Medical Mycology Case Reports 17 (2017) 8–10

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Medical Mycology Case Reports

journal homepage: www.elsevier.com/locate/mmcr

Penicillium citrinum: Opportunistic pathogen or idle bystander? A case MARK

analysis with demonstration of galactomannan cross-reactivity
⁎
Shayla E. Hessea, , Paul M. Luethyb, John H. Beigelc, Adrian M. Zelaznyb
a
National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
b
Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, MD, USA
c
Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD, USA

A R T I C L E I N F O A B S T R A C T

Keywords: We present a case of an immunocompromised woman with fever, pulmonary infiltrates and multiple
Penicillium citrinum bronchoalveolar lavage (BAL) cultures positive for Penicillium citrinum with a concomitant high BAL
Galactomannan galactomannan level. We report the results of Aspergillus galactomannan testing performed on culture super-
Aspergillus antigen natants from her P. citrinum strain that confirmed the suspected cross-reactivity. Finally, we discuss the clinical
significance and antifungal susceptibility of P. citrinum in our case and review the literature.

1. Introduction suspected the organism's legitimate presence in her tracheobronchial

tree.
Non-marneffei Penicillium species are among the most common Finally we reviewed reported anti-fungal sensitivity data for other
fungi worldwide [1]. They inhabit diverse indoor and outdoor environ- clinical P. citrinum isolates in conjunction with the data obtained from
ments causing the occasional nuisance (moldly bread) in addition to our patient's isolate. It became apparent that the mean inhibitory
having played spoiler in the perhaps the greatest failed experiment of concentration (MIC) for voriconazole was consistently high (> 16 μg/
all time (Alexander Fleming's discovery of penicillin). Despite their ml), while other triazoles and other classes of anti-fungals displayed less
ubiquity, non-marneffei Penicillium species very rarely cause human skewed MIC distributions.
disease.
We present a case of an immunocompromised stem cell transplant 2. Case
recipient with acute respiratory symptoms and a bronchoalveolar
lavage (BAL) culture that grew Penicillium citrinum on multiple plates. A 25-year-old woman with history of aplastic anemia treated with
The BAL galactomannan level was very high despite negative fungal haplo-cord stem cell transplant 7 months prior presented to the hospital
smears and no isolation of Aspergillus sp. in culture. A number of non- with acute neurologic symptoms. Brain magnetic resonance imaging
Aspergillus fungi have been reported to have galactomannan cross- (MRI) revealed large, enhancing bilateral basal ganglia lesions with
reactivity including some strains of Fusarium sp., Paecilomyces sp. and vasogenic edema producing mass effect. The patient was started on IV
Penicillium sp. (not P. citrinum) [2–5]. We present the first data steroids to decrease cerebral edema and rituximab based on high
confirming galactomannan cross-reactivity specifically for Penicillium suspicion for Epstein-Barr virus (EBV)-related post-transplant lympho-
citrinum as measured by a validated clinical assay. proliferative disorder (PTLD). A plan for multi-viral T cell therapy led to
We performed an extensive literature search identifying a total of a preparative steroid taper. One week into the steroid taper the patient
four reports of P. citrinum infection in humans, three of which occurred was suddenly found unresponsive. Repeat MRI showed acute bilateral
in patients with acute leukemia receiving intensive chemotherapy occipital lobe infarctions, presumably secondary to herniation syn-
[6–8] and one which occurred in the setting of direct inoculation into drome given the lack of vascular obstruction or stenosis detected by
an immune-privileged space [9]. Based on our patient's significantly magnetic resonance angiography (MRA) or magnetic resonance veno-
milder degree of immunocompromise relative to that induced by acute graphy (MRV). The patient was restarted on high dose steroids with a
leukemia plus chemotherapy, we concluded that P. citrinum was peak dose of intravenous (IV) dexamethasone 6 mg (mg) every 6 h.
unlikely to have been a tissue-invasive cause of pneumonia in her case. Brain biopsy was performed which confirmed the diagnosis of EBV
However, given growth of P. citrinum from multiple BAL cultures, we PTLD.

