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LETTER TO EDITOR  
Year : 2017  |  Volume : 9  |  Issue : 3  |  Page : 127-128
Geotrichum candidum in infective endocarditis


1 Department of Microbiology, Mycology Section, AIIMS, New Delhi, India
2 Department of CTVS, AIIMS, New Delhi, India

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Date of Web Publication9-Aug-2017
 

How to cite this article:
Meena S, Singh G, Dabas Y, Rajshekhar P, Xess I. Geotrichum candidum in infective endocarditis. J Global Infect Dis 2017;9:127-8

How to cite this URL:
Meena S, Singh G, Dabas Y, Rajshekhar P, Xess I. Geotrichum candidum in infective endocarditis. J Global Infect Dis [serial online] 2017 [cited 2019 Jul 16];9:127-8. Available from: http://www.jgid.org/text.asp?2017/9/3/127/212576


Sir,

Geotrichum candidum is yeast found globally in soil, water, air, and sewage, as well as in plants, cereals, and dairy products which is rarely pathogenic in humans. It is a budding pathogen in immunocompromised hosts. We report a case of G. candidum infective endocarditis in a 6-year-old child with pulmonary atresia. The boy presented to the pediatric outpatient department at our hospital with complaints of fever for 3 months associated with weight loss and anorexia. On examination, there was facial puffiness, abdominal distension, and pedal edema. Auscultation revealed a mid-systolic murmur. Further, echocardiography revealed a mobile tricuspid valve vegetation (1.3 cm × 1.5 cm) attached to septal tricuspid leaflet and anterior tricuspid leaflet. The grade of tricuspid valve regurgitation was evaluated as 4°. The left ventricular ejection fraction was normal. A chest X-ray revealed pulmonary congestion. The cardiothoracic ratio was increased suggesting heart failure. The patient was started empirically on vancomycin, cefoperazone, and liposomal amphotericin B which was later changed to voriconazole after identification of the etiology. Subsequently, vegetectomy and valve reconstruction using homologous anterior mitral leaflet and moderate tricuspid valve annuloplasty was done.

Vegetation was sent to bacteriology and mycology laboratory to discern out the pathogen. The isolate was identified as G. candidum based on morphological characteristics and sugar assimilation. To confirm the identity of the isolate, DNA sequence of the 18S (partial), ITS1, 5.8S, ITS2, and 28S (partial) ribosomal region. The sequence obtained was compared with that in the GenBank DNA database and gave 100% identity with an ex-type strain of G. candidum (accession no. KX237567). Antifungal susceptibility testing of the strain was performed to determine the minimum inhibitory concentration (MIC) by the approved protocol of Clinical and Laboratory Standards Institute document M27-A3.[1] The isolate was susceptible to voriconazole (0.016 μg/ml), posaconazole (0.016 μg/ml), caspofungin (0.032 μg/ml), micafungin (0.016 μg/ml) but resistant to amphotericin B (>16 μg/ml), and itraconazole (>16 μg/ml). The patient improved dramatically after voriconazole and was discharged after 10-week postsurgery but voriconazole was continued for 6 more months with regular follow-up on an outpatient basis.

Invasive infections by rare and opportunistic fungal pathogens in immunocompromised patients are posing a major trouble in the management of these patients. Since the first report of invasive geotrichosis in 1971 by Ghamande et al., few sporadic cases have been reported over the year. Infective fungal endocarditis is a severe opportunistic infection with a high mortality rate of about 50%.[2] Among yeasts, various candida species, Trichosporon species, Saccharomyces cervisiae has been reported. [Table 1] summarizes reported cases of infective endocarditis in which Geotrichum and its synonyms have been isolated. The optimal approach to therapy is not yet defined. Although in vitro susceptibility testing has demonstrated decreased antifungal activity to amphotericin B, clinical results have been promising with or without flucytosine or high-dose fluconazole. Voriconazole yields very low MICs against G. candidum and may represent first-line therapy. In the present case, the patient was started empirically on amphotericin B. However, on the identification of the etiological agent, the patient was shifted on voriconazole following which fever spikes subsided.
Table 1: Summary of Case Reports of Infective Endocarditis Due to Geotrichum spp

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.[5]

 
   References Top

1.
Clinical and Laboratory Standards Institute. Reference Method for Broth Dilution Antifungal Susceptibility of Yeasts; Approved Standard-third Edition. CLSI Document M27-A3. Wayne, PA: Clinical and Laboratory Standards Institute; 2008.  Back to cited text no. 1
    
2.
Ghamande AR, Landis FB, Snider GL. Bronchial geotrichosis with fungemia complicating bronchogenic carcinoma. Chest 1971;59:98-101.  Back to cited text no. 2
    
3.
Polacheck I, Salkin IF, Kitzes-Cohen R, Raz R. Endocarditis caused by Blastoschizomyces capitatus and taxonomic review of the genus. J Clin Microbiol 1992;30:2318-22.  Back to cited text no. 3
    
4.
Arnold AG, Gribbin B, De Leval M, Macartney F, Slack M. Trichosporon capitatum causing recurrent fungal endocarditis. Thorax 1981;36:478-80.  Back to cited text no. 4
    
5.
Oscar VT, Teresita CR, Alfredo BA, Ignacio MB, DeJesus CLJ, Gerardo GG, et al. Polymicrobial endocarditis by Geotrichum penicillicatum, Cryptococcus albidus and Staphylococcus epidermidis in a girl. Acta Pediátr Méx 2001;22:406-10.  Back to cited text no. 5
    

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Correspondence Address:
Immaculata Xess
Department of Microbiology, Mycology Section, AIIMS, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgid.jgid_112_16

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2008 Journal of Global Infectious Diseases | Published by Wolters Kluwer - Medknow
Online since 10th December, 2008