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Journal of Clinical and Diagnostic Research. 2018 Feb, Vol-12(2): DD04-DD05
44
DOI: 10.7860/JCDR/2018/30933.11210
Penicillium roqueforti: A Rare
Fungus Causing Infection in
an Immunocompromised Host
Microbiology Section
Case Report
CASE REPORT
A six-year-old boy was admitted to haemato-oncology unit at
a tertiary care centre in North Kerala with febrile neutropenia.
He was a known case of Acute Lymphoblastic Leukaemia (ALL)
on maintenance chemotherapy since two years. He revealed
hepatosplenomegaly, moderate ascites and left sided pleural
effusion. Computed Tomography Scan and Ultrasonography
revealed grossly dilated gallbladder with minimal pericholecystal
fluid suggestive of cholecystitis. He was a Hepatitis B carrier and
had prolonged fever and persistent neutropenia. He was on broad
spectrum antibiotics as per febrile neutropenia protocol since two
weeks but was not responding to it [1].
In his previous admission for maintenance chemotherapy, he com-
plained of throat pain and mild difficulty in swallowing. He had fever
with neutropenia; his absolute neutrophil count was 230 cells/µL. His
blood sample was collected for routine blood culture in Brain Heart
Infusion Broth (BHIB) and was incubated at 37°C for 24 hours. After
24 hours, it was subcultured onto Blood Agar (BA), MacConkey
(MA) agar and Sabouraud’s Dextrose Agar (SDA) as a part of
routine bacterial and fungal culture. On the fourth day, the fungal
culture on SDA kept at room temperature (27˚C), yielded growth of
the fungi. By the end of one week, the BHIB and BA also showed
similar growth. Microscopic examination using Lactophenol Cotton
Blue (LCB) stain, showed hyaline fungi morphologically resembling
Penicillium. Septate hyaline hyphae and branching conidiophores
were seen. From the tip of the conidiophores, phialides grouped
in brush like clusters were found which contain unicellular round to
ovoid smooth conidia arranged in chains [Table/Fig-1a,b].
JISHA ASOKAN1, AJITH KUMAR VELLANI THAMUNNI2, REMA DEVI SURENDRAN3
Keywords: Acute Lymphoblastic Leukaemia, North Kerala, Penicillium species, Systemic mycosis
ABSTRACT
Penicillium roqueforti is a fungus that widely exists in the environment and is often non-pathogenic to humans. However, in
immunocompromised hosts, it may be recognized as a cause of systemic mycosis. We report a rare case of mycosis due to
Penicillium roqueforti in six-year-old haemato-oncology patient.
300 mg/kg/day (IV) 8th hourly and was put on prophylactic oral
Fluconazole 100 mg/kg/day and was sent home. On subsequent
admission, he continued having fever and neutropenia and hence,
was started on broad spectrum antifungal amphotericin B. The
average absolute neutrophil count was around 600 cells/µL. Blood
culture report of his second and third sample too revealed the same
fungus as that in the previous admission. Although, the child was put
on Amphotericin B (IV) 60 mg/kg/day for two weeks, his condition
kept deteriorating. Finally, (IV) Voriconazole was given 4 mg/kg 8th
hourly, was used to treat the infection, for four days.
Since, all three samples from the immunocompromised child grew
the same fungus, it was really significant. Speciation was done at
Microbiological Laboratories Coimbatore by MALDI-TOF, where
it was identified as Penicillium roqueforti. By the time the species
identification was done, the patient deteriorated and succumbed to
death on 29th day of admission.
DISCUSSION
Invasive Fungal Infection (IFI) is among the major causes for morbidity,
mortality and economic burden in haemato-oncology patients like
those with Acute Lymphoblastic Leukaemia (ALL) [2].
Penicillium species are usually non-pathogenic to humans and are
commonly found in the environment. However, they can be virulent
pathogens and that can cause invasive infection and death in an
immunocompromised hosts.
Penicillium roqueforti is a common saprophytic fungus that is used
as a starter culture in the production of Roquefort cheese and other
varieties of blue cheese containing an internal mould [3].
Penicillium roqueforti belong to the family Trichocomaceae. It is
widespread in nature and can be isolated from soil, decaying
organic matter and plants [4].
