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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 287-289

Fungal rhinosinusitis by Geotrichum candidum


1 Department of Microbiology, Rajarajeswari Medical College and Hospital, Bengaluru, Karnataka, India
2 Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission04-Jan-2020
Date of Decision11-Mar-2020
Date of Acceptance30-Apr-2020
Date of Web Publication28-Jul-2020

Correspondence Address:
Dr. Kirtilaxmi K Benachinmardi
Department of Microbiology, Rajarajeswari Medical College and Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_117_19

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  Abstract 


Rhinosinusitis is an inflammatory infection of the sinuses caused by infectious agents such as bacteria and fungus. Fungal rhino-sinusitis by Geotrichum candidum is rare. A 45-year-old woman presented with complaints of serous nasal discharge from the left nostril for 3 months associated with dental pain in both upper and lower jaws. The patient was recently diagnosed of diabetes mellitus and hypertension. Pus from nasal douching was sent for fungal culture and sensitivity. KOH preparation revealed occasional hyphae. Fungal culture grew white, cottony aerial mycelia. On microscopy, rectangular arthroconidia varying in length between 4 and 10 μm were seen. The isolate was confirmed as G. candidum based on internal transcribed spacer regions of fungal ribosomal DNA. She was started on oral itraconazole for 14 days. Repeated isolation of same etiological agent in culture and confirmation with molecular techniques is essential for accurate diagnosis and appropriate management of fungal infections.

Keywords: Fungal rhinosinusitis, Geotrichum candidum, immunocompromised, itraconazole


How to cite this article:
Benachinmardi KK, Sangeetha S, Rudramurthy SM. Fungal rhinosinusitis by Geotrichum candidum. Int J Health Allied Sci 2020;9:287-9

How to cite this URL:
Benachinmardi KK, Sangeetha S, Rudramurthy SM. Fungal rhinosinusitis by Geotrichum candidum. Int J Health Allied Sci [serial online] 2020 [cited 2020 Aug 6];9:287-9. Available from: http://www.ijhas.in/text.asp?2020/9/3/287/290706




  Introduction Top


Rhinosinusitis is an inflammatory infection of the sinuses caused by infectious agents such as bacteria and fungus. Fungal rhinosinusitis has been reported in literature and is divided into either invasive or noninvasive fungal sinusitis. Invasive sinusitis involves tissue in and around the sinuses of the brain and meninges. Noninvasive sinusitis is restricted only to the sinus mucosa. Different fungal agents causing fungal sinusitis infection include Aspergillus, Penicillium, and mucor.[1]

Geotrichum candidum is a ubiquitous organism present in water and environmental surfaces and is also a commensal of human gastrointestinal tract (GIT) and nostrils. G. candidum as a causative agent of rhinosinusitis is very rare and is always associated with immunocompromised conditions such as diabetes mellitus (DM), HIV, patients on chemotherapy/radiotherapy, and transplant patients on immunosuppressive drugs.[2]

Here, we report a case of fungal rhino-sinusitis by G. candidum in a newly diagnosed DM patient.


  Case Report Top


A 45-year-old young woman presented to our hospital with complaints of serous nasal discharge from the left nostril for the last 3 months associated with dental pain in both upper and lower jaws on the same side. The patient is a known case of DM and hypertension and was on regular medication along with insulin. The patient had a history of previous hospital admission 3 months ago for uncontrolled DM. The patient is moderately built and nourished. On examination, a left maxillary polyp was found. There was poor dental hygiene, and a small swelling was present on the left side of the hard palate. A provisional diagnosis of left maxillary sinusitis/polyp or invasive fungal infection or fungal rhinosinusitis was made. Nasal douching was done, and pus was sent for fungal culture and sensitivity. KOH preparation revealed occasional hyphae. Fungal culture on Sabouraud's dextrose agar at 25°C and 37°C grew white, moist, short cottony aerial mycelia. On microscopy, these colonies revealed rectangular arthroconidia varying in length between 4 and 10 μm, as shown in [Figure 1]. Few rectangular cells rounded at ends and characteristically germinate from one corner giving the appearance of a hockey stick were seen. Preliminary identification of Geotrichum was made and sent to Post Graduate Institute of Medical Research, Chandigarh – mycology reference center for confirmation. The isolate was confirmed as G. candidum based on internal transcribed spacer regions of fungal ribosomal DNA.
Figure 1: (a) Geotrichum candidum growth on Sabouraud's dextrose agar, (b) lactophenol cotton blue preparation showing arthroconidia, and (c) Gram-stain showing Gram-positive arthroconidia

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In addition to other routine investigations, the patient underwent contrast-enhanced computed tomography (CECT) of the paranasal sinuses. CECT showed enhanced tissue density lesion in the left maxillary sinus with involvement of the adjacent structure, giving an impression of fungal sinusitis or osteomyelitis of maxilla. She was started on oral itraconazole 100 mg once a day for 14 days. The patient also underwent functional endoscopic sinus surgery after 9 days of admission, and the biopsy material was sent for histopathology. Histopathology report was suggestive of inflammatory polyp of the left nasal cavity with involvement of the middle meatus. The patient underwent polypectomy and improved without any sequelae.


