Sternal Wound Infection byTrichosporon inkinfollowing Cardiac Surgery

Abstract

Wound infection following cardiac surgery is well described but is rarely due to fungal infection. We describe a case of sternal wound infection caused by Trichosporon inkin with a fatal outcome, in an immunocompetent patient following aortic root surgery. CASE REPORTA 71-year-old female with known severe aortic stenosis and a dilated aortic root was admitted for elective aortic root replacement surgery. She had a medical history of severe emphysema, leading to breathlessness at rest, and spirometry revealed a forced expiratory volume in 1 s of just 500 ml. The operation involved implantation of a porcine aortic root and a Dacron graft but was complicated by bleeding from the left coronary artery origin, necessitating saphenous vein grafting onto the left coronary. The surgery lasted for 8 h, and teicoplanin and gentamicin were administered as antibiotic prophylaxis prior to surgery, in accordance with local protocols.Postoperatively the patient was transferred to the intensive care unit, where she remained intubated and ventilated. A tracheostomy was performed on day 3, because a prolonged period of ventilation was anticipated. Further complications included acute renal failure, requiring continuous venous-venous hemofiltration. The patient also developed an intrinsic nodal cardiac rhythm and was paced via epicardial wires, inserted in theater and removed on day 7. On day 8 of her intensive care stay, she developed a ventilator-associated pneumonia, which was treated with cefuroxime and gentamicin, with some clinical response.A subsequent septic decline (accompanied by negative blood cultures) was treated with an empirical course of vancomycin and ceftazidime, but with no substantial change in the patient's condition and a continued inotrope requirement. On day 24 of admission, Candida albicans was isolated from a central venous catheter tip, urine, and respiratory secretions, and treatment with intravenous fluconazole (400 mg daily) was commenced. It was noted, on examination, that the patient had developed a left pleural rub, and a small left-sided pleural effusion was seen on a chest radiograph. Bloody material began to ooze from the lower portion of the sternal wound and previous epicardial pacing wire sites. The gram stain of this fluid revealed numerous pus cells with yeasts and fungal hyphae (Fig. 1). The wound dehisced, and one liter of pus drained spontaneously from the wound. There was associated sternal instability elicited upon examination. The patient was not considered a candidate for further surgical intervention, and her condition continued to deteriorate. She died 2 days later, 26 days postoperatively. No autopsy was performed.Subsequent to her death, blood cultures became positive after 2 days of incubation (Fig. 2) using the BacT/ALERT system (bioMérieux Inc., Durham, N.C.). The yeast isolated from both blood and sternal fluid was identified by the Mycology Reference Laboratory (HPA, Bristol, United Kingdom) as Trichosporon inkin by using AUXACOLOR (Bio-Rad, Marnes la Coquette, France), givin...

Molecular Identification and Susceptibility ofTrichosporonSpecies Isolated from Clinical Specimens in Qatar: Isolation ofTrichosporon dohaenseTaj-Aldeen, Meis & Boekhout sp. nov

“…inkin is frequently isolated from clinical specimens (66), such as white piedra (13,23,76), but also from patients with peritonitis (12,36,37), endocarditis (61), lung abscesses (60), subcutaneous nodules (rheumatoid arthritis patients receiving corticosteroid therapy) (65), sternal surgical wound infections (13), and invasive infections (31,82). In the present study, T. inkin was isolated in cases of white piedra, balanitis, and urethral discharge.…”

Trichosporon mycotoxinivorans , a Novel Respiratory Pathogen in Patients with Cystic Fibrosis

“…As reflected by more recently published reports, the preponderance of these isolates likely represent T. asahii and T. mucoides, which are associated with invasive disease in immunocompromised and, rarely, immunocompetent patients (2, 7, 13, 21). In contrast, T. ovoides, T. cutaneum, T. inkin, and T. asteroides (now called T. jirovici) are more commonly associated with superficial infections such as white piedra of the scalp or pubic hair (T. inkin and T. ovoides) and dermatophytic infections (T. inkin and T. jirovici) and are only rarely associated with central venous line infections or disseminated disease in the immunocompromised host (5,16). T. pullulans bears morphological similarities to the other Trichosporon species; however, it is phylogenetically distinct and should be classified elsewhere.…”

Trichosporon Surgical Wound Infection in a Renal Allograft Recipient Successfully Treated With Voriconazole

“…Asymptomatic Trichosporon funguria has been reported in renal transplant recipients (7). Sternal wound infection after cardiac surgery has been reported (8). Other infections because of Trichosporon that have been reported include peritonitis in a chronic ambulatory peritoneal dialysis patient, endocarditis, catheter infection, and lung abscess (9 -12).…”