SUMMARY Trichosporon spp. are basidiomycetous yeast-like fungi found widely in nature. Clinical isolates are generally related to superficial infections. However, this fungus has been recognized as an opportunistic agent of invasive infections, mostly in cancer patients and those exposed to invasive medical procedures. It is possible that the ability of Trichosporon strains to form biofilms on implanted devices, the presence of glucuronoxylomannan in their cell walls, and the ability to produce proteases and lipases are all factors likely related to the virulence of this genus and therefore may account for the progress of invasive trichosporonosis. Disseminated trichosporonosis has been increasingly reported worldwide and represents a challenge for both diagnosis and species identification. Phenotypic identification methods are useful for Trichosporon sp. screening, but only molecular methods, such as IGS region sequencing, allow the complete identification of Trichosporon isolates at the species level. Methods for the diagnosis of invasive trichosporonosis include PCR-based methods, Luminex xMAP technology, and, more recently, proteomics. Treating patients with trichosporonosis remains a challenge because of limited data on the in vitro and in vivo activities of antifungal drugs against clinically relevant species of the genus. Despite the mentioned limitations, the use of antifungal regimens containing triazoles appears to be the best therapeutic approach.

Current Knowledge of Trichosporon spp. and Trichosporonosis

During mycologic monitoring of the air in a hematology ward, we found massive air contamination caused by Trichosporon asahii, both in the room where neutropenic patients were staying and the corridor immediately outside the room. This fungal species had never been isolated in previous samplings. The urine culture taken from one of the patients in this room, whose urinary catheter had been removed immediately prior to air sampling, resulted positive for T. asahii. Both macroscopic and microscopic morphologic observation was insufficient for confirming the hypothesis of a close relationship between the strains isolated from the patient, from the air in the room and corridor. Therefore, we used genomic typing with random amplified polymorphic DNA (RAPD). The five primers used, (GTG)(5), (GACA)(4), M13, OPE01, RC08, produced different patterns of polymerase chain reaction (PCR) products; the genomic profiles obtained with the same primer, however, resulted perfectly superimposable for all the strains. This result led us to conclude that the massive air contamination caused by T. asahii can have effectively been determined by the removal of the urinary catheter from the patient who presented an asymptomatic infection caused by this microorganism.

Isolation of Trichosporon in a hematology ward.

Trichosporon species isolated from the perigenital region, urine and catheters of a Brazilian population

Four months after receiving an orthotopic liver transplant, a 51-year-old man was admitted for progressive liver failure and severe hepatocellular necrosis thought to be due to tacrolimus. During his hospitalization he experienced bloodstream infections including fungemia due to Trichosporon mucoides and prolonged undulating fever despite antifungal and antibacterial treatment. He underwent removal of the allograft and implantation of another liver. Fever continued postoperatively until therapy with posaconazole was initiated. Initiation of posaconazole led to clinical improvement until the patient's demise from bacteremic vancomycin-resistant enterococcal peritonitis. Trichosporonosis appears to be an emerging fungal infection among immunocompromised individuals (including both hematological and solid organ transplant recipients). T. mucoides is a rare cause of systemic infection. When it occurs, trichosporonosis usually is associated with hematological malignancies and, to the best of our knowledge, has not been previously reported in a liver transplant recipient. The optimal treatment is not well defined. We report here the first case using posaconazole for treatment of trichosporonosis in a liver transplant recipient caused by T. mucoides.

Trichosporon mucoides fungemia in a liver transplant recipient: case report and review

Trichosporon asahii, formerly known as Trichosporon beigelii, is a ubiquitous yeast found naturally in soil and in stagnant or fresh water. It causes superficial infection of the hair shafts, commonly referred to as white piedra. Other superficial infections caused by T. asahii include onychomycosis and otomycosis. Deep infections caused by T. asahii, known as trichosporonosis, occur most often in patients with underlying immunocompromising conditions such as cytotoxic chemotherapy-induced granulocytopenia, hemochromatosis, AIDS or steroid-induced altered immune function. In these patients infection may be limited to a single organ site or may become disseminated. Reports of T. asahii colonization or invasive disease in very low birth weight (VLBW) neonates are rare. Most reported cases have been associated with an outbreak in one neonatal intensive care unit. These infections are almost uniformly fatal in these neonatal immunocompromised hosts. We report two neonates with trichosporonosis and review the possible underlying risk factors, clinical presentation, management and outcome for our patients and those reported previously in the literature.

Trichosporonosis, an unusual fungal infection in neonates.

Although the natural habitat of Trichosporon species is considered to be the soil, the role of normal skin in the carriage of Trichosporon beigelii is unknown. The purpose of this study was to determine the prevalence of T. beigelii colonization on normal perigenital skin. Inguinal skin scrapings were obtained from 322 asymptomatic volunteers. There were 261 males and 61 females ranging in age from 18 to 89; 136 were white, 134 were black, and 52 were Hispanic. Specimens were cultured on Sabouraud's glucose agar containing 500 micrograms ml-1 chloramphenicol, and incubated at 23-26 degrees C for up to 4 weeks. The overall incidence of T. beigelii colonization was 12.4%. However, this varied with patient's age, sex, race and socioeconomic background. The highest prevalence (27.1%) was found in black males who attended a Veterans Affairs hospital. The prevalence was lowest in females (1.6%), and no patients who attended a private clinic were colonized. It was concluded that T. beigelii colonizes normal skin with some regularity.

Prevalence of Trichosporon beigelii. Colonization of normal perigenital skin.

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Prevalence of Trichosporon beigelii. Colonization of normal perigenital skin.