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2. Patient History
• A 62 year-old male patient presents to the ER with a 3-day fever as his
chief complaint.
• He develops skin lesions over the first few days of admission, which
progressively got worse.
• The patient has a history of acute myeloid leukemia (AML), for which he
received a stem cell transplant and chemotherapy.
Photos Courtesy of University of Utah/ARUP Laboratories
3. Opportunistic Pathogens of the
Immunocompromised Host
• Because of his treatment for AML, the patient had a suppressed
immune system.
• Immunosuppressed patients are at risk for many infections, which
can be caused by primary or opportunistic pathogens.
– Primary Pathogens: those that can infect otherwise healthy individuals.
– Opportunistic Pathogens: organisms that only infect humans in certain
host conditions, such as immunosuppression.
4. Skin Biopsy Results
• The pathology report from the skin
biopsy stated there were fungal hyphae
invading the blood vessels.
• These hyphae were described as being
septated (walls between cells) with
acute angle-branching, with some
features being compatible with the
fungus Aspergillus.
Photo Courtesy of University of Utah/ARUP Laboratories
5. Microbiology Work-Up
• Specimens were submitted for culture to determine if
there was a bacterial or fungal etiologic agent causing his
symptoms.
– Blood was submitted to detect disseminating (spreading
throughout the body) organisms.
– Tissue from the skin biopsy was submitted to help
identify the fungal organism that was seen on the stain
from the lesion.
• Nucleic acid, antigen, and antibody testing was also
performed to help detect infections with viruses and fungi.
6. Microbiology Laboratory Results
• All bacterial and viral test results were
negative…
• BUT a fungus grew in the blood culture
bottle and was visible upon Gram stain.
• The same fungus also grew from the tissue
culture.
Stain of Blood Culture Bottle (10x)
Stain of Blood Culture Bottle (40x)
Photos Courtesy of University of Utah/ARUP Laboratories
7. Medical Mycology
• Fungi are often identified using colony
appearance and sexual/asexual
reproductive structures that are
observed microscopically.
– The microbiologist must have a high-level
of expertise and experience.
• Based on phenotypic analysis, this
organism was identified as a
Fusarium species.
Colony Appearance
Microscopic Structures
Photo Credits: Centers for Disease Control and Prevention and Wikimedia
8. Diagnosis: Fusariosis
• Many Fusarium species are primarily soil saprophytes or plant pathogens, but certain
species can be opportunistic pathogens of humans.
– Because of this patient’s immunosuppression, he is at risk for opportunistic infections.
– Fusarium infections, or fusariosis, can be superficial, locally invasive, or disseminated.
• Because of their ubiquitous nature, however, isolation of Fusarium species in culture may be
due environmental contamination.
• Therefore, the microbiologist and clinician must work
together to interpret the results.
• Clues for clinically significant results are:
Fungi seen on direct stain of tissue.
Site of isolation and the host.
Same fungus from multiple specimens.
Multiple colonies from same specimen.
In Tissue
From Blood
Photos: Courtesy of University of Utah/ARUP Laboratories and Centers for Disease Control and Prevention
Multiple Specimens
9. Importance of Mould Identification
• Some fungi may look similar in tissue stains, but have very
different susceptibility profiles to different antifungal drugs.
• Therefore, the microbiologist plays an important role in helping
make the correct identification to guide appropriate
antifungal therapy.
10. Patient Outcome
• The patient’s suppressed immune system put him at risk for invasive fungal disease.
• Two different antifungal drugs were given and the patient was monitored closely.
• The symptoms, including lesions, improved with no evidence of treatment failure.
• The clinical microbiology results were essential in making sure the patient received the
appropriate therapy!
A. Michal Stevens, M.D.
Infectious Disease Fellow
University of Utah
Created by:
Margaret Powers-Fletcher, Ph.D.,
Medical Microbiology Fellow
University of Utah/ARUP Laboratories
11. Margaret Powers-Fletcher, Ph.D.
Dr. Powers-Fletcher is a Fellow in the
Medical and Public Health Laboratory
Microbiology program at the
University of Utah/ARUP Laboratories.
Her research has focused primarily on
medical mycology, with emphasis on
pathogenesis mechanisms, antifungal
susceptibility testing, and fungal
diagnostic and detection techniques.
Photo Credit: Margaret Powers-Fletcher, Ph.D
