Article: Answer to Photo Quiz: It took a torpedo to sink the Lusitania... (full text) - May 2018 - NJM
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Answer to Photo Quiz: It took a torpedo to sink the Lusitania...



PHOTO QUIZ
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DIAGNOSIS

Directly after noticing the fungal hyphae we started therapy with voriconazole, suspecting opportunistic infection with Aspergillus. But eventually the cultures revealed Clavispora lusitaniae, sensitive to voriconazole. Because of persistent doubts about the questionable PJP diagnosis we considered a double infection in an immunocompromised patient, and decided to also continue treatment with co-trimoxazole alongside the voriconazole. Our patient gradually recovered.
Clavispora lusitaniae (until 1996 known as Candida lusitaniae, nomenclature by van Uden and do Carmo-Sousa in 1959 because it was first isolated from the alimentary canals of warm-blooded animals in Portugal)1 is sporadically described as a fungal organism that can cause systemic infection in humans.2,3 Large studies on the epidemiology of fungal infections show a 1-4% incidence of Clavispora lusitaniae among all fungal isolates from blood cultures until 1990; after 1990 the incidence of this pathogen is increasing (2-8%). The reason for this increase is generally thought to be the dramatic increase in use of (adjuvant) chemotherapy for cancer treatment worldwide during that decade.2 Fungaemia, as primary infection or as co-infection, is mostly seen in immunocompromised patients with underlying malignancies,2-5 and upon autopsy this yeast is found in the lung, kidney and upper intestinal tract.4 Clavispora lusitaniae is known to develop secondary resistance to amfotericine-B.2 Although intrinsically susceptible to fluconazole and echinocandins, development of resistance in Clavispora lusitaniae isolates during fluconazole and echinocandin treatments was  observed.3,5,6 So, when aiming at this Lusitania, the right ‘torpedo’ should be chosen: voriconazole.7

RMS Lusitania was a British ocean liner, named after the ancient Roman province (Hispania) Lusitania on the west of the Iberian Peninsula, the region that is now southern Portugal. She was launched in 1906 and briefly was the world’s largest passenger ship. She made a total of 202 trans-Atlantic crossings, until she was struck by a torpedo launched by a German submarine during World War I. She sank 18 km of the southern coast of Ireland, resulting in the death of 1198 passengers and crew, causing a major diplomatic uproar.8


REFERENCES

  1. Vincent S. Origin of the names of species of Candida. (Accessed 21 December 2017, at http://www.antimicrobe.org/h04c.files/history/ candida-history.asp) 
  2. Krcmery V Jr, Mateicka F, Grausova S, et al. Invasive infections due to Clavispora lusitaniae. FEMS Immunol Microbiol. 1999;23:75-8. 
  3. Desnos-Ollivier M, Moquet O, Chouaki T, et al. Development of echinocandin resistance in Clavispora lusitaniae during caspofungin treatment. J Clin Microbiol. 2011;49:2304-6. 
  4. Gargeya IB, Pruitt WR, Simmons RB, et al. Occurrence of Clavispora lusitaniae, the Teleomorph of Candida lusitaniae, among clinical isolates. J Clin Microbiol. 1990;28:2224-7. 
  5. Krcmery V, Barnes AJ. Non-albicans Candida spp. causing fungaemia: pathogenicity and antifungal resistance. J Hosp Infect. 2002;50:243-60. 
  6. Asner SA, Giulieri S, Diezi M, et al. Acquired multidrug antifungal resistance in Candida lusitaniae during therapy. Antimicrob Agents Chemother. 2015;59:7715-22. 
  7. Pelletier R, Loranger L, Marcotte H, et al. Voriconazole and fluconazole susceptibility of Candida isolates. J Med Microbiol. 2002;51:479-83. 
  8. RMS Lusitania – Wikipedia.