Correspondence
Malassezia pachydermatis Infections
N Engl J Med 1998; 339:270-271July 23, 1998
- Article
To the Editor:
Chang et al. (March 12 issue)1 describe an outbreak of Malassezia pachydermatis in a neonatal intensive care unit. Several prior studies have reported similar infections in neonates,2,3 and there is a report of an adult with canaliculitis due to M. pachydermatis infection.4 We report a severe systemic infection with M. pachydermatis in an adult.
A 21-year-old man with acute myeloid leukemia underwent an allogeneic bone marrow transplantation, which was subsequently complicated by primary graft failure. Thirty-one days after the transplantation, he began to have fevers (temperature, up to 38.3°C) with rigors, arthralgias, and respiratory distress. Two central catheters had been in place for approximately 40 days, but he had received no parenteral nutrition. Blood cultures obtained from both central catheters grew multiple organisms (bacillus species, Klebsiella oxytoca, Enterobacter cloacae, and coagulase-negative staphylococcus). The patient was treated with vancomycin, ceftazidime, and metronidazole but remained critically ill. Routine cultures of blood obtained both centrally and peripherally in the next two days revealed no bacteria but grew M. pachydermatis. Treatment with amphotericin B was begun, and both central catheters were removed. A culture from the tip of one catheter grew more than 15 colonies of M. pachydermatis; the other catheter was contaminated on removal, and no culture was performed. All subsequent blood cultures were negative, and amphotericin B was continued. The patient died of unrelated causes three weeks later.
The risk factors for infection with M. pachydermatis remain unclear. Chang et al. concluded that a greater severity of illness, arterial catheterization, and exposure to a certain nurse were independent risk factors for infection or colonization. As suggested by our case, parenteral nutrition with lipids may not be a risk factor for infection with M. pachydermatis, since fatty acids are not required for its growth. This characteristic is useful in distinguishing M. pachydermatis from M. furfur, which may cause a similar syndrome but requires lipids for growth.
Finally, the diagnosis of M. pachydermatis infection is complicated by the fact that this organism may be misidentified as Candida lipolytica by some commercial identification systems.5
M. pachydermatis may cause a severe systemic infection in adults that is similar to the infection previously noted in neonates.
5 ReferencesEbbing Lautenbach, M.D., M.P.H.
Irving Nachamkin, Dr.P.H.
Mindy G. Schuster, M.D.
Hospital of the University of Pennsylvania, Philadelphia, PA 19104-60731
Chang HJ ,Miller HL ,Watkins N , et al. An epidemic of Malassezia pachydermatis in an intensive care nursery associated with colonization of health care workers' pet dogs. N Engl J Med 1998;338:706-711
Full Text | Web of Science | Medline2
Mickelson PA ,Viano-Paulson MC ,Stevens DA ,Diaz PS . Clinical and microbiological features of infection with Malassezia pachydermatis in high-risk infants. J Infect Dis 1988;157:1163-1168
CrossRef | Web of Science | Medline3
Larocco M ,Dorenbaum A ,Robinson A ,Pickering LK . Recovery of Malassezia pachydermatis from eight infants in a neonatal intensive care nursery: clinical and laboratory features. Pediatr Infect Dis J 1988;7:398-401
CrossRef | Web of Science | Medline4
Romano A ,Segal E ,Blumenthal M . Canaliculitis with isolation of Pityrosporum pachydermatis. Br J Ophthalmol 1978;62:732-734
CrossRef | Web of Science | Medline5
Larone DH. Medically important fungi: a guide to identification. 3rd ed. Washington, D.C.: ASM Press, 1995.
To the Editor:
Although M. pachydermatis is certainly associated with otitis externa and dermatitis in dogs, it is also considered part of their natural flora. Several different strains have been isolated from dogs, with no correlation noted between the strain and pathogenicity.1 According to a recent report, 95 percent of “normal” dogs had at least one positive culture when 10 sites were sampled,2 but only 12 of 39 dogs had positive cultures in the study by Chang et al.
In an accompanying editorial, Marcus and Marcus (March 12 issue)3 assert that the infected dogs should have been treated to eliminate the source of infection.3 Unfortunately, this is probably not feasible. Oral ketoconazole is perhaps the most efficacious therapy for dogs, but the cost for an average 25-kg dog is at least $150 to $200, so an owner's compliance with treatment for an asymptomatic dog is doubtful. Another alternative for dogs is twice-weekly bathing with a degreasing shampoo, followed by the use of a shampoo with residual antifungal activity for a minimum of six weeks.4 Cost and effort also make compliance with this regimen unlikely. Symptomatic animals should certainly be treated, and the underlying causes addressed.
Diligent hand washing will probably remain the best protection against future malassezia epidemics. Recently marketed veterinary products containing 1 percent acetic acid and 1 percent boric acid have shown promise in early studies for the treatment of otitis or dermatitis in dogs when the product is in contact with the affected area for a sufficient period. Perhaps a similar product would be useful for health care workers in future outbreaks and if M. pachydermatis becomes a more common zoonotic risk.