  Discussion Top


G. candidum is a yeast-like fungus with worldwide distribution. There are reports of it causing oral infections, fungemia in HIV, DM, chronic myeloid leukemia, and acute myeloid leukemia patients. Renal calculi and renal bezoar have been reported in literature as well.[3] It has been reported to cause geotrichosis – a local or disseminated disease. It can affect bronchi, lungs, mouth, and GIT.[4]G. candidum is a potential pathogen among immunocompromised patients, although rare in presentation and reporting. It is commonly either underreported or misreported/misdiagnosed as Candida or Trichosporon.[5] Hence, repeated sampling to isolate and culture the fungus from multiple samples will help making a final diagnosis.[3]

Geotrichum is a genus of yeast-like imperfect fungi of the family Endomycetaceae, belonging to the order Saccharomycetales. It is a saprophytic, ubiquitous fungus found in fruits, decaying vegetables, soil, dairy products, and also as normal flora on the human skin and GIT.[4]

In severe neutropenic patients, it can lead to disseminated infections such as septicemia, involving the heart, lungs, liver, spleen, kidneys, or lymphnodes. There also have been reports of it causing brain abscess and traumatic joint infections.[6],[7] It has also been found in association with Mycobacterium tuberculosis and herpes simplex in causing lung infections.[8],[9]G. candidum is usually sensitive to antifungal therapy. Amphotericin-B and itraconazole have been used for the successful treatment of their infections.[4] In this patient, oral itraconazole 100 mg given for 14 days cured the sinusitis.

Mycoses or fungal balls of sinuses were first reported in 1885 by Schubert.[10] Kecht found 98 cases of Aspergillus-associated sinusitis over a period of 90 years. The most prevalent genera were Aspergillus, Penicillium, Cladosporium, Fusarium, Acremonium, Candida, Alternaria, and Aureobasidium. Other rarely reported agents include Eurolium, Chaetomium, Geotrichum, Verticillium, and Rhizopus.[11] Mohammadi et al. reported 27 cases of fungal sinusitis; among them, two cases were of G. candidum.[12]

Fungi can be found in any sample of nose and sinuses if not collected under strict aseptic precautions. This finding in our study is not surprising as sino-nasal mucosa is a sticky surface, which on exposure to ambient air will invariably be covered with airborne fungal spores. However, in certain patients, this normal flora triggers inflammatory and immunological reactions resulting in chronic rhinosinusitis and polyposis – a theory currently under research.[10] This case is similar and supports this theory, after taking fungal culture and histopathology reports into consideration. Here, fungal culture grew Geotrichum, and histopathology report showed an inflammatory polyp. To the best of our knowledge, this is the first reported case of fungal sinusitis caused by G. candidum from India.

Invasive geotrichosis was first reported in 1971 by Meena et al.[13] The etiological agents of fungal sinusitis differ from the Indian subcontinent to Western countries, where dematiaceous fungi are common, whereas Aspergillus are commonly isolated from the Indian subcontinent. Housing conditions and environmental factors play major roles in the isolation pattern of fungi from the Indian subcontinent when compared to those of Western countries. Fungal sinusitis can be either noninvasive or invasive. Noninvasive fungal sinusitis can present either as allergic fungal sinusitis with recurrent nasal polyposis as seen in our case or as a fungal ball in the sinus. Invasive fungal sinusitis invades the orbit and the central nervous system with a high mortality rate.[14]

Henrich et al. reported a series of 12 cases with G. candidum infections from 1971 through 2007 from transplant patients. The various samples tested were blood, sputum, central venous catheter tip, terminal ileum, skin, heart, lung, liver, spleen, kidney, lymph node, bone marrow, esophageal ulcer, oral epithelium, urine, synovial fluid, and skin and soft tissues.[15]

