A Case of Magnusiomyces capitatus Peritonitis Without Underlying Malignancies

Abstract

Magnusiomyces capitatus is a rare cause of fungal infection in immunocompromised patients, mainly seen in hematological malignancies. M capitatus infections are extremely rare in immunocompetent patients, as it is part of normal human microbial flora. We are presenting an extremely rare case of M capitatus peritonitis in an otherwise immunocompetent patient who suffered from gastrointestinal leakage due to pancreatitis. Fungal identification was performed at reference laboratory by phenotypic characteristics and DNA sequencing of target internal transcribed spacer region of the rRNA gene and the D1-D2 domain of the large-subunit rRNA gene and susceptibility testing by Clinical and Laboratory Standards Institute guidelines (document M27-S4) broth dilution method. He was successfully treated with a combination of surgical repair and voriconazole single therapy.

Full text

https://doi.org/10.1177/2324709618795268
Journal of Investigative Medicine High
Impact Case Reports
Volume 6: 1–4
© 2018 American Federation for
Medical Research
DOI: 10.1177/2324709618795268
journals.sagepub.com/home/hic
Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License
(http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further
permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
Case Report
Introduction
Magnusiomyces capitatus, previously known as Geotrichum
capitatum, Dipodascus capitatus, Trichosporon captiatum,
Saprochaete capitata, or Blastoschizomyces capitatus,1 is a
rare cause of fungal infection in immunocompromised
patients, mainly seen in hematological malignancies.2-17 M
capitatus is extremely rare in immunocompetent patients, as
it is part of normal human microbial flora.18 Presented here is
a case of peritonitis infection with M capitatus without
underlying malignancies.
Case Report
A 32-year-old alcoholic male with liver steatosis presented
with hemorrhagic necrotizing pancreatitis with peritonitis
and retroperitoneum involvement. He was started on conser-
vative therapy and percutaneous irrigation and drainage.
Unfortunately, he rapidly deteriorated on hospital day 4 into
acute abdominal compartment syndrome with acute respira-
tory distress. He was intubated and underwent damage con-
trol laparotomy resulting in pancreatic necrosectomy with
subtotal pancreatectomy, splenectomy, repair of superior
mesenteric vein, and wedge liver biopsy. Intraoperatively,
peripancreatic necrosis was noted to extend proximally to
diaphragm with extensive dissection throughout the retro-
peritoneum and at the root of the small bowel retroperitoneal
area. During his second relaparotomy on hospital day 5 for
removal of abdominal packing, incidental duodenal and gas-
tric enterotomies were noted and repaired. Retroperitoneal
edema was much improved. Cholecystectomy was per-
formed for eosinophilic cholecystitis. Large Davol sump
drains were placed for postoperative irrigation. Whittman
patch and wound vacuum-assisted closure were placed. He
required prolonged intensive care unit (ICU) admission with
mechanical ventilation. Four additional operations were
required to reapproximate his abdominal fascia. Skin was
eventually closed on hospital day 17.
795268HICXXX10.1177/2324709618795268Journal of Investigative Medicine High Impact Case ReportsD’Assumpcao et al
case-report20182018
1Ross University, Miramar, FL, USA
2Kern Medical—University of California Los Angeles, Bakersfield, CA,
USA
Received April 18, 2018. Revised July 16, 2018. Accepted July 22, 2018.
Corresponding Author:
Carlos D’Assumpcao, MD, Kern Medical—UCLA, 1700 Mount Vernon
Avenue, Bakersfield, CA 93306, USA.
Email: cdassumpcao@gmail.com
A Case of Magnusiomyces capitatus
Peritonitis Without Underlying
Malignancies
Carlos D’Assumpcao, MD1,2 , Benson Lee, DO2,
and Arash Heidari, MD2
Abstract
Magnusiomyces capitatus is a rare cause of fungal infection in immunocompromised patients, mainly seen in hematological
malignancies. M capitatus infections are extremely rare in immunocompetent patients, as it is part of normal human microbial
flora. We are presenting an extremely rare case of M capitatus peritonitis in an otherwise immunocompetent patient who
suffered from gastrointestinal leakage due to pancreatitis. Fungal identification was performed at reference laboratory by
phenotypic characteristics and DNA sequencing of target internal transcribed spacer region of the rRNA gene and the
D1-D2 domain of the large-subunit rRNA gene and susceptibility testing by Clinical and Laboratory Standards Institute
guidelines (document M27-S4) broth dilution method. He was successfully treated with a combination of surgical repair and
voriconazole single therapy.
Keywords
Magnusiomyces capitatus, Geotrichum capitatum, Dipodascus capitatus, Trichosporon captiatum, Saprochaete capitata,
Blastoschizomyces capitatus, peritonitis