4 ReferencesPaul M. Groshek, D.V.M.
222 Penn Dr., West Hartford, CT 061191
Guillot J ,Gueho E ,Chevrier G ,Chermette R . Epidemiological analysis of Malassezia pachydermatis isolates by partial sequencing of the large subunit ribosomal RNA. Res Vet Sci 1997;62:22-25
CrossRef | Web of Science | Medline2
Kennis RA ,Rosser EJ Jr ,Olivier NB ,Walker RW . Quantity and distribution of Malassezia organisms on the skin of clinically normal dogs. J Am Vet Med Assoc 1996;208:1048-1051
Web of Science | Medline3
Marcus LC ,Marcus E . Nosocomial zoonoses. N Engl J Med 1998;338:757-759
Full Text | Web of Science | Medline4
Ihrke PJ. Topical therapy treatment for malassezia dermatitis management. Int Symp Derm Proc. January 1996.
To the Editor:
In the report by Chang et al., how can we be sure that the yeast infection did not originate in the intensive care nursery unit and that it was not subsequently carried home to innocent pets on the hands of the intermediate health care workers?
Thomas J. Lester, M.D.
Katonah Medical Group, Katonah, NY 10536Author/Editor Response
The authors reply:
To the Editor: It is likely that we will see more infections caused by M. pachydermatis and other emerging nosocomial pathogens, such as the case described by Lautenbach et al. That case involved an adult who was immunocompromised, which is consistent with our finding that all the affected infants in the intensive care nursery weighed 1300 g or less at birth. The case report supports our observation that this organism, although opportunistic, does not appear to be lethal if treated appropriately.
With regard to Dr. Groshek's comments about M. pachydermatis infection in dogs, the information we found also indicates that although M. pachydermatis may be the cause of otitis in dogs, it may also be part of a dog's natural flora. In our survey, none of the animals were known to be infected at the time of culture, but several (particularly floppy-eared dogs) were considered to be “prone” to otitis by their owners. The information we found in the veterinary literature, combined with the fact that the hospital is located in an area where many people own dogs, led to the idea of sampling the ears of the animals.
Although we cannot be sure the yeast infection did not originate in the intensive care nursery, as suggested by Dr. Lester, it is more likely that it was introduced on the hands of a health care worker, family member, or visitor who had had contact with an infected or colonized dog. Since this organism is generally known to colonize dogs, they are a plausible source. Also, there were four M. pachydermatis genotypes present among the dogs from which we obtained cultures (of seven known strains), whereas there was only one strain among the patients and health care workers from whom we obtained cultures.
Finally, inadequate hand washing has been associated with numerous outbreaks.1 Education of health care workers has improved compliance with recommendations for hand washing,2 and when performed diligently, hand washing has been shown to put an end to outbreaks such as the one we described.
2 ReferencesHuan J. Chang, M.D.
Centers for Disease Control and Prevention, Atlanta, GA 30333C. Fordham von Reyn, M.D.
Dartmouth–Hitchcock Medical Center, Lebanon, NH 03756William R. Jarvis, M.D.
Centers for Disease Control and Prevention, Atlanta, GA 303331
Casewell M ,Phillips I . Hands as route of transmission for Klebsiella species. BMJ 1977;2:1315-1317
CrossRef | Web of Science | Medline2
Graham M . Frequency and duration of handwashing in an intensive care unit. Am J Infect Control 1990;18:77-81
CrossRef | Web of Science | Medline
Author/Editor Response
The principle we tried to establish in our editorial is that control of a zoonotic epidemic usually requires the reduction or elimination of the infection at its source. Physicians should advise their patients that affected animals need to be evaluated and treated by a veterinarian.
Fortunately, the epidemic in the nursery that was reported by Chang et al. was stopped by hand washing. If this had not been successful, it would have been appropriate to treat or get rid of infected dogs. We think that most health care workers would be sufficiently motivated in that hypothetical situation to take the time, trouble, and expense to treat their pets.
Leonard C. Marcus, V.M.D., M.D.
Travelers' Health and Immunization Services, Newton, MA 02465-2510Eugenia Marcus, M.D.
Pediatric Health Care at Newton–Wellesley, Newton, MA 02462- Citing Articles (4)
Citing Articles
1
J. Scott Weese, Martha B. Fulford. 2011. Fungal Diseases. , 275-298.
CrossRef2
Janine R. Maenza, William G. Merz. 2010. Serious Infections Caused by Uncommon Yeasts. .
CrossRef3
Ross Bond. (2010) Superficial veterinary mycoses. Clinics in Dermatology 28:2, 226-236
CrossRef4
Shinichi Watanabe, Rui Kano, Hiroko Sato, Yuka Nakamura, Atsuhiko Hasegawa. (2001) The Effects of Malassezia Yeasts on Cytokine Production by Human Keratinocytes. Journal of Investigative Dermatology 116:5, 769-773
CrossRef
