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CASE REPORT
Year : 2014  |  Volume : 8  |  Issue : 1  |  Page : 48-50

Rhodotorula spp. infection presenting as meningitis and fungaemia in human immunodeficiency virus infected patient


1 Department of Medicine, Infectious Disease Unit, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Microbiology, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Medicine, Bayero University, Kano, Nigeria

Date of Web Publication18-Sep-2014

Correspondence Address:
Abdulrazaq G Habib
Department of Medicine, Infectious Disease Unit, BUK/AKTH, P.M.B 3011, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0331-3131.141031

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   Abstract 

This case presents an uncommon fungal infection in the setting of HIV infection. This patient with meningitis from Rhodotorula spp. presented with headache, neck pain, and seizures; in the setting of low CD4 cell count of 50 cells/μl. The diagnosis was confirmed by the isolation of the fungus from the CSF and blood. She improved remarkably on high dose fluconazole.

Keywords: Fungaemia, HIV, meningitis, rhodotorula spp


How to cite this article:
Tiamiyu AB, Dayyab FM, Edwin CP, Iliyasu G, Dalhat MM, Habib AG. Rhodotorula spp. infection presenting as meningitis and fungaemia in human immunodeficiency virus infected patient. Ann Nigerian Med 2014;8:48-50

How to cite this URL:
Tiamiyu AB, Dayyab FM, Edwin CP, Iliyasu G, Dalhat MM, Habib AG. Rhodotorula spp. infection presenting as meningitis and fungaemia in human immunodeficiency virus infected patient. Ann Nigerian Med [serial online] 2014 [cited 2021 Apr 18];8:48-50. Available from: https://www.anmjournal.com/text.asp?2014/8/1/48/141031


   Introduction Top


Rhodotorula is a pigmented yeast, belonging to the Basidiomycota phylum. It is a common environmental inhabitant. It can be cultured from soil, water, and air samples. The main risk factors for Rhodotorula infection are immunosuppression, malignancies and foreign-body-intravascular devices such as central venous catheters. [1] There have been few reports on Rhodotorula meningitis in HIV positive patients worldwide.


   Case Report Top


A 40-year-old single civil servant, known to have human immunodeficiency virus (HIV) infection diagnosed 5 months prior to admission; and had been on tenofovir, lamivudine and nevirapine. CD4 count on presentation was 50 cells/μl. She presented with 2 months history of headache, neck pain and convulsions. No history of fever, photophobia or loss of consciousness. She also had no history of vomiting, ear discharge, toothache, cough or drenching night sweat. On day one of admission, she developed reduced hearing in both ears and facial asymmetry. She had received syndromic empirical treatment for acute meningitis with ceftriaxone and short course oral fluconazole 4 months ago at another facility. She had no history of cigarette smoking or ingestion of alcoholic beverages. Physical examination revealed a young woman who was chronically-ill looking, wasted, not pale, had an axillary temperature of 36.6 0 C, fully conscious, and oriented in time place and person. She had neck stiffness, negative Kernig's sign and a right upper motor neuron facial nerve palsy. She had bilateral pupillary dilatation with blurred disc margins on fundoscopy. Pulse rate was 98 beats/min, blood pressure of 130/90 mmHg and a respiratory rate of 18 cycles/min. Total white cell count and differential, platelet and haematocrit were within normal limit. Serum electrolytes and urea revealed; urea of 4.8 mmol/l, creatinine of 141 μmol/l, sodium of 134 mmol/l, and HCO 3 of 16 mmol/l. She had a slight elevation of aspartate aminotransferase (76U/l); other liver enzymes and serum protein were all within normal limit. Cerebrospinal fluid (CSF) analysis showed many yeast cells on wet preparation, cell count was 9 × 10 6 cells/ml with 80% neutrophils, negative Indian ink stain, glucose of 1.0 mg/dl, and protein of 34 mg/dl. Both blood and CSF analysis confirmed the diagnosis of Rhodotorula species using the methodology described below. Brain CT scan revealed ventromegaly with hydrocephalus. Erythrocyte sedimentation rate was 12 mm/hr. She was treated with high dose fluconazole, sodium valproate 400 mg twice daily and 20% mannitol for cerebral decompression. She was maintained on trimethoprim-sulfamethoxazole and antiretroviral medications, and was discharged following remarkable improvement.