2 Journal of Investigative Medicine High Impact Case Reports
His course was also complicated by pleural effusions, pul-
monary embolism, and persistent fevers and leukocytosis.
Pleural effusions were therapeutically drained and were cul-
ture negative. Heparin was bridged to warfarin for his pul-
monary embolism. Meropenem, linezolid, and micafungin
were started empirically on hospital day 19.
Peritoneal fluid was collected on hospital day 19 and sent
for culture, which grew Klebsiella oxytoca and vancomy-
cin-resistant Enterococcus faecium (VITEK2, bioMérieux,
Durham, NC). There was suspicion of incomplete drainage
of intraabdominal fluid, and so a retroperitoneal drain was
placed by interventional radiology on hospital day 31.
Culture of this retroperitoneal fluid grew vancomycin-resis-
tant enterococci E faecium (VITEK2, bioMérieux) and M
capitatus (identification by phenotypic characterization and
DNA sequencing of targets internal transcribed spacer region
of the rRNA gene and the D1-D2 domain of the large-subunit
rRNA gene and the D1-D2 domain of the large-subunit rRNA
gene by University of Texas Health Science, San Antonio,
TX; see Figures 1-3). Peritoneal fluid was collected again
from hospital day 40, and it grew M capitatus, K oxytoca,
and Streptococcus sanguinis (VITEK2, bioMérieux). He
also developed eosinophilia (absolute eosinophil count of
800) on hospital days 42 to 46.
Meropenem was de-escalated to a 2-week course of cef-
triaxone on hospital day 45 (changed to ciprofloxacin at dis-
charge). Linezolid was discontinued after a 2-week course
was completed. A 12-week course of voriconazole (mini-
mum inhibitory concentration = 0.25 µg/mL by Clinical and
Laboratory Standards Institute broth dilution M27-S4
method by the University of Texas Health Science, San
Antonio, TX; see Table 1) was started on hospital day 45.
Warfarin for his pulmonary embolism was switched to
enoxaparin due to drug-drug interaction of warfarin with
voriconazole. He started to improve and was eventually dis-
charged home on hospital day 50 with follow-up in outpa-
tient clinic, ambulating and tolerating food.
At 12-week follow-up, the patient reported abstinence
from alcohol since initial hospital admission. The patient’s
wife was supportive during the entire hospital stay as well
as the post hospital recovery, ensuring wound dressing
changes and medication compliance. Liver function was
monitored every 3 to 4 weeks as an outpatient throughout
the 12-week course of voriconazole. Liver function was
within normal limits. He completed a 90-day course of
anticoagulation.
Figure 1. Magnusiomyces capitatus, peritoneal fluid, 5-day culture
on Sabouraud Dextrose Agar, Emmons media (Thermo Scientific,
Remel, Lenexa, KS).
Figure 2. Magnusiomyces capitatus, peritoneal fluid, 2-day culture,
lactophenol cotton blue stain, 40× magnification.
Figure 3. Magnusiomyces capitatus, retroperitoneal fluid, 7-day
culture, lactophenol cotton blue stain, 40× magnification.

