Pichia fabianii Fungemia in a Neonate

To the Editors: Extremely low birth weight (ELBW, <1000 g birth weight) is associated with a high risk of neonatal fungal infections. Candida albicans and Candida parapsilosis cause about 90% of fungemia in neonates, but less common yeasts such as Trichosporon asahii and Pichia spp. have been reported as causes of septicemia in preterm neonates.1 We describe fungemia in an ELBW neonate caused by Pichia fabianii, a very uncommon species. A female infant, born at 24 weeks of gestation, was admitted to our neonatal intensive care unit. She was born by spontaneous delivery after premature rupture of membranes, and weighed 700 g. She was intubated at birth for poor respiratory effort. APGAR scores were 5 and 7 at one and five minutes, respectively. Central venous catheters were placed. Cefotaxime and amikacin were administered intravenously for 1 week because growth of Enterobactercloacae from the placenta and gastric aspirate of infant was seen. Erythema was observed on day 11 (D11). Trichosporon asahii and yeasts belonging to genus Pichia, initially identified as Pichia jadinii (teleomorph of Candida utilis), were isolated from the skin lesion. Enterococcus faecalis purulent pleurisy occurred on D14 and intravenous ampicillin was administered. Hypotension, oliguria, and abdominal distension occurred 4 days later; they were managed with furosemide, dopamine, imipenem, and ornidazole. Increasing skin lesions, colonization of the groin, axillae, and mouth with Pichia sp. and C. albicans, and thigh edema were observed at D18 and D22, respectively. Topical econazole was used. On D27, the infant was still hypoxic; gastrointestinal and tracheal hemorrhages were noted. Despite treatment with intravenous fluconazole 12 mg/kg/d on D31, Pichia sp. was isolated from blood culture and pleural fluid aspirate. Liposomal amphotericin B 5 mg/kg/d and flucytosine 25 mg/kg/q.i.d. were given. Severe oligoanuria and anasarca (a 600 g gain in weight over 4 days) were observed and death occurred at D41. Minimal inhibitory concentrations (determined by the E-test method) for the Pichia sp. from blood were 2 μg/mL to fluconazole, 0.25 μg/mL to flucytosine and 0.5 μg/mL to amphotericin B. Sequential Pichia isolates (blood culture, pleural aspirate, and peripheral isolates) were subsequently identified as P.fabiani by sequencing of 26S ribosomal DNA and internal transcribed spacer (described elsewhere2). Pichia anomala and Pichia guilliermondii (teleomorph of Candida guilliermondii) can cause disseminated infections, especially in preterm neonates.1,3,4Pichia fabianii has been previously described in only 1 case of fungemia in a preterm neonate and 3 other human cases.5 This species has been isolated from environmental sources (soil, fermented beverages).5 In our case, the origin of P. fabianii colonization was not identified. There was no concomitant isolation of P. fabianii from other NICU patients, nor was there colonization of the mother during or after pregnancy. Biochemical methods used in routine practice are unable to identify P. fabianii: molecular identification is required. As a result, this species is possibly underreported. Our case underlines the fact that clinicians should be aware that disseminated infections can occur in high-risk ELBW preterms highly colonized with uncommon non-Candida yeast species. Frédéric Grenouillet, PharmD, PhD Laurence Millon, PharmD, PhD Department of Mycology-Parasitology University Hospital Besançon, France Abdourahim Chamouine, MD Gérard Thiriez, MD, PhD Olivier Schulze, MD Department of Neonatology University Hospital Besançon, France Joel Leroy, MD Department of Infectious Diseases University Hospital Besançon, France