Ann Lab Med 2019; 39(1): 99-101  https://doi.org/10.3343/alm.2019.39.1.99
First Case of Catheter-related Malassezia pachydermatis Fungemia in an Adult
Jaehyeon Lee, M.D. Ph.D.1,3, Yong Gon Cho, M.D. Ph.D.2,3, Dal Sik Kim, M.D. Ph.D.2,3, Sam Im Choi, M.D. Ph.D.2,3, and Hye Soo Lee, M.D. Ph.D.2,3*

1Department of Laboratory Medicine, Chonbuk National University Hospital, Jeonju, Korea.

2Department of Laboratory Medicine, Chonbuk National University Medical School, Jeonju, Korea.

3Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea.

Corresponding author: Hye Soo Lee, M.D. Department of Laboratory Medicine, Chonbuk National University Medical School, 20 Geonji-ro, Dukjin-gu, Jeonju 54907, Korea. Tel: +82-63-250-1218, Fax: +82-63-250-1200, leehs@jbnu.ac.kr
Received: February 28, 2018; Revised: May 16, 2018; Accepted: August 16, 2018; Published online: September 13, 2018.
© Korean Society for Laboratory Medicine. All rights reserved.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Body

Dear Editor,

Malassezia yeast species are normal microbiota in the skin of humans and various animals and are mainly lipophilic. Unlike other Malassezia species, M. pachydermatis is non-lipid-dependent; it is a zoonophilic yeast that has been associated with otitis externa and seborrheic dermatitis in dogs [1]. Reported Malassezia species infections have mainly involved M. furfur, and most were localized skin infections [1, 2]. Systemic infection by M. pachydermatis in adults is extremely rare, with only three cases being reported so far (Table 1) [3, 4, 5]. We report a case of M. pachydermatis fungemia in an adult. The Institutional Review Board of Chonbuk National University Hospital exempted this study (IRB No. CUH 2014-08-002).

A 62-year-old male presented to the emergency room of Chonbuk National University Hospital in May 2014 with abdominal pain. He had undergone radical total gastrectomy with adjuvant chemotherapy for poorly differentiated (stage IIIa, T2bN2M0) tubular adenocarcinoma a month previously. On arrival, he was diagnosed as having ileus and an intraabdominal abscess. On hospital day 32, his white blood cell count and C-reactive protein level increased to 1.6×109/L and 1,122.1 nmol/L, respectively, and his body temperature was 37℃. Two sets of venous blood cultures (FA Plus, FN Plus, BacT/Alert 3D system, bioMérieux, Durham, NC, USA) were conducted. Following three days of incubation, very tiny, dry-looking, creamy colonies that broke easily were observed on 5% sheep blood agar and Sabouraud dextrose agar. These colonies were identified as M. pachydermatis using Vitek 2 (bioMérieux, Hazelwood, MO, USA) and VITEK MS (bioMérieux, Marcy L'Etoile, France). Internal transcribed spacer ribosomal RNA sequencing demonstrated 100% identity with GenBank entry NR 126114. A total of four sets (FA Plus, FN Plus) of blood culture—two sets of venous blood culture and two sets of blood culture—were conducted, and all sets gave positive results. The differential time to positivity (DTP) for the chemoport and peripheral venous blood was six hours and five hours, respectively. The patient was treated with a lipid infusion one day after admission, and colony growth was enhanced with olive oil. Antifungal susceptibility results using ETEST (bioMérieux, Marcy L'Etoile, France) demonstrated that the minimal inhibitory concentrations of fluconazole, 5-flucytosine, and voriconazole were 32 µg/mL, >32 µg/mL, and 0.25 µg/mL, respectively [6].

The source of M. pachydermatis infection in this case is unclear, as the patient, his family, and the medical team confirmed that the patient had no contact with dogs. As most M. pachydermatis systemic infections are reported in neonates, risk factors have been determined for only pediatric patients [7, 8]. There is no clear consensus concerning risk factors in adults because of the low incidence in adults (only three cases to date; Table 1) [3, 4, 5]. A recent study suggested that a DTP over two hrs in catheter-related candidemia, except for Candida glabrata, is an optimal cut-off [9]. Although the DTP cut-off has not been determined for Malassezia species, in this case, the DTP was over five hours. We therefore hypothesize that this is a case of catheter-related fungemia, as our patient had a chemoport. Although Chang et al. [2] identified various risk factors for Malassezia infections, they did not consider the influence of intravascular devices because their study was conducted in a neonatal intensive care unit. Lipid infusion could also be a risk factor.

