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

Compared to the great number of Ascomycota fungi
which are the cause of many human diseases, filamen-
tous Basidiomycota are rarely reported in the medical
literature as being associated with human infections
[1]. However, Schizophyllum commune is a basidomyce-
tous fungus that had been described with increasing
sinusitis, fungus ball, lung abscess, allergic broncho-
pulmonary disorder, mucoid impaction of the bronchi
and chronic eosinophilic pneumonia [14]. In addition,
it had been reported in association with other clinical
entities such as onychomycosis, brain abscess, atypical
meningitis, ulcerative lesions of the hard palate [2,58].
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
Microbiology, Microbiology Section, University of Turin, Via
Santena 9, 10126 Turin, Italy. Tel: 39/0116705637; fax: 39/
0112365637. E-mail: vivian.tullio@unito.it
2008 ISHAM
Case report
A 59-year-old white male patient with a history of
gastric carcinoma and quiescent Hodgkins disease, was
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).

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produced colonies composed of hypahe with clamp
connections and similar basidiocarps. Macroscopic and
microscopic examinations allowed the isolate to be
identified as S. commune. The same fungus was con-
sistently isolated from the three samples of the bronchial
aspirate. The patient received intravenous fluconazole
(600 mg twice daily) over a six week period. In the
meantime, in vitro antifungal susceptibility studies were
conducted [9] which demonstrated that the minimal
inhibitory concentration of the isolate to fluconazole
was 4 mg/ml. After treatment, direct microscopic exam-
ination of additional bronchial aspirate specimens were
negative as were the cultures inoculated with portions of
the same samples. The patient showed clinical and
radiological improvement. He was surgically treated
for cancer and, after checks, discharged from the
hospital. The patient has been followed up for one
year and no signs of recurrence of the fungal infection
have been noted.
Discussion
In the last few years, the frequency and types of
microbial infections has increased dramatically in
immunocompromised patients due to numerous fac-
tors, such as chemotherapy-induced neutropenia, ex-
tensive surgery, use of prosthetic devices and vascular
catheters, treatment with glucocorticosteroids, perito-
neal dialysis or haemodialysis, organ transplant asso-
ciated immunotherapy, malignancy, diabetes,
malnutrition and HIV infection [10]. In such patients
these factors enhance the development of mycotic
diseases, including those by less common fungal
pathogens. Fungal infections caused by basidiomycetes
have been recorded with increasing frequency in the
medical literature. In particular, S. commune has
become a much more common human pathogen than
expected in both immunocompetent and immunocom-
promised hosts [1,7]. This fungus is common in the
environment and its basidiospores could be transported
by air currents and inhaled through the nasal route.
There are only few well-documented reports of human
diseases caused by invasion of tissues due to this
basidiomycetous fungus [2,11]. The first confirmed
case of infection in which S. commune was isolated
from the oral palate of a 4-month-old child, was
reported by Restrepo et al. in 1973 [12]. Since then,
S. commune has been described as the cause of a
growing number of human infections involving the
respiratory tract and invasive lesions [8,13]. These
clinical reports strongly suggest that the pathogenicity
of this fungus may be much higher than is generally
accepted. Details remain unknown, but the progress of
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Schizophyllum commune in bronchopneumonia 737
infection could be influenced by the age of the host, the
size of the inoculum, and previous treatment with an
immunosuppressive agent [3,14]. Therefore, clinicians
should include this fungus in the differential diagnosis,
especially in pulmonary diseases. They should attempt
to distinguish between S. commune and other hyaline
moulds (i.e., aspergilli and penicilli), as the latter
appear similar to S. commune and may be transmitted
by the air-borne route. However, it is likely that
infections caused by S. commune are still misdiagnosed
because of the clinicians lack of familiarity with this
fungus and the inability of many laboratories to
identify this basidiomycete. A broad knowledge of
fungal clinical presentations and a high index of
suspicion are required to ensure accurate diagnosis
and correct treatment of the clinical manifestations.
Since the criteria suggested by McGinnis [11] required
to establish the aetiology of fungal infection, are met in
this case report we consider it as another probable case
of infection due to the basidiomycetes S. commune.
Acknowledgements
The authors thank the participating microbiological
laboratory of San Giovanni Battista Hospital of Turin
for providing clinical data.
Declaration of interest: The authors report no conflicts
of interest. The authors alone are responsible for the
content and writing of the paper.
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