A Rare Case of Disseminated Trichosporon Asahii Infection After Orthotopic Liver Transplant

Abstract

SESSION TITLE: Critical Care 4 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Trichosporon Asahii is a rare cause of disseminated fungal infection in immunocompromised patients, presenting a diagnostic and therapeutic challenge. CASE PRESENTATION: A 67 year old male presented with a widespread erythematous rash prior to sustaining a syncopal episode outside the dermatologist’s office. On arrival he presented with worsening mental status and tachypnea. Physical exam was pertinent for reduced air entry and a diffuse exfoliating erythematous rash. Significant past medical history included a deceased donor liver transplant 15 months prior to admission from primary biliary cirrhosis induced liver failure; complicated by myelodysplastic syndrome six months after transplant with a hypocellular marrow on biopsy. Laboratory studies demonstrated pancytopenia with an absolute neutrophil count (ANC) of 1.4 x 109/L. Additional tests were unremarkable. Chest radiograph demonstrated bilateral interstitial infiltrates. He was started on broad spectrum coverage while continuing immunosuppression with tacrolimus and prednisone. Regardless, his hospital course was complicated with septic shock, refractory cytopenia with an ANC of 0.79 x 109/L and a widespread desquamating rash with areas of one centimeter deep abrasions. Further studies demonstrated a skin biopsy inconclusive for graft versus host or drug reaction, Klebsiella pneumoniae bacteremia, and a positive (1-3)-β-d-glucan assay test, the first indication of a coexisting fungal infection. Subsequent cultures reported a false positive Candida with the ensuing agent identified as Trichosporon asahii. Voriconazole was commenced in addition to targeted antibiotic therapy with notable improvement and negative repeat cultures. Following this recovery, his condition worsened with recurrent multi-drug resistant K.pneumoniae bacteremia and multi-system organ failure. The patient expired thereafter from causes unrelated to Trichosporon infection. DISCUSSION: Disseminated Trichosporon asahii is rare; nonetheless, neutropenia from hematologic disorders and orthotopic liver transplant (OLT) immunosuppression have been implicated as a risk factor1. But, of the four documented cases post OLT this is the first documented case complicated by myelodysplastic syndrome. CONCLUSIONS: Due to the rarity of disseminated T.Asahii infections the gold standard management has not been established. Reference #1: Colombo, A, Padovan, A, Chaves, G. Current knowledge of Trichosporon spp. and Trichosporonosis. Clin Microbiol Rev. 2011; 24(4): 682-700. DISCLOSURE: The following authors have nothing to disclose: Emily Doole, Fidencio Davalos, Catherine Allen, John Oropello, Adel Bassily-Marcus, Anthony Manasia, Roopa Kohli-Seth No Product/Research Disclosure Information