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Medical Mycology November 2008, 46, 735738

Case report

Schizophyllum commune: an unusual agent of


bronchopneumonia in an immunocompromised patient
VIVIAN TULLIO*, NARCISA MANDRAS*, GIULIANA BANCHE*, VALERIA ALLIZOND*, ESTER GAIDO$,
JANIRA ROANA*, ANNA MARIA CUFFINI* & NICOLA A. CARLONE*
*Department of Public Health and Microbiology, University of Turin, Turin, and $Microbiology Laboratory, S. Giovanni Battista
Hospital, Turin, Italy

We report a case of bronchopneumonia due to Schizophyllum commune in an


immunocompromised patient. While this fungus rarely causes disease in humans, it
has been reported in association with several clinical entities and lung disorders. A
59-year-old white man with a gastric carcinoma was admitted to S. Giovanni
Battista Hospital (Turin, Italy). Three days after the admission, he developed a
bronchopneumonia, which was diagnosed through the use of X-ray and showed an
abnormal infiltrative shadow. Samples of bronchial aspirate were collected for
laboratory microbiological investigation. Direct microscopic examination of these
specimens revealed the presence of numerous septate, hyaline hyphae and rare
clamp connections. Sabouraud Dextrose Agar and Columbia agar plus 5% blood
media inoculated with portions of the same specimens yielded, after 45 days of
incubation at 258C and 378C, a cottony white mould. The fungus was identified on
the basis of its macroscopic and microscopic morphology. The macroscopic
examination of the colony showed raised, curved, fan-shaped and shell-like
basidiocarps. The microscope examination revealed the presence of hyaline, septate
hyphae with clamp connections and short, thin spicules. The fungal isolate was
identified as S. commune. The patient was cured after therapy with intravenous
fluconazole (600 mg twice daily for over six weeks).
Keywords Basidiomycota, bronchopneumonia, fungal infections, Schizophyllum
commune

Introduction frequency as cause of respiratory tract infections such as


sinusitis, fungus ball, lung abscess, allergic broncho-
Compared to the great number of Ascomycota fungi
pulmonary disorder, mucoid impaction of the bronchi
which are the cause of many human diseases, filamen-
and chronic eosinophilic pneumonia [14]. In addition,
tous Basidiomycota are rarely reported in the medical
it had been reported in association with other clinical
literature as being associated with human infections entities such as onychomycosis, brain abscess, atypical
[1]. However, Schizophyllum commune is a basidomyce- meningitis, ulcerative lesions of the hard palate [2,58].
tous fungus that had been described with increasing In this study, we present another probable case of
infection caused by this basidiomycetous fungus.

Received 31 March 2008; Accepted 7 June 2008


Correspondence: Vivian Tullio, Department of Public Health and Case report
Microbiology, Microbiology Section, University of Turin, Via
Santena 9, 10126 Turin, Italy. Tel: 39/0116705637; fax: 39/ A 59-year-old white male patient with a history of
0112365637. E-mail: vivian.tullio@unito.it gastric carcinoma and quiescent Hodgkins disease, was
2008 ISHAM DOI: 10.1080/13693780802256091

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736 Tullio et al.

admitted to the Oncology Surgery Division of the S.