Methodology

CSF sample was centrifuged and the resultant sediment was used for Gram-staining, India ink preparation and culture. Microscopy of Gram-stained smear of the CSF showed pear to oval shaped clusters of budding yeast cells [Figure 1]a]. No capsule was detected on the India ink preparation. The CSF was inoculated on Sabouraud-dextrose agar, in addition to blood and chocolate agar. Concomitantly collected peripheral blood culture sample was inoculated into BACTEC aerobic blood culture bottle (BD Diagnostic systems) and incubated in an automated and computerized continuous-reading BACTEC 9050 blood culture system (BD Diagnostic systems). The blood culture machine signalled growth in the sample bottle after 4 days. Microscopy of Gram-stained smear of the blood culture broth showed yeast cells with exactly the same morphology as in the CSF [Figure 1]b]. The broth was subcultured on Sabouraud-dextrose agar (SDA) and Chrome agar, and incubated at 37 0 C. After 72 hours of incubation orange to red pigment colonies were seen for both the CSF and blood culture [Figure 2]. Inoculation of the colonies onto Christense's urease agar revealed urease enzyme production, with the organism not fermenting lactose after more than 1 week of incubation.
Figure 1:

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Figure 2: Orange to red pigment colonies seen in both the CSF and blood culture after 72 hours of incubation on Sabouraud-dextrose and chrome agar at 370C

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Putting the red pigmentation of the colonies together with the other characteristics, the organism was identified as a Rhodotorula spp. Speciation and antifungal susceptibility testing could not be done.


   Discussion Top


Rhodotorula is a pigmented yeast and a normal environmental inhabitant; and was previously considered non-pathogenic, [2] but has now emerged as an opportunistic etiologic agent, particularly in immuno-compromised patients. Such opportunistic infections include those of the blood stream, endocarditis, meningitis, peritonitis and endophthalmitis. [2] Rhodotorula produces pink to red colonies and blastoconidia that are unicellular lacking pseudohyphae and hyphae. [3 Its recognition as an emerging yeast pathogen in humans in the last few decades, is most likely due to the wider use of intensive treatments and central venous catheters (CVCs). [4]

Rhodotorula causes disseminated infections similar to Candida spp. [5] Rhodotorula fungemia has been associated with crude mortality of up to 20% and has been reported in patients with indwelling vascular catheters, granulocytopenia, damage to the normal anatomic barriers (skin, mucosa, especially gastrointestinal), cellular immune dysfunction and parenteral nutrition. [6] In a systemic review of 128 cases of Rhodotorula infections, 79% were fungemia (Rhodotorula mucilaginosa being the most common etiologic species), 7% eye infections and 5% peritonitis associated with continuous ambulatory peritoneal dialysis.

Our index patient is immune-suppressed (HIV positive), on anti- retroviral therapy and presented with both meningitis and fungemia. This could have been a relapse case after initial suboptimal empiric treatment with oral fluconazole 4 months prior to her presentation. Relapse with Rhodutorula meningitis was reported by Gyaurgieva et al., and was treated with itraconazole therapy. [7] We used high dose prolonged fluconazole therapy because amphotericin ± flucytocin (drugs of choice) were not readily available. The infection with this rare yeast could be underreported due to its similarity with Cryptococcus neoformans. In this case, the possibility of contamination was ruled out because CSF is a sterile fluid; and growth was obtained twice on SDA medium from two different samples (CSF and blood) of the same patient.

Finally, it is prudent to request for mycology investigations of the CSF and blood of patients, especially immune-suppressed, who present with clinical features of meningitis; in addition to other routine investigations. Appropriate antifungal therapy should be promptly given if mycology investigations are positive.


   Acknowledgement Top


The entire staff of Medicine and Microbiology Department of Aminu Kano Teaching Hospital, Kano Nigeria.

 
   References Top

1.Kiehn TE, Gorey E, Brown AE, Edwards FF, Armstrong D. Sepsis due to Rhodotorula related to use of indwelling central venous catheters. Clin Infect Dis 1992;14:841-6.  Back to cited text no. 1
    
2.Duggal S, Jain H, Tyagi A, Sharma A, Chugh TD. Rhodotorula fungemia: Two cases and a brief review. Med Mycol 2011;49:879-82.  Back to cited text no. 2
    
3.Fernanda W, Luciano ZG. Review Article Epidemiology of Rhodotorula: An Emerging Pathogen. Interdiscip Perspect Infect Dis 2012;2012:465717.  Back to cited text no. 3
    
4.Miceli MH, Díaz JA, Lee SA. Emerging opportunistic yeast infections. Lancet Infect Dis 2011;11:142-51.  Back to cited text no. 4
    
5.Pasqualotto GC, Copetti FA, Meneses CF, Machado AR, Brunetto AL. Infection by Rhodotorula spp. in children receiving treatment for malignant diseases. J Pediatr Hematol Oncol 2005;27:232-3.   Back to cited text no. 5
    
6.Pfaller MA, Dickerna DJ, Merz WG. Infections caused by non-C andid a, non- Cryptococcus yeasts. In: Anaissie EJ, McGinnis MR, Pfaller MA, editors. Clinical Mycology. 2 nd ed. China: Churchill Livingstone Elsevier; 2009. p. 258-9.  Back to cited text no. 6
    
7.Gyaurgieva OH, Bogomolova TS, Gorshkova GI. Meningitis caused by Rhodotorula rubra in an HIV-infected patient. J Med Vet Mycol 1996;34:357-9.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]


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