INTRODUCTION:Paecilomyces is an infrequent cause of infection in human. Most cases of disease caused by the genus Paecilomyces occur in patients who have compromised immune systems, indwelling foreign devices, or intraocular lens implants. Rarely has disease been reported in an immunocompetent host without identifiable risk factors.However infectious forms of Paecilomyces in immunocompetent hosts have become more frequent in the last several years. Here we report a case of pneumonia caused by Paecilomyces in an immunocompetent host.
CASE PRESENTATION:Sixty seven year old music teacher and professional musician with no significant past medical, surgical, or social history was in his usual state of good health until one month prior to admission, when he began experiencing fever, productive cough, and shortness of breath. He reported that his symptoms had begun shortly after returning to Los Angeles after performing concerts in Phoenix and Las Vegas. His cough was constant throughout day and night with two to three teaspoons of white-yellow sputum production each day. He reported low-grade fevers, but denied any chills, rigor, or sick contacts. Initially he was treated for bronchitis with a seven-day course of levaquin 500mg/daily by his primary care physician, but his condition did not improve. He was referred to our chest clinic and a CT of the chest revealed left lower lobe pneumonia with bilateral hilar lymphadenopathy. Concurrently, sputum for microbiology was sent which showed mold and yeast; hence the patient was started on Itraconazole 200mg twicw daily pending culture results. However, his cough and shortness of breath worsened despite of the treatment. Subsequently, sputum culture identified Paecilomyces. Itraconazole was switched to Posaconazole due to few reports that suggested Paecilomyces was relatively resistant to Itraconazole. Over a period of four weeks, patient showed significant improvement of his symptoms and a repeat CT of the chest showed clearance of the previously seen infiltrates.
DISCUSSIONS:Paecilomyces is a filamentous fungus, which inhabits the soil, decaying plants, and food products. Some species of Paecilomyces are isolated from insects. Presence of Paecilomyces have been considered as contaminant, however several cases of infection in humans and animals have been reported. There are rare case reports in humans involve corneal ulcer, keratitis, and endophthalmitis following extended wear contact lens use or ocular surgery (1); and cellulitis and onychomycosis after direct cutaneous inoculation in immunocompromised patients. However pneumonia secondary to paeciliomyces has not been reported. Paecilomyces has been reported to be one of the many emerging fungal pathogens in the recent years. Our case is unique in that it is the first reported case of pneumonia from Paecilomyces, and that it occurred in an otherwise healthy immunocompetent host. Furthermore, we observed that Paecilomyces demonstrated resistance to Itraconazole in vivo, and that Posaconazole had a significant effect in the treatment of pneumonia caused by this pathogen.
CONCLUSION:Paecilomyces is among the emerging causative agents of opportunistic mycoses, which can cause various infections in both immunocompromised and immunocompetent hosts. We report the first case of pneumonia caused by this pathogen in an immunocompetent host. Although the data is limited regarding the susceptibility, Paecilomyces appears to be resistant to Itraconazole. Posaconazole, the novel triazole which was shown to be active in vitro, demonstrated effectiveness in treatment of pneumonia from Paecilomyces in our patient. Further studies are needed to elucidate the epidemiology, clinical manifestations, and treatment strategies of infections from Paecilomyces.
DISCLOSURE:Nariman Saddad, None.