[Table/Fig-1]: a) Lactophenol cotton blue (LPCB) mount of Penicillium roqueforti
isolated from blood of haemato-oncology patient; b) LPCB mount of isolate showing
Flask shaped phialides bearing unbranched round conidia (marked in the circle)
(Images from left to right)
On further incubation, the SDA showed greenish pink, velvety
colonies with woolly areal hyphae. Culture on reverse showed
reddish brown pigment production [Table/Fig-2a,b].
This was thought to be a contaminant. The patient slightly improved
with antibiotics; Vancomycin 1 gm (IV) BD and Piperacillin/Tazobactam
[Table/Fig-2]: a) Growth of Penicillium roqueforti on Sabouraud’s Dextrose Agar
(SDA) showing greenish pink and yellow velvety colonies with woolly areal hyphae; b)
Culture on SDA on the reverse side showing reddish brown pigment production.
www.jcdr.net Jisha Asokan et al., Penicillium roqueforti: A Rare Fungus Causing Infection in an Immunocompromised Host
Journal of Clinical and Diagnostic Research. 2018 Feb, Vol-12(2): DD04-DD05 55
Keywords: Acute Lymphoblastic Leukaemia, North Kerala, Penicillium species, Systemic mycosis
Though it gives colour and flavour to blue-veined cheeses, it is
also a common spoilage organism in various food products [5]. It
destroys large amounts of vegetables, fruits, and cereal grain, both
pre- and post-harvest every year. The fungus produces allergenic
spores and hazardous mycotoxins that cause reduced nutritional
values of food and feed [6].
Penicillium species can cause opportunistic infections [7]. Patients
with Penicillium species infections have been treated successfully
with itraconazole [8] Amphotericin B or fluconazole [8,9]. However,
some patients with conditions caused by Penicillium species have
died despite treatment with Amphotericin B and Itraconazole [7,10].
In patients with nosocomial infections or infections complicating
organ failure, higher mortality rates are seen when pulmonary
infections are caused by fungi, including Penicillium species [11].
In a large retrospective study conducted among patients in Italy
with haematologic malignancies, two-thirds of the 538 Invasive
Fungal Infection cases were attributable to moulds out of which
Penicillium caused only less than 2% of invasive infections [12]. In
the present case, the patient must have acquired the pathogen from
an environmental source, which, over a period of time, ended up in
a fatal systemic infection.
P. roqueforti from multiple cultures combined with it being a
relatively uncommon species in our institution, makes laboratory
contamination less likely in our case. It is striking that all three
blood culture report showed the same result in this patient. ALL
with intensive chemotherapy imposes a far greater degree of an
immunocompromised state for an opportunistic pathogen. Unlike
the fatal pneumonia case caused by P.digitatum, an immunodiffusion
testing for antibodies was not done here due to lack of facilities [7].
CONCLUSION
To the best of our knowledge, this is the first report of invasive
infection with Penicillium roqueforti. The patient had no known
history of exposure to cheese, but was likely to get it from soil or
spores present in air. Moreover, chemotherapy was going on for
ALL could have been one of the factors that might have facilitated
the infection. In this case, antifungals were ineffective in treating
the blood stream involvement. Although, human infections with
P. roqueforti are considered rare, it appears that this organism
can be very virulent and resistant to antifungals. Hence, further
investigations are warranted to render diagnosis and treatment of
such rare fungal infections.
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PARTICULARS OF CONTRIBUTORS:
1. Senior Resident, Department of Microbiology, Government Medical College, Kozhikode, Kerala, India.
2. Professor and Head, Department of Paediatrics, Government Medical College, Manjeri, Kerala, India.
3. Professor and Head, Department of Microbiology, Dr. SMCSI Medical College, Thiruvananthapuram, Kerala, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Jisha Asokan,
Chaithanya, 33/5580, Golf Link Road, Chevayur, Kozhikode, Kerala-673017, India.
E-mail: drjisha@rediffmail.com
FINANCIAL OR OTHER COMPETING INTERESTS: None.
Date of Submission: Jun 23, 2017
Date of Peer Review: Aug 12, 2017
Date of Acceptance: Oct 16, 2017
Date of Publishing: Feb 01, 2018