D’Assumpcao et al 3
Discussion
To our knowledge, this is an extremely rare case of M capi-
tatus peritonitis in an otherwise immunocompetent patient
who suffered from gastrointestinal leakage due to pancreati-
tis, likely from the gastric and duodenal enterotomies found
and repaired on hospital day 5. He was successfully treated
with a combination of surgical repair and voriconazole.
Literature review suggests an intrinsic resistance to echino-
candins19; however, in vitro and in vivo activity of antifungals
may differ. Liposomal amphotericin B and azoles, specifically
voriconazole and posaconazole, have had reported clinical
success.7,16,20 In vitro studies with flucytosine, fluconazole,
and itraconazole showed poor susceptibilities.21 No suscepti-
bility break points have been determined yet.
The newest triazole, isavuconazole, demonstrated excel-
lent in vitro activity against M capitatus.22 In the SECURE
trial, a phase 3, randomized, controlled, noninferiority clini-
cal trial against aspergillus and other filamentous fungi, isa-
vuconazole was equally tolerable but had better
pharmacokinetics and fewer drug-related adverse events
compared with voriconazole.23 Due to identical minimum
inhibitory concentration of our patient’s isolate to voricon-
azole and isavuconazole (see Table 1), voriconazole was
selected as the initial triazole antifungal therapy so that isa-
vuconazole could be reserved for rescue therapy in the event
that voriconazole did not improve clinical status. Recently,
ICU admissions have been linked to the development of M
capitatus infection. In Italy, a non-neutropenic patient in the
ICU after cardiac surgery developed M capitatus fungemia.24
In Croatia, a fatal M capitatus respiratory tract infection was
diagnosed posthumously in a patient who became febrile 7
days into his ICU admission for polytrauma.25 Moreover, a
recent survey of M capitatus infections in the ICU and hema-
tology-oncology unit within a single hospital in Turkey
found the strains to be genetic clones. However, microbio-
logical investigations of the hospital environment failed to
find the isolate.26 While M capitatus is considered a ubiqui-
tous environmental organism and part of the normal human
gastrointestinal flora,18 to the authors’ knowledge, there has
not been any case reports or studies tracing M capitatus to a
hospital fomite. More studies are needed to determine a true
correlation between ICU admissions and M capitatus
infections.
Vancomycin-resistant E faecium, S sanguinis, and K oxy-
toca likely had a gastrointestinal instead of a cutaneous
source. While coinfection may have caused peritonitis in this
patient, his clinical status did not improve until the addition
of the appropriate antifungal covering this particular strain of
M capitatus.
Authors’ Note
This case report was presented as a poster at the Solomon Scholars
Research Program at UCLA Department of Medicine, in June 2017;
American College of Physicians Southern California Chapters
Regions I, II, and III at Marina del Rey, California, in September
2017; as well as American Federation for Medical Research Western
Medical Research Conference in Carmel, California, in January 2018.
Acknowledgments
The authors wish to acknowledge the contributions of the follow-
ing: Danna Mejia, Jocelyn Oats, and Joan Buddecke.
Declaration of Conflicting Interests
The authors(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors(s) received no financial support for the research,
authorship, and/or publication of this article.
Ethics Approval
Ethical approval to report this case was obtained from the Kern
Medical Center Institutional Review Board (Study #17037).
Informed Consent
Informed consent for patient information to be published in this
article was not obtained because patient or legal representative was
not available in time for publication. The information in the inves-
tigator’s written request for “Waiver of Consent” coupled with the
written research proposal disclosing the data use plan were reviewed
by the Kern Medical Center Institutional Review Board to deter-
mine that under the conditions of study approval, there should be
minimal or less risk for exposure of patient identity. The Kern
Medical Center Institutional Review Board approved the request
for the Waiver of Consent as part of its ethics approval of the study.
ORCID iD
Carlos D’Assumpcao https://orcid.org/0000-0001-9967-9612
References
1. de Hoog GS, Smith MT. Ribosomal gene phylogeny and spe-
cies delimitation in Geotrichum and its teleomorphs. Stud
Mycol. 2004;50:489-515.
Table 1. Magnusiomyces capitatus, Retroperitoneal Fluid,
Antifungal Sensitivities by the University of Texas Health Science,
San Antonio, TX, by the Clinical and Laboratory Standards
Institute Broth Dilution (M27-S4) Method. No Established Break
Points.
Antifungal Agent
Minimum Inhibitory
Concentration
Amphotericin B 1 µg/mL
Natamycin 8 µg/mL
Fluconazole 8 µg/mL
Itraconazole 1 µg/mL
Posaconazole 0.5 µg/mL
Voriconazole 0.25 µg/mL
Isavuconazole 0.25 µg/mL

