here we report the first case of Rasamsonia infection in an immunocompetent host, presenting as a pulmonary and aortic graft infection. Its morphological similarity to nonpathogenic Penicillium species delayed the diagnosis and initiation of appropriate treatment. CASE REPORTA 56-year-old man presented to our clinic in 2009 for evaluation of progressive, chronic necrotizing pulmonary aspergillosis. In 1998, he had been diagnosed with an aneurysm of the proximal descending thoracic aorta, believed to be secondary to a traumatic aortic injury suffered during a motor vehicle accident in 1979. An endovascular stent graft was placed for treatment of his aortic aneurysm, and he was followed with serial imaging. On routine follow-up imaging of his aneurysm in 2005, he was found to have a cavitary lesion in the left upper lobe of his lung. A bronchoscopy was performed, and cultures revealed Aspergillus fumigatus. He was treated with itraconazole following this diagnosis, and subsequent chest computed tomography (CT) later that year revealed radiographic improvement. In January 2009, repeat CT showed an increase in the size of the cystic cavities in the left lung, and new lesions were visualized in the left lower lobe. He was referred to our clinic for evaluation.At the time of his visit, the patient described a mild cough and scant hemoptysis several times per week. He denied any constitutional symptoms or pleuritic chest pain. Given the concern for a poorly controlled Aspergillus infection, a decision was made to change to voriconazole, but due to financial constraints, itraconazole was continued. The patient continued to suffer from hemoptysis. The close proximity of the pulmonary infection to the aortic aneurysm was concerning for future direct spread of infection, so the decision of surgical therapy was made. In August 2010, the patient underwent a left lower lobectomy with resection of the pulmonary cavity. The infection was found to abut the aortic aneurysm, but there was no evidence of invasion. Pathological examination of the resected lung lesion revealed pleural and subpleural fibrosis with septate fungal hyphae thought to be consistent with an Aspergillus species (Fig. 1). The intraoperative fungal cultures were reported as Penicillium. It was concluded that the cultures at the time of surgery were negative for Aspergillus due to the concurrent itraconazole therapy and that the Penicillium species was a colonizer, not a pathogen. Shortly after surgery, the patient was switched to voriconazole at 200 mg by mouth twice daily.Following surgery, the patient continued to complain of cough and hemoptysis. A CT scan in September 2011 revealed communication between the superior lingual bronchus and new left-sided loculated hydropneumothorax, as well as fluid within the aneurysm sac near the aortic graft (Fig. 2). These findings were very suspicious for progressive infection now i...

Airway persistence by the emerging multi‐azole‐resistant Rasamsonia argillacea complex in cystic fibrosis

“…The presence of R. argillacea complex has been reported in invasive infections in CGD to airway colonisation in patients with CF . Infections in bone marrow transplant recipients and immunocompetent hosts have also been reported.…”

“…Rasamsonia argillacea (previously Geosmithia argillacea ) belongs to the emerging, thermotolerant polyphyletic Eurotiales (family Trichocomacea ) and is a causative agent of invasive mycosis in patients with chronic granulomatous disease (CGD) and graft‐versus‐host disease . Pulmonary and aortic valve infection in an immunocompetent patient has been described . In addition, this emerging fungal pathogen has been found to colonise CF airways .…”

Identification and Antifungal Susceptibility of Penicillium-Like Fungi from Clinical Samples in the United States

“…We also identified two isolates belonging to Rasamsonia, one as R. argillacea and the other as R. eburnea (formerly Talaromyces eburneus). Recently, rates of infections by isolates within this genus appear to have increased in humans and animals, and those species are considered emerging pathogens (34)(35)(36). In 2011, nine cases of invasive infections by Rasamsonia argillacea were reported in patients with chronic granulomatous disease (37,38) and, more recently, in a patient with graft-versus-host disease (39).…”

Evaluation of the Vitek MS Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry System for Identification of Clinically Relevant Filamentous Fungi

“…R. argillacea has been identified as a colonizing organism in cystic fibrosis patients and as a cause of pulmonary infections. It is resistant to voriconazole, with variable resistance to itraconazole and amphotericin B (36). Two isolates identified as Menispora spp.…”