Article

Letter to the Editor

Ann Lab Med 2022; 42(6): 697-699

Published online November 1, 2022 https://doi.org/10.3343/alm.2022.42.6.697

Copyright © Korean Society for Laboratory Medicine.

The First Case of Prosthesis-related Infection Caused by Quambalaria cyanescens in Korea

Seok Ryun Kwon, M.D.1,2 , Taek Soo Kim, M.D.1,2 , Hyunwoong Park, M.D.1,3 , and Jae Hyeon Park, M.D.1,2

1Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea; 2Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea; 3Department of Laboratory Medicine, Seoul National University Boramae Medical Center, Seoul, Korea

Correspondence to: Jae Hyeon Park, M.D.
Department of Laboratory Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea
Tel: +82-2-2072-7545, Fax: +82-2-747-0359
E-mail: bjack9@gmail.com

Received: December 29, 2021; Revised: February 23, 2022; Accepted: May 31, 2022

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.

Dear Editor,

Quambalaria cyanescens (formerly Sporothrix cyanescens) is a plant pathogen that has rarely been isolated from clinical specimens; only two cases have been identified using sequence analysis [1, 2]. We report the first case of prosthesis-related human infection caused by Q. cyanescens in Korea. The Institutional Review Board of Seoul National University Hospital approved the study (2105-096-1219) and waived the need for informed consent.

In December 2020, a 61-year-old man with spinal metastases of renal cell carcinoma was hospitalized for pain, warmth, and redness at the surgical site. The patient had undergone multiple surgeries for tumor removal, spinal metastases, and spinal fixation 17 months prior. The patient’s body temperature was 36.2°C; laboratory tests showed a white blood cell count of 9.28×109/L (reference interval, RI: 4.0–10.0×109/L), neutrophil count of 7.43×109/L (RI: 1.8–7.0×109/L), and C-reactive protein (CRP) level of 87.5 mg/L (RI: 0.0–5.0 mg/L). On hospitalization day 2, magnetic resonance imaging revealed an abscess around the thoracic spine. Cefazolin was used as empirical antimicrobial therapy due to the prior methicillin-susceptible Staphylococcus aureus infection. On day 5, tissue debridement was performed, and abscess specimens were collected.

The specimens were cultured on blood agar and Brucella agar at 35°C and Sabouraud dextrose agar (SDA) at 30°C. Atypical yeast-like colonies were observed on the blood agar after 48 hours of incubation. The colonies were subcultured on SDA and incubated at 30°C for 72 hours. The colonies were smooth, butyrous, and white (Fig. 1A). Microscopic examination revealed pseudohyphal budding patterns with sympodial conidiogenesis (Fig. 1B). Gram-positive rods also grew on Brucella agar.

Figure 1. Colony morphology, microscopic examination, and phylogenetic analysis of the Quambalaria isolate. (A) Colonies on a Sabouraud dextrose agar incubated at 30°C for 72 hours. (B) Microscopic examination of lactophenol cotton blue-stained Quambalaria isolate (400×). (C) Phylogenetic analysis of Quambalaria isolates (23 type and reference strains) based on the internal transcribed spacer region (619 nucleotide positions). The tree was constructed using the maximum-likelihood method and the GTR + I + G model, with Microstroma juglandis KR 0015442 (EU069498.1) considered as the outgroup. Bootstrap values are expressed as percentages of 1,000 replications, and the scale bar indicates the estimated number of substitutions per base. GenBank accession numbers are provided within parentheses.

Matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS; MALDI Biotyper, Bruker Daltonics GmbH, Bremen, Germany) was unreliable for identification of the fungi. The 28S rRNA gene D1/D2 region was sequenced using the NL1/NL4 primer pair and searched against GenBank [3]. The results showed 100.0% identity with Q. cyanescens (MN_162210.1) and Q. simpsonii (MH_874927.1). Because the identification was ambiguous, the internal transcribed spacer (ITS) region was sequenced using the ITS5/ITS4 primer pair [3]. The results revealed 100.0% identity with Q. cyanescens (KX_674666.1) and 96.12% identity with Q. simpsonii (MT_879594.1). Phylogenetic analysis using MEGA X (https://www.megasoftware.net) confirmed the isolate as Q. cyanescens (Fig. 1C).

The gram-positive rods were identified as Cutibacterium sp. using MALDI-TOF MS. Cutibacterium acnes was specifically identified by 16S rRNA amplicon sequencing of the abscess specimen using a MinION sequencer (Oxford Nanopore Technologies, Oxford, UK) [4].

Antifungal susceptibility testing (AST) of the Q. cyanescens isolate was performed using a Sensititre YeastOne YO10 panel (TREK Diagnostic Systems Inc., Independence, OH, USA). The results showed high minimum inhibitory concentrations (MICs) for 5-flucytosine and echinocandins and low MICs for amphotericin B and azoles (Table 1). Seven days post debridement, the patient’s serum CRP level had decreased to 33.9 mg/L. Follow-up cultures of tissue and wound specimens collected on day 36 during additional spinal fixation yielded negative results. No antifungal agents were administered during the 44 days of hospitalization. The abscess did not recur within six months of discharge.

Table 1 . MIC values for the Quambalaria cyanescens isolate

Antifungal agentMIC (μg/mL)
Anidulafungin>8
Micafungin>8
Caspofungin8
5-Flucytosine> 64
Posaconazole≤ 0.008
Voriconazole≤ 0.008
Itraconazole≤ 0.015
Fluconazole≤ 0.12
Amphotericin B0.12

Abbreviation: MIC, minimum inhibitory concentration.



Since being first described in 1973, the taxonomic classification of S. cyanescens has been changed several times, first to the genus Cerinosterus and then to the genus Fugomyces. The current genus classification of Quambalaria is based on phylogenetic analysis of ribosomal large subunit sequences and ultrastructural characteristics [5]. Several S. cyanescens infections (e.g., skin infections, nosocomial pneumonia, and fungemia) have been reported; however, their diagnoses may be inaccurate as they were based only on morphological and physiological results [6, 7]. The current case is the third reported human infection caused by Q. cyanescens and confirmed using ITS sequence analysis. The sequence analysis was important for identifying the isolate as using morphological phenotypes and MALDI-TOF MS was challenging and ambiguous. The AST results for the isolate were consistent with those published previously [1, 2].

Postoperative spinal infection can be a significant complication of spinal surgery [8]. C. acnes appeared to be a contamination of the normal skin flora, considering that prosthesis-related infection by C. acnes is associated with low CRP levels and usually requires long-term antibiotic treatment [9, 10]. The current patient had an increased risk of infection due to his advanced age and immunocompromised status. As in the case of breast implant-related infection, Q. cyanescens can cause prosthesis-related infection with the patient improving only after debridement [1].

This is the first case of Q. cyanescens human infection in Korea. Q. cyanescens should be considered a potential pathogen causing prosthesis-related infections, and ITS region sequence analysis may be required to definitively identify Q. cyanescens.

Conceptualization: Kwon SR and Park JH. Data curation: Kwon SR and Park JH. Formal analysis: Park JH. Methodology: Kim TS and Park JH. Investigation: Kwon SR and Park JH. Writing—original draft: Kwon SR; Writing—review and editing: Kwon SR, Kim TS, Park H, and Park JH.

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

This work was supported by the Seoul National University Hospital Research Fund (grant number 0420160720).

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