Giovanni Battista Hospital (Turin, Italy) for surgical
treatment of his cancer. There was no history of asthma
or other allergic disease, smoking or drug abuse.
Potential risk factor was immunodeficiency due to
Hodgkins disease. Three days after admission he
developed a bronchopneumonia, diagnosed using com-
mon radiographic and computer tomography. The
X-ray showed an abnormal infiltrative shadow and the
symptoms were nonspecific. Laboratory findings re-
vealed a high white blood cell count (19.45 103/ml) but
both counts of eosinophil (0.1%) and serum total IgE
concentration (reference range 0100 kU/l) were normal
which permitted the exclusion of an allergic bronchop-
neumonia. Three samples of bronchial aspirate were
collected for laboratory microbiological investigation at
one week intervals. Direct microscopy of each bronchial
aspirate specimen revealed the presence of numerous
septate, hyaline, hyphal elements measuring 1.3 to
3.9 mm in diameter, many branched hyphae and the
presence of rare clamp connections. Each sample of
bronchial aspirate was inoculated onto different media
suitable for aerobe, anaerobe, bacteria and fungal
development. Specifically Columbia agar base plus
defibrinated horse blood (5%; Oxoid S.p.A., Garbag-
nate Milanese, Milan, Italy) for aerobic bacteria,
Schaedler agar plus 5% blood (Oxoid) for anaerobic
bacteria, Sabouraud Dextrose agar containing cloram-
phenicol (SABC, Sigma, St. Louis, Mo) for yeasts and
moulds. The plates were incubated for 24 days at 378C
and 258C. The cultures were negative for aerobic and
anaerobic bacteria, as well as yeasts after 48 h of
incubation. A cottony white mould was isolated on
both SABC and Columbia agar after 45 days at both
temperatures. Each fungal culture on SABC agar was
sent to the Mycology Laboratory, Department of Public
Health and Microbiology, University of Turin, for
further investigations. The microscopic examination of
the colony, performed with a 400objective, showed
the presence of hyaline, septate hyphae with clamp
connections and short, thin spicules (small, lateral
hyphal projection; Fig. 1a). After further 10 days of
incubation on SABC at 258C, macroscopic examina-
tion of the colony revealed raised, curved, fan-shaped
and shell-like fruiting bodies, i.e., the basidiocarps. The
latter had longitudinally split gills and were from 0.5 to 2
cm in height and from 0.3 to 1.5 cm in diameter. The
fruiting body surfaces were white, thick and shaggy
(Fig. 1c). Furthermore, it was possible to see small
Fig. 1 Microscopic and macroscopic appearance of the clinical
cavities in which were formed typical basidia and oval
isolate revealing dikaryotic mycelium with hyaline septate hyphae
basidiospores (Fig. 1b). Subcultures on SAB, Czapeks with clamp connections (a; 0) and spicules (a; ); basidiospores
dox agar and potato dextrose agar (Merck KGaA, (b) and fruiting body of Schizophyllum commune on Sabouraud
Darmstadt, Germany) incubated for 15 days at 258C Dextrose agar (c).

2008 ISHAM, Medical Mycology, 46, 735738

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Schizophyllum commune in bronchopneumonia 737