Standardized assays to determine the in vitro antifungal susceptibilities of Malassezia species are unavailable; therefore, we carried out antifungal susceptibility tests based on the CLSI method [6]; to date, most of the results have been reported for animal isolates. The three previously reported fungemia cases in adults were treated with amphotericin B; however, no susceptibility test results are available [3, 4, 5]. Although our patient was treated with amphotericin B for two days, he died of multiple organ failure. As there is no study on the DTP cut-off in Malassezia infections, and there is limited information regarding treatment, clinicians should consider an approach similar to the one outlined for C. glabrata in the European Society of Clinical Microbiology and Infectious Diseases guidelines for the diagnosis and management of Candida diseases [10].

In conclusion, although information regarding human infections is limited, lipid infusion and intravascular catheters should be considered as risk factors for M. pachydermatis infection in adults. Further studies on the risk factors and antifungal susceptibility tests are needed.

Acknowledgment

This paper was supported by the Fund of Biomedical Research Institute, Chonbuk National University Hospital.

Authors' Disclosures of Potential Conflicts of Interest

No potential conflicts of interest relevant to this article were reported.

Tables

Cases of Malassezia pachydermatis systemic infection reported in adults to date

No. CasePredisposing DiagnosisAge/SexProphylactic antifungal agentsReported risk factorsNot considered risk factors (to date)OutcomeReference
Arterial catherizationContact with a potential carrier, including animalsLipid infusionIntravascular devices
1Acute myeloid leukemia21/MNoN/MYesNoTwo central cathetersDied3 (Lautenbach et al., 1998)
2Acute myeloid leukemia69/MPosaconazoleN/MNoN/MPeripherally inserted central catheter lineImproved4 (Choudhury et al., 2014)
3Leprosy, Pneumonia53/MNoNoNoNoMidline catheterFully recovered5 (Roman et al., 2016)
Present patientGastric cancer62/MNoYesNoYesChemoportDied

Abbreviations: N/M, not mentioned; M, male.

References
  1. Prohic, A, Jovovic Sadikovic, T, Krupalija-Fazlic, M, Kuskunovic-Vlahovljak, S. Malassezia species in healthy skin and in dermatological conditions. Int J Dermatol, 2016;55;494-504 2016;55.
    Pubmed
  2. Chang, HJ, Miller, HL, Watkins, N, Arduino, MJ, Ashford, DA, Midgley, G, et al. An epidemic of Malassezia pachydermatis in an intensive care nursery associated with colonization of health care workers' pet dogs. N Engl J Med, 1998;338;706-711 1998;338.
    Pubmed
  3. Groshek, PM. Malassezia pachydermatis infections. N Engl J Med, 1998;339;270-271 1998;339.
  4. Choudhury, S. Malassezia pachydermatis fungaemia in an adult on posaconazole prophylaxis for acute myeloid leukaemia. Pathology, 2014;46;466-467 2014;46.
    Pubmed
  5. Roman, J, Bagla, P, Ren, P, Blanton, LS, Berman, MA. Malassezia pachydermatis fungemia in an adult with multibacillary leprosy. Med Mycol Case Rep, 2016;12;1-3 2016;12.
    Pubmed
  6. Cafarchia, C, Figueredo, LA, Iatta, R, Colao, V, Montagna, MT, Otranto, D. In vitro evaluation of Malassezia pachydermatis susceptibility to azole compounds using E-test and CLSI microdilution methods. Med Mycol, 2012;50;795-801 2012;50.
    Pubmed
  7. Mickelsen, PA, Viano-Paulson, MC, Stevens, DA, Diaz, PS. Clinical and microbiological features of infection with Malassezia pachydermatis in high-risk infants. J Infect Dis, 1988;157;1163-1168 1988;157.
    Pubmed
  8. Gaitanis, G, Magiatis, P, Hantschke, M, Bassukas, ID, Velegraki, A. The Malassezia genus in skin and systemic diseases. Clin Microbiol Rev, 2012;25;106-141 2012;25.
    Pubmed
  9. Park, KH, Lee, MS, Lee, SO, Choi, SH, Sung, H, Kim, MN, et al. Diagnostic usefulness of differential time to positivity for catheter-related candidemia. J Clin Microbiol, 2014;52;2566-2572 2014;52.
    Pubmed
  10. Cornely, OA, Bassetti, M, Calandra, T, Garbino, J, Kullberg, BJ, Lortholary, O, et al. ESCMID* guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients. Clin Microbiol Infect, 2012;18;19-37 2012;18.
    Pubmed



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