⁎
Corresponding author.
E-mail address: [email protected] (S.E. Hesse).

http://dx.doi.org/10.1016/j.mmcr.2017.05.003
Received 29 April 2017; Received in revised form 11 May 2017; Accepted 22 May 2017
Available online 22 May 2017
2211-7539/ Published by Elsevier B.V. on behalf of International Society for Human and Animal Mycology. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
S.E. Hesse et al. Medical Mycology Case Reports 17 (2017) 8–10

One month into her hospitalization the patient developed low-grade Table 1
fever and a low-flow oxygen requirement associated with symptoms of Results of Platelia™ Aspergillus Enzyme Immunoassay Testing.
dry cough and mild shortness of breath (day 0 for reference). Same-day
Culture sample Index value Interpretation
computed tomography angiography (CTA) of the chest showed new
diffuse, bilateral pulmonary infiltrates without evidence of pulmonary Sterile media 0.39 Negative
embolism. At this point her steroid dose had been tapered down to Penicillium citrinum 6.85 Positive
Aspergillus fumigatus 3.75 Positive
dexamethasone 2 mg IV every 12 h and she was on Day 2 of
piperacillin-tazobactam for a possible Citrobacter urinary tract infec-
tion (UTI). She remained on prophylactic micafungin 100 mg daily microbiologic assays for Pneumocystis, Herpes simplex virus (HSV),
(started on day −12) and prophylactic trimethoprim sulfamethoxazole Histoplasma, Toxoplasma, human herpesvirus 6 (HHV-6) and common
in addition to pre-emptive ganciclovir therapy (started on day −14). respiratory viruses also returned negative.
She had completed a 5-day course of oseltamivir three weeks prior To assess whether P. citrinum could account for the positive BAL
following a positive nasal wash test for Influenza A. Mild symptoms of galactomannan, supernatant from a pure P. citrinum broth culture was
nasal congestion without fever, shortness of breath or myalgias had submitted for testing by the Platelia™ Aspergillus Enzyme Immunoassay
prompted respiratory viral testing at that time. (MiraVista Diagnostics). Aspergillus fumigatus broth culture supernatant
On exam (day 0) the patient was febrile to 38.4 C, tachycardic with (positive control) and sterile fungal broth culture media (negative
rate 110–120 beats minute−1 and normotensive. She was slightly control) were submitted in parallel. Results are summarized in Table 1.
tachypneic while saturating 91–93% on room air. Oxygen saturation Relative differences in index values between Penicillium citrinum and
improved to > 95% with 2 l of oxygen via nasal cannula. Laboratory Aspergillus fumigatus culture supernatants cannot be ascribed any
data were notable for stable lymphopenia (absolute lymphocyte count definite significance (as may be growth rate and strain dependent),
380 cells dl−1) and lack of neutropenia (absolute neutrophil count 1670 although it is worth noting that both molds were inoculated at the same
cells dl−1). Computed tomography (CT) of the chest revealed diffuse time with the aim of producing approximately equal culture densities.
bilateral peri-hilar nodules and ground-glass opacities. The P. citrinum BAL isolate was sent to the University of Texas
Bronchoalveolar lavage was performed (day +1) which did not Health Science Center (San Antonio, TX) for sensitivity testing by a
reveal any endobronchial lesions nor any thick or bloody secretions. clinical mycology reference laboratory. The following MICs (μg ml−1)
Gram stain, wet mount and acid-fast stains were negative. Qualitative were reported (results obtained on day +30): 1 for amphotericin B,
cytomegalovirus (CMV) PCR was positive as well as PCR for Influenza A 0.125 for caspofungin, 0.06 for micafungin, 4 for itraconazole, 2 for
(the same subtype as was previously detected in her nasal wash). Of posaconazole and > 16 for voriconazole. There are no clinical break-
note, serum CMV levels measured concurrently were low. The BAL points for filamentous molds set by the Clinical and Laboratory
galactomannan level registered above the limits of quantification Standards Institute (CLSI), so these MICs represent unofficial bench-
(index ≥ 3.750) although no Aspergillus species were detected by wet marks only and have no established clinical interpretation.
mount or culture. By day 4 Penicillium citrinum had grown from three A broad differential diagnosis was entertained for this presentation
separate cultures (fungal, Legionella, and Nocardia) inoculated with the of fever plus an acute pulmonary process. After assimilation of all
same BAL specimen. The isolate displayed a characteristic grey-green clinical, radiographic and microbiologic data, Influenza pneumonia,
colony with yellow diffusing pigment as classically described (Fig. 1). pulmonary EBV-PTLD and post-transplant pulmonary complications
Organism identification was initially performed by matrix-assisted laser such as cryptogenic organizing pneumonia (COP) were considered
desorption ionization-time of flight (MALDI-TOF) mass spectrometry reasonably likely etiologies. Considered less likely but still possible
(duplicate scores > 2.00) and later confirmed by genetic sequencing of was pneumonia secondary to other respiratory viruses, Aspergillus or
the internal transcribed spacer (ITS) region (100% match to type strain other commonly invasive fungi, Penicillium citrinum, hospital-acquired
CBS 117.65 (GenBank accession number GU944562)). Routine bacter- bacterial organisms, CMV, Nocardia, Pneumocystis jirovecii or
ial and acid-fast bacilli (AFB) cultures were negative. Additional Toxoplasma gondii.The patient was covered broadly for the potential
infectious etiologies described above. Oseltamivir and posaconazole
were started (on day +1 and +4 respectively), micafungin, ganciclo-
vir, and trimethoprim-sulfamethoxazole were continued, and pipera-
cillin-tazobactam was exchanged briefly for meropenem before broad-
spectrum anti-bacterial agents were discontinued altogether.
Dexamethasone tapering continued but the patient did not receive
EBV-PTLD-specific treatment (rituximab or cytotoxic T cells) in this
acute time period.
The patient continued to spike intermittent low-grade fevers for one
week with negative blood cultures. Serial CT chest scans showed
gradual improvement over the course of several weeks. By day 31,
almost complete radiographic resolution had been achieved and
supplemental oxygen was unnecessary. The patient had completed a
7 day course of oseltamivir by this point and had received 27 days of IV
posaconazole. Serum posaconazole levels were serially checked and
consistently therapeutic (1750 ng/ml on day +10, 939 ng/ml on day
+37). Posaconazole 300 mg IV daily was thereafter transitioned to oral
posaconazole at the same dose before its eventual discontinuation on
day 97.