produced colonies composed of hypahe with clamp infection could be influenced by the age of the host, the
connections and similar basidiocarps. Macroscopic and size of the inoculum, and previous treatment with an
microscopic examinations allowed the isolate to be immunosuppressive agent [3,14]. Therefore, clinicians
identified as S. commune. The same fungus was con- should include this fungus in the differential diagnosis,
sistently isolated from the three samples of the bronchial especially in pulmonary diseases. They should attempt
aspirate. The patient received intravenous fluconazole to distinguish between S. commune and other hyaline
(600 mg twice daily) over a six week period. In the moulds (i.e., aspergilli and penicilli), as the latter
meantime, in vitro antifungal susceptibility studies were appear similar to S. commune and may be transmitted
conducted [9] which demonstrated that the minimal by the air-borne route. However, it is likely that
inhibitory concentration of the isolate to fluconazole infections caused by S. commune are still misdiagnosed
was 4 mg/ml. After treatment, direct microscopic exam- because of the clinicians lack of familiarity with this
ination of additional bronchial aspirate specimens were fungus and the inability of many laboratories to
negative as were the cultures inoculated with portions of identify this basidiomycete. A broad knowledge of
the same samples. The patient showed clinical and fungal clinical presentations and a high index of
radiological improvement. He was surgically treated suspicion are required to ensure accurate diagnosis
for cancer and, after checks, discharged from the and correct treatment of the clinical manifestations.
hospital. The patient has been followed up for one Since the criteria suggested by McGinnis [11] required
year and no signs of recurrence of the fungal infection to establish the aetiology of fungal infection, are met in
have been noted. this case report we consider it as another probable case
of infection due to the basidiomycetes S. commune.
Discussion
Acknowledgements
In the last few years, the frequency and types of
microbial infections has increased dramatically in The authors thank the participating microbiological
immunocompromised patients due to numerous fac- laboratory of San Giovanni Battista Hospital of Turin
tors, such as chemotherapy-induced neutropenia, ex- for providing clinical data.
tensive surgery, use of prosthetic devices and vascular
catheters, treatment with glucocorticosteroids, perito- Declaration of interest: The authors report no conflicts
neal dialysis or haemodialysis, organ transplant asso- of interest. The authors alone are responsible for the
ciated immunotherapy, malignancy, diabetes, content and writing of the paper.
malnutrition and HIV infection [10]. In such patients
these factors enhance the development of mycotic
References
diseases, including those by less common fungal
pathogens. Fungal infections caused by basidiomycetes 1 Buzina W, Lang-Loidolt D, Braun H, Freudenschuss K, Stamm-
have been recorded with increasing frequency in the berger H. Development of molecular methods for identification of
Schizophyllum commune from clinical samples. J Clin Microbiol
medical literature. In particular, S. commune has 2001; 39: 23912396.
become a much more common human pathogen than 2 Bulajic N, Cvijanovic V, Vukojevic J, Tomic D, Johnson E.
expected in both immunocompetent and immunocom- Schizophyllum commune associated with bronchogenous cyst.
promised hosts [1,7]. This fungus is common in the Mycoses 2006; 49: 343345.
environment and its basidiospores could be transported 3 Sigler L, Bartley JR, Parr DH, Morris AJ. Maxillary sinusitis
caused by medusoid form of Schizophyllum commune. J Clin
by air currents and inhaled through the nasal route. Microbiol 1996; 37: 33953398.
There are only few well-documented reports of human 4 Taguchi K, Oharaseki T, Yokouchi Y, et al. Allergic fungal
diseases caused by invasion of tissues due to this sinusitis caused by Bipolaris spicifera and Schizophyllum commune.
basidiomycetous fungus [2,11]. The first confirmed Med Mycol 2007; 45: 559564.
case of infection in which S. commune was isolated 5 Kano R, Oomae S, Nakano Y, et al. First report on Schizophyllum
commune from a dog. J Clin Microbiol 2002; 40: 35353537.
from the oral palate of a 4-month-old child, was 6 Kawayama T, Fujiki R, Rikimaru T, Aizawa H. Chronic
reported by Restrepo et al. in 1973 [12]. Since then, eosinophilic pneumonia associated with Schizophyllum commune.
S. commune has been described as the cause of a Respirology 2003; 8: 529531.
growing number of human infections involving the 7 Lacaz Cda S, Heins-Vaccari EM, De Melo NT, Hernandez-
Arriagada GL. Basidiomycosis: a review of the literature. Rev Inv
respiratory tract and invasive lesions [8,13]. These
Med Trop Sao Paulo 1996; 38: 379390.
clinical reports strongly suggest that the pathogenicity 8 Rihs JD, Padhye AA, Good CB. Brain abscess caused by
of this fungus may be much higher than is generally Schizophyllum commune: an emerging basidiomycete pathogen.
accepted. Details remain unknown, but the progress of J Clin Microbiol 1996; 34: 16281632.

2008 ISHAM, Medical Mycology, 46, 735738

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by guest
on 12 November 2017
738 Tullio et al.

9 Tullio V, Nostro A, Mandras N, et al. Antifungal activity of 12 Restrepo A, Greer DL, Robledo M, Osorio O, Mondragon H.
essential oils against filamentous fungi determined by broth Ulceration of the palate caused by a basidiomycete Schizophyllum
microdilution and vapour contact methods. J Appl Microbiol commune. Sabouraudia 1973; 11: 201204.
2007; 102: 15441550. 13 Buzina W, Braun H, Freudenschuss K, et al. The basidiomycete
10 Roh ML, Tuazon CU, Mandler R, Kwon-Chung KJ, Geist CE. Schizophyllum commune in paranasal sinuses. Mycoses 2003; 46:
Sphenocavernous syndrome associated with Schizophyllum com- 2327.
mune infection of the sphenoid sinus. Ophthal Plast Reconstr Surg 14 Unno H, Kamei K, Honda A, Nishimura K, Kuriyama T.
2005; 21: 7174. A murine model of pulmonary basidiomycosis by Schizophyllum
11 McGinnis MR. Laboratory Handbook of Medical Mycology. New commune. J Infect Chemother 2005; 11: 136140.
York: Academic Press, 1980.

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