Among the various Geotrichum species, Geotrichum candidum is the most common infectious agent. Other species are Geotrichum clavatum, Geotrichum fici, and Geotrichum silvicola. Direct microscopic demonstration of pathogen in clinical specimen and its repeated isolation in pure and luxuriant growth remains the gold standard in the diagnosis of geotrichosis.[16]


  Conclusion Top


Computed tomography scan, endoscopy, and histopathological investigations are nonspecific in the diagnosis of allergic fungal sinusitis and fungal ball. Hence, repeated isolation of same etiological agent on culture media and confirmation with molecular techniques is essential for accurate diagnosis and appropriate management of these fungal infections.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chakrabarti A, Denning DW, Ferguson BJ, Ponikau J, Buzina W, Kita H, et al. Fungal rhinosinusitis: A categorization and definitional schema addressing current controversies. Laryngoscope 2009;119:1809-18.  Back to cited text no. 1
    
2.
Bonifaz A, Vázquez-González D, Macías B, Paredes-Farrera F, Hernández MA, Araiza J, et al. Oral geotrichosis: Report of 12 cases. J Oral Sci 2010;52:477-83.  Back to cited text no. 2
    
3.
Yegneswaran Prakash P, Seetaramaiah VK, Thomas J, Khanna V, Rao SP. Renal fungal bezoar owing to Geotrichum candidum. Med Mycol Case Rep 2012;1:63-5.  Back to cited text no. 3
    
4.
Sfakianakis A, Krasagakis K, Stefanidou M, Maraki S, Koutsopoulos A, Kofteridis D, et al. Invasive cutaneous infection with Geotrichum candidum: Sequential treatment with amphotericin B and voriconazole. Med Mycol 2007;45:81-4.  Back to cited text no. 4
    
5.
Kassamali H, Anaissie E, Ro J, Rolston K, Kantarjian H, Fainstein V, et al. Disseminated Geotrichum candidum infection. J Clin Microbiol 1987;25:1782-3.  Back to cited text no. 5
    
6.
Kasantikul V, Chamsuwan A. Brain abscesses due to Geotrichum candidum. Southeast Asian J Trop Med Public Health 1995;26:805-7.  Back to cited text no. 6
    
7.
Hrdy DB, Nassar NN, Rinaldi MG. Traumatic joint infection due to Geotrichum candidum. Clin Infect Dis 1995;20:468-9.  Back to cited text no. 7
    
8.
Popescu L, Verescu O, Crişan E, Vlădescu A. Secondary active-evolutive cavitary pulmonary tuberculosis of the apicodorsal segment of the left upper lobe associated with bronchial tuberculosis and bronchial geotrichosis. Pneumoftiziologia 1997;46:127-30.  Back to cited text no. 8
    
9.
Depagne C, Louerat C, Nesme P. Herpes simplex and Geotrichum candidum pneumonia in a patient with moderate renal failure. Rev Pneumol Clin 2003;59:297-300.  Back to cited text no. 9
    
10.
Buzina W, Braun H, Freudenschuss K, Lackner A, Habermann W, Stammberger H. Fungal biodiversity-as found in nasal mucus. Med Mycol 2003;41:149-61.  Back to cited text no. 10
    
11.
Twarużek M, Soszczyńska E, Winiarski P, Zwierz A, Grajewski J. The occurrence of molds in patients with chronic sinusitis. Eur Arch Otorhinolaryngol 2014;271:1143-8.  Back to cited text no. 11
    
12.
Mohammadi A, Hashemi SM, Abtahi SH, Lajevardi SM, Kianipour S, Mohammadi R. An investigation on non-invasive fungal sinusitis; Molecular identification of etiologic agents. J Res Med Sci 2017;22:67.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Meena S, Singh G, Dabas Y, Rajshekhar P, Xess I. Geotrichum candidum in infective endocarditis. J Glob Infect Dis 2017;9:127-8.  Back to cited text no. 13
    
14.
Michael RC, Michael JS, Ashbee RH, Mathews MS. Mycological profile of fungal sinusitis: An audit of specimens over a 7-year period in a tertiary care hospital in Tamil Nadu. Indian J Pathol Microbiol 2008;51:493-6.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Henrich TJ, Marty FM, Milner DA Jr., Thorner AR. Disseminated Geotrichum candidum infection in a patient with relapsed acute myelogenous leukemia following allogeneic stem cell transplantation and review of the literature. Transpl Infect Dis 2009:11:458-62.  Back to cited text no. 15
    
16.
Turda C. Annals of the University of Oradea, Ecotoxicolgy, Animal Husbandry and Food Industry Technologies.. 2013;12:391-6.  Back to cited text no. 16
    


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