3. Discussion

Fig. 1. P. citrinum colony growth after 4 days of incubation on Sabouraud dextrose agar at The growth of P. citrinum in three separate BAL cultures from a
27 °C. symptomatic, immunocompromised patient prompted careful consid-

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S.E. Hesse et al. Medical Mycology Case Reports 17 (2017) 8–10

eration of a P. citrinum pneumonia diagnosis. After review of the only other report of P. citrinum sensitivities encountered after a
literature and consultation with a clinical mycology expert, we broad literature search was authored by a group at the Fungal
concluded that P. citrinum pneumonia was an unlikely diagnosis in Testing Laboratory at the University of Texas Health Science Center
our patient but that the organism was likely to have been present in her [11]. Their report included MIC data from a bank of fungal isolates
tracheobronchial tree. sent from around the United States and primarily derived from
This case highlights several important aspects related to interpreta- patients. Of the 10 P. citrinum isolates tested, all 10 had a measured
tion and management of P. citrinum-positive clinical isolates. We voriconazole MIC > 16 μg ml−1. No other anti-fungal drug tested in
summarize the three most salient below: the panel, including other triazoles, demonstrated this degree of
MIC laterality.
1. Infection with P. citrinum is exceedingly rare despite its environmental
ubiquity P. citrinum-positive cultures require careful clinical interpretation.
A thorough literature search yielded only four reports of P. citrinum Although P. citrinum was unlikely to have been the etiologic agent of
infections in humans [6–9]. One report described P. citrinum pneumonia in this case, it is our aim that the analysis presented here
keratitis in immunocompetent farmers after corneal trauma from will provide helpful guidance for clinicians considering or managing P.
vegetable matter debris. Two reports were of cavitary P. citrinum citrinum infection.
pneumonia and the fourth report documented an ulcerative P.
citrinum skin lesion. In the latter three cases the diagnosis was Conflict of interest
supported by tissue biopsy demonstrating septate hyphae plus a
positive culture of P. citrinum (and no other molds) from the site of The authors have no conflicts of interest.
infection. Excluding keratitis, we did not encounter any reports of P.
citrinum infection based on positive culture results alone. We favor Funding sources
preservation of a strict case definition seeing as how more often than
not, microbiologic recovery of Penicillium species reflects laboratory This project has been funded in part by the Intramural Research
contamination or its non-pathogenic presence, rather than true Program of the NIH Clinical Center and by federal funds of the National
infection. The isolation of P. citrinum from multiple cultures Cancer Institute, National Institutes of Health, under Contract No.
combined with its being a relatively uncommon species in our HHSN261200800001E.
institution makes laboratory contamination less likely in our case.
It is striking that all three reports of non-ophthalmic infection Acknowledgements
occurred in patients with acute leukemia receiving intensive che-
motherapy. An immunocompromised state would seem to be a hard We thank Dr. John Bennett for his expert opinion and critical review
and fast prerequisite for systemic P. citrinum infection, but these of this case.
cases suggest that the bar may be set even higher. Extrapolating
from our clinical experience, acute leukemia plus chemotherapy References
imposes a far greater degree of immunocompromise than that
expected from a moderate amount of steroids and mild leukopenia [1] C.M. Visagie, J. Houbraken, J.C. Frisvad, S.B. Hong, C.H. Klaassen, G. Perrone,
in an engrafted 7-month post-transplant patient. This lack of et al., Identification and nomenclature of the genus Penicillium, Stud. Mycol. 78
(2014) 343–371.
appropriate pre-disposition, in addition to uncharacteristic radio- [2] A.M. Tortorano, M.C. Esposto, A. Prigitano, A. Grancini, C. Ossi, C. Cavanna, et al.,
