1. Support Care Cancer (2000) 8 : 504–505
DOI 10.1007/s005209900123 SHORT COMMUNICATION
Simone Cesaro Saccharomyces cerevisiae fungemia in a
Pierangelo Chinello
Lucia Rossi neutropenic patient treated with
Luigi Zanesco
Saccharomyces boulardii
Published online: 7 March 2000 Abstract A case of Saccharomyces of the central venous catheter. The
Q Springer-Verlag 2000 fungemia in an 8-month-old baby common biochemical characteris-
affected by acute myeloid leukemia tics make it difficult to differentiate
while receiving intensive chemo- between the strain of Saccharo-
therapy is reported. The patient myces cerevisiae and that of Sac-
was receiving prophylaxis treat- charomyces boulardii with routine
ment with Saccharomyces boulardii methods. In other cases, authors
S. Cesaro, M.D. (Y) 7 P. Chinello, M.D. capsules (Codex) to prevent diarr- demonstrated an identity between
L. Rossi, M.D. 7 L. Zanesco, M.D. hea, which is commonly associated the two strains with a more de-
II Clinic of Pediatrics, Pediatric
Oncology-Hematology Division,
with this type of chemotherapy. tailed analysis. These reports raise
Department of Pediatrics, Fever spiked just the day after concern about the potential side
University of Padua, Via Giustiniani 3, ending the chemotherapy course, effects of such biotherapeutic
I-35128 Padua, Italy and a strain of Saccharomyces cere- agents.
e-mail: scesaro6oncopedipd.org visiae was isolated from blood cul-
Tel.: c39-049-8213579
Fax: 0039-049-8213510 ture although the patient was also Key words Infection 7
receiving antifungal prophylaxis Immunocompromised host 7
S. Cesaro, M.D. 7 P. Chinello, M.D.
L. Rossi, M.D. 7 L. Zanesco, M.D.
with fluconazole. The patient re- Saccharomyces boulardii 7
Microbiology Service, Padua Hospital, covered, though still neutropenic, Saccharomyces cerevisiae 7
I-35128 Padua, Italy with amphotericin-B and removal Fungemia
Introduction Case report
A 8-month-old baby affected by acute myeloid leukemia was
Saccharomyces boulardii is an essentially nonpathogen- started on an intensive treatment protocol based on high doses of
ic yeast that is administered as a biotherapeutic agent idarubicin, cytarabine, and etoposide (ICE). Common side effects
to treat diarrhea caused by Clostridium difficile or to of this therapy are gastrointestinal symptoms such as mucositis,
prevent antibiotic-associated diarrhea [4, 5]. The taxon- nausea and vomiting, and diarrhea. Codex capsules (Saccharo-
myces boulardii, SmithKline Beecham, Milan, Italy) were admin-
omic status of Saccharomyces boulardii is still uncer- istered beforehand to preserve the nonpathogenic intestinal flora
tain, and originally it was described as Saccharomyces [8] and to prevent antibiotic-associated diarrhea [4, 5]. As pro-
cerevisiae, a yeast used in the production of beer and phylaxis, the patient was receiving cotrimoxazole (24 mg/kg three
baked food. Both yeasts have been associated with in- times a week), paromomycin (20 mg/kg per day in three doses),
and fluconazole (6 mg/kg per day). The day after ending the sec-
vasive infection or fungemia in severely immunocom- ond cycle of ICE, while the patient was neutropenic (WBC
promised hosts, but the common biochemical charac- 1300!10 9/l, 700 neutrophils 1300!10 9/l), fever spiked to 38.8 7C
teristics make it difficult to differentiate between the and C-RP rose to 106 mg/l (normal value less than 6 mg/l). The
two strains [1, 3, 5–7]. patient was started empirically on antibiotics (ceftazidime and
amikacin). As the Saccharomyces cerevisiae strain was isolated in
We describe a case of Saccharomyces cerevisiae fun- a blood culture from the central venous catheter, amphotericin-B
gemia in an immunocompromised patient receiving was added and Codex administration was withdrawn. The identif-
prophylaxis with Saccharomyces boulardii capsules. ication of the strain was performed with API 32 C test strips,

2. 505
(bioMèrieux, Marcy l’Etoile, France). The in vitro test confirmed ing immunosuppressive therapy (steroids and cyclo-
susceptibility of the strain to amphotericin-B. Three days after phosphamide) for polyarteritis nodosa, Bassetti et al.