4 Journal of Investigative Medicine High Impact Case Reports
2. Martino P, Venditti M, Micozzi A, et al. Blastoschizomyces
capitatus: an emerging cause of invasive fungal disease in leu-
kemia patients. Rev Infect Dis. 1990;12:570-582.
3. Pagano L, Morace G, Ortu-La Barbera E, Sanguinetti M,
Leone G. Adjuvant therapy with rhGM-CSF for the treatment
of Blastoschizomyces capitatus systemic infection in a patient
with acute myeloid leukemia. Ann Hematol. 1996;73:33-34.
4. Schiemann R, Glasmacher A, Bailly E, et al. Geotrichum
capitatum septicemia in neutropenic patients: case report and
review of the literature. Mycoses. 1998;41:113-116.
5. DeMaio J, Colman L. The use of adjuvant interferon-gamma
therapy for hepatosplenic Blastoschizomyces capitatus infec-
tion in a patient with leukemia. Clin Infect Dis. 2000;31:822-
824.
6. Pérez-Sanchez I, Anguita J, Martín-Rabadan P, et al.
Blastoschizomyces capitatus infection in acute leukemia
patients. Leuk Lymphoma. 2000;39:209-212.
7. Gadea I, Cuenca-Estrella M, Prieto E, et al. Genotyping and
antifungal susceptibility profile of Dipodascus capitatus iso-
lates causing disseminated infection in seven hematological
patients of a tertiary hospital. J Clin Microbiol. 2004;42:1832-
1836.
8. Martino R, Salavert M, Parody R, et al. Blastoschizomyces
capitatus infection in patients with leukemia: report of 26
cases. Clin Infect Dis. 2004;38:335-341.
9. Girmenia C, Pagano L, Martino B, et al. GIMEMA infection
program, invasive infections caused by Trichosporon species
and Geotrichum capitatum in patients with hematological
malignancies: a retrospective multicenter study from Italy and
review of the literature. J Clin Microbiol. 2005;43:1818-1828.
10. Bonini A, Capatti C, Parmeggiani M, et al. Galactomannan
detection in Geotrichum capitatum invasive infections: report
of 2 new cases and review of diagnostic options. Diagn
Microbiol Infect Dis. 2008;62:450-452.
11. Özkaya-Parlakay A, Cengiz AB, Karadağ-Öncel E, et al.
Geotrichum capitatum septicemia in a hematological malig-
nancy patient with positive galactomannan antigen: case report
and review of the literature. Turk J Pediatr. 2012;54:674-678.
12. Saghrouni F, Abdeljelil JB, Youssef YB, et al. Geotrichum
capitatum septicemia in patients with acute myeloid leukemia.
Report of their cases. Med Mycol Case Reports. 2012;1:88-90.
13. Miglietta F, Vella A, Faneschi ML, et al. Geotrichum capi-
tatum septicaemia in a haematological patient after acute
myeloid leukaemia relapse: identification using MALDI-TOF
mass spectrometry and review of the literature. Infez Med.
2015;23:161-167.
14. Trabelsi H, Néji S, Gargouri L, et al. Geotrichum capita-
tum septicemia: case report and review of the literature.
Mycopathologia. 2015;179:465-469.
15. Karapinar DY, Karadaş N, Siviş ZO, et al. Rare severe mycotic
infections in children receiving empirical caspofungin treat-
ment for febrile neutropenia. Braz J Infect Dis. 2015;19:549-
552.
16. Cofrancesco E, Viviani MA, Boschetti C, Tortorano AM,
Balzani A, Castagnone D. Treatment of chronic disseminated
Geotrichum capitatum infection with high cumulative dose
of colloidal amphotericin B and itraconazole in a leukaemia
patient. Mycoses. 2016;38:377-384.
17. Tanuskova D, Horakova J, Svec P, et al. First case of invasive
Magnusiomyces capitatus infection in Slovakia. Med Mycol
Case Rep. 2017;16:12-15.
18. Bouza E, Muñoz P. Invasive infections caused by
Blastoschizomyces capitatus and Scedosporium spp. Clin
Microbiol Infect. 2004;10(suppl 1):76-85.
19. Arendrup MC, Boekhout T, Akova M, et al. ESCMID and
ECMM joint clinical guidelines for the diagnosis and manage-
ment of rare invasive yeast infections. Clin Microbiol Infect.
2014;20(suppl 3):76-98.
20. Birrenbach T, Bertschy S, Aebersold F, et al. Emergence of
Blastoschizomyces capitatus yeast infections, Central Europe.
Emerg Infect Dis. 2012;18:98-101.
21. Girmenia C, Pizzarelli G, D’Antonio D, Cristini F, Martino P.
In vitro susceptibility testing of Geotrichum capitatum: com-
parison of the E-Test, disk diffusion, and Sensititre colorimetric
methods with the NCCLS M27-A2 broth microdilution refer-
ence method. Antimicrob Agents Chemother. 2003;47:3985-
3988.
22. Thompson GR 3rd, Wiederhold NP, Sutton DA, Fothergill
A, Patterson TF. In vitro activity of isavuconazole against
Trichosporon, Rhodotorula, Geotrichum, Saccharomyces and
Pichia species. J Antimicrob Chemother. 2009;64:79-83.
23. Maertens JA, Raad II, Marr KA, et al. Isavuconazole versus
voriconazole for primary treatment of invasive mould disease
caused by Aspergillus and other filamentous fungi (SECURE):
a phase 3, randomised-controlled, non-inferiority trial. Lancet.
2016;387:760-769.
24. Cavanna C, Lallitto F, Mangione F, Tamarozzi F, Marone P,
Ceriana P. Fungemia due to Saprochaete capitata in a non-
neutropenic patient hospitalized in an intensive care unit after
cardiac surgery. J Mycol Med. 2017;27:281-284.
25. Radic M, Barisic IG, Kuscevic D, Novak A, Tonkic M, Rubic
Z. Geotrichum capitatum respiratory tract infection in a patient
with polytrauma. Infez Med. 2015;23:270-274.
26. Koç AN, Atalay MA, Timur D, Demir G, Kaynar L. Molecular
epidemiology and antifungal susceptibility of Saprochaete
capitata (Blastoschizomyces capitatus) isolates causing noso-
comial infection in Kayseri/Turkey. Infect Dis (Lond). 2016;48:
596-603.