graphic features and a plausible alternate explanation for the Cross-reactivity of Fusarium spp. in the Aspergillus galactomannan enzyme-linked
positive BAL culture, ultimately led us reject P. citrinum pneumonia immunosorbent assay, J. Clin. Microbiol. 50 (3) (2012) 1051–1053.
[3] Y.T. Huang, C.C. Hung, P.R. Hsueh, Aspergillus galactomannan antigenemia in
as a likely diagnosis in this case. penicilliosis marneffei, AIDS 21 (14) (2007) 1990–1991.
2. P. citrinum demonstrates cross-reactivity in clinical Aspergillus antigen [4] C.M. Swanink, J.F. Meis, A.J. Rijs, J.P. Donnelly, P.E. Verweij, Specificity of a
assays sandwich enzyme-linked immunosorbent assay for detecting Aspergillus galacto-
mannan, J. Clin. Microbiol. 35 (1) (1997) 257–260.
To the best of our knowledge this is the first report to confirm P. [5] J.R. Cummings, G.R. Jamison, J.W. Boudreaux, M.J. Howles, T.J. Walsh,
citrinum cross-reactivity with a clinically-validated Aspergillus anti- R.T. Hayden, Cross-reactivity of non-Aspergillus fungal species in the Aspergillus
gen (galactomannan) assay. This result is consistent with reports of galactomannan enzyme immunoassay, Diagn. Microbiol Infect. Dis. 59 (1) (2007)
113–115.
galactomannan cross-reactivity exhibited by few other Penicillium
[6] T. Mok, A.P. Koehler, M.Y. Yu, D.H. Ellis, P.J. Johnson, N.W. Wickham, Fatal
species [3–5]. This information may have clinical utility in cases Penicillium citrinum pneumonia with pericarditis in a patient with acute leukemia,
such as the one described here, but it is worth underscoring that J. Clin. Microbiol. 35 (10) (1997) 2654–2656.
antigen cross-reactivity, even if wide, does not necessarily confer [7] T. Mori, M. Matsumura, T. Kohara, Y. Watanabe, T. Ishiyama, Y. Wakabayashi,
et al., A fatal case of pulmonary Pencilliosis, Jpn J. Med. Mycol. 28 (1987) 341–348.
poor test specificity. Illustratively, a positive BAL galactomannan [8] S.G. Krishnan, N.W. Sim Tee, A.L. Tan, A.M. Tan, M.J. Aan Koh, C.Y. Chong, et al., A
level has shown good specificity for invasive Aspergillosis when case of cutaneous penicilliosis in a child with acute myeloid leukaemia, JMM Case
applied to a high pre-test probability transplant population [10]. It Rep. 2 (5) (2015).
[9] H.C. Gugnani, S. Gupta, R.S. Talwar, Role of opportunistic fungi in ocular infections
is also important to note that our patient received piperacillin- in Nigeria, Mycopathologia 65 (1–3) (1978) 155–166.
tazobactam, an antibiotic to which false-positive galactomannan test [10] S.C. Heng, O. Morrissey, S.C. Chen, K. Thursky, R.L. Manser, R.L. Nation, et al.,
results have been attributed. However, a recent report has shown Utility of bronchoalveolar lavage fluid galactomannan alone or in combination with
PCR for the diagnosis of invasive aspergillosis in adult hematology patients: a
that this no longer occurs with either generic or brand name systematic review and meta-analysis, Crit. Rev. Microbiol 41 (1) (2015) 124–134.
formulations used in the United States [12]. [11] M. Guevara-Suarez, D.A. Sutton, J.F. Cano-Lira, D. Garcia, A. Martin-Vicente,
3. Voriconazole should not be considered first-line for the empiric treatment N. Wiederhold, et al., Identification and antifungal susceptibility of penicillium-like
fungi from clinical samples in the United States, J. Clin. Microbiol. 54 (8) (2016)
of P. citrinum
2155–2161.
The voriconazole MIC for our patient's isolate was > 16 μg ml−1, [12] P. Vergidis, R.R. Razonable, L.J. Wheat, L. Estes, A.M. Caliendo, L.R. Baden, et al.,
well out of accepted susceptibility range if the isolate had been Reduction in false-positive Aspergillus serum galactomannan enzyme immunoassay
results associated with use of piperacillin-tazobactam in the United States, J. Clin.
Aspergillus fumigatus. Only one of the 4 published case reports of P.
Microbiol. 52 (6) (2014) 2199–2201.
citrinum infections reported a voriconazole MIC. That MIC was also
above the limits of quantification, albeit at > 256 μg ml−1 [8]. The

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