amphotericin-B was started, the central venous catheter was re-
moved owing to occlusion of the lumen while the patient was still demonstrated an identical DNA-restriction pattern in
febrile. Thereafter, the fever resolved though the patient was still the Saccharomyces strain isolated in the blood and in
neutropenic. A culture from the catheter tip was negative. No that administered to the patient [4].
other cause or site of infection was found in spite of through Overall, these reports raise concern about the poten-
anti-infective and daily clinical evaluation. The antifungal treat-
ment was carried out for 14 days until complete recovery from
tial risks of giving biotherapeutic agents for fungemia
neutropenia. The patient carried on regularly with another che- [1].
motherapy course, followed by transplantation of bone marrow In our case we did not perform any DNA analysis of
from an HLA-matched sibling donor. The child is now alive and the strain isolated from the blood (identified as Saccha-
well more than 3 years after receiving the transplant. romyces cerevisiae with API 32 test strips) and that of
Saccharomyces boulardii (contained in Codex cap-
Discussion sules), because the method was not available at our la-
boratory. However, the episode was interpreted as be-
The biotherapeutic agent Saccharomyces boulardii has ing related to the administration of Codex capsules, not
so far been largely considered a safe tool for prevention only because of the difficulty of distinguishing the two
of antibiotic-associated diarrhea or treatment of diarr- strains on the basis of biochemical characteristics but
hea due to Clostridium difficile [4]. The use of Saccha- also because it is so rare for Saccharomyces cerevisiae
romyces boulardii capsules has been reported by sev- to be isolated from a blood culture. In our experience,
eral authors to be associated with infective complica- its isolation from a blood culture is exceptional and had
tions, however, ranging from vaginitis and endocarditis never occurred before, even though Saccharomyces cer-
to fungemia in immunocompromised patients [1–3]. evisiae commonly colonizes human mucosal surfaces.
Moreover, a case of Saccharomyces boulardii fungemia Surprisingly, the prophylaxis with fluconazole did not
in a nonimmunocompromised patient affected by prevent the patient from developing Saccharomyces
chronic obstructive pulmonary disease after enteral fungemia.
treatment with Saccharomyces boulardii capsules was In conclusion, the use of biotherapeutic agents for
described recently by Niault et al. [6]. prophylaxis and treatment of antibiotic-associated
A common feature of the case reports on Saccharo- diarrhea or for the prevention of infection by intestinal
myces boulardii fungemia is the routine identification bacterial pathogens and Candida spp. in the neutropen-
of the causative strain as Saccharomyces cerevisiae. In ic patient should not be considered completely safe (at
fact, routine methods, such as the use of API 32 test least in immunosuppressed hosts). The impaired im-
strips, fail to distinguish between the two strains be- mune response and disruption of the mucosal barriers
cause of their common biochemical characteristics. determined by chemotherapy could expose the patient
More detailed analysis of the strain isolated from blood to the risk of severe infection. Since no guidelines are
and identified as Saccharomyces cerevisiae revealed the reported on the use of biotherapeutic agents, physi-
same pattern as in the Saccharomyces boulardii strain cians must be aware that immunocompromised patients
administered orally or enterally to patients. Fredenucci receiving broad-spectrum antibiotic treatment and with
et al., for example, found an identical pattern on mucositis or bowel disease can be at risk of fungemia.
pulsed-field gel electrophoresis for the Saccharomyces
strain isolated in a patient with fungemia and for that Acknowledgement We thank Lucia Agostini for her skilful as-
contained in the capsules [3]. In an adult patient receiv- sistance.
References
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