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Medical Mycology November 2008, 46, 735738

Case report

Schizophyllum commune: an unusual agent of

bronchopneumonia in an immunocompromised patient
*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

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: 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).

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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.
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
diseases, including those by less common fungal
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