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Table 1.  

Patient Age, y/sex Underlying condition Exposure Type of infection Therapy Outcome
1 67/F Diabetes, endometrial cancer (remission) Pigeon Fungemia + UTI FLC + CAS Survived
2 63/F Esophagus squamous cell carcinoma Pigeon Mediastinitis after gastric ulceration CAS Survived
3 66/M CDP (endocrine carcinoma), recurrent angiocholitis NA Angiocholitis FLC, surgery† Survived
4 84/F Esophageal achalasia None Esophagitis PPI, surgery‡ Survived
5 68/F CVID, gastro–jejunal anastomotic stenosis NA Colonization None Survived
6 46/M Caustic esophageal stenosis,pneumonia NA Colonization None Survived
7 59/F Systemic scleroderma NA Colonization None Died (cardiogenic shock)
8 40/M Former smoker, Staphylococcus ventilator-associated pneumonia NA Colonization None Survived
9 51/F AutoHSCT for oculo-cerebral NHL NA Colonization FLC Survived
10 60/M Proven Mycobacterium fortuitum infection NA Colonization None Survived
11 59/M COPD, emphysema, denutrition NA Colonization None Survived
12 77/M Congestive heart failure, ischemic cardiomyopathy, smoker NA Colonization None Died; multiorgan failure after cardiac surgery
13 66/M Angioimmunoblastic T-cell lymphoma, neutropenia, pulmonary tuberculosis NA Colonization None Died 5 mo later; cerebral toxoplasmosis, T-cell lymphoma progression

Table 1. Clinical characteristics of Kazachstania spp. infections and colonizations, Strasbourg, France, 2007–2020*

*AutoHSCT, autologous hematopoietic stem cell transplantation; CDP, cephalic duodenopancreatectomy; CAS, caspofungin; COPD, chronic obstructive pulmonary disease; CVID, common variable immunodeficiency; FLC, fluconazole; NHL, non-Hodgkin lymphoma; NA, not applicable; PPI, proton pump inhibitor; UTI, urinary tract infection.
†Degastrogastrectomy and hepatico–jejunal and gastrointestinal anastomosis.
‡Peroral endoscopic myotomy to treat achalasia.

Table 2.  

Patient Sample Fungus species Identification technique Antifungal susceptibility, μg/mL GenBank accession no.
Method FLC VRC 5FC AMB CAS
1 2 blood cultures,urine K. bovina+ Candida albicans Sequencing Etest 24 0.125 0.012 0.047 0.25 MZ435268
        EUCAST 2 ≤0.016 ≤0.125 0.015 0.015  
2 Mediastinal collection; false membranes; pleural fluid† K. bovina+ C. albicans, + C. glabrata Sequencing Etest 8 0.125 NA 0.5 0.19 MZ435270
3 Bile (surgical sample) K. telluris SC+C. albicans MALDI-TOF Etest >256 0.19 NA 0.047 0.25 Not stored
4 Esophageal biopsy;fibroscopy: white plaques of the mucosa‡ K. bovina + C. albicans Sequencing Etest 6 0.032 NA 0.125 0.25 MZ435269
5 Gastric liquid K. telluris SC+ C. albicans MALDI-TOF   NA NA NA NA NA Not stored
6 BAL fluid K. telluris SC MALDI-TOF   NA NA NA NA NA Not stored
7 Stool K. telluris SC+ C. lusitaniae MALDI-TOF   NA NA NA NA NA Not stored
8 BAL fluid K. telluris SC MALDI-TOF   NA NA NA NA NA Not stored
9 Urine, stool K. telluris SC+ C. albicans MALDI-TOF   NA NA NA NA NA Not stored
10 BAL fluid K. telluris SC+ C. albicans MALDI-TOF   NA NA NA NA NA Not stored
11 Sputum K. telluris SC+ C. albicans C. dubliniensis A. niger MALDI-TOF AMB-fungus 4 0.25 <4 <0.5 NA Not stored
12 Stool K. telluris SC+ C. albicans MALDI-TOF   NA NA NA NA NA Not stored
13 BAL fluid, stool K. telluris + C. kefyr MALDI-TOF AMB-fungus 8 0.125 <4 <0.5 NA Not stored

Table 2. Mycologic characteristics of Kazachstania spp. infections and colonizations, Strasbourg, France, 2007–2020*

*AMB, amphotericin B; AMB; BAL, bronchoalveolar lavage; CAS, caspofungin; Etest (bioMérieux, https://www.biomerieux.fr); EUCAST, European Committee on Antimicrobial Susceptibility Testing; 5FC, flucytosine; FLC, fluconazole; ITC, itraconazole; MALDI-TOF, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry; NA, not applicable; SC, species complex; VRC, voriconazole .
†Anatomopathologic examination of the gastric perforation showed necrosis and inflammation.
‡Anatomopathologic examination of the esophageal biopsy showed no signs of invasion, leading to the diagnosis of mucocutaneous fungal infection.

CME / ABIM MOC

Fungal Infections Caused by Kazachstania spp., Strasbourg, France, 2007–2020

  • Authors: Charlotte Kaeuffer, MD; Mathieu Baldacini, MD; Tiffany Ruge, MD; Yvon Ruch, MD; Yves-Jean Zhu, BS; Manon De Cian, MD; Guillaume Philouze, MD; Philippe Bachellier, MD; Julie Denis, PharmD; Nicolas Lefebvre, MD; Francis Schneider, MD, PhD; Yves Hansmann, MD; Valérie Letscher-Bru, PhD; Raoul Herbrecht, MD; Marcela Sabou, MD, PhD; François Danion, MD, PhD
  • CME / ABIM MOC Released: 12/17/2021
  • Valid for credit through: 12/17/2022
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  • Credits Available

    Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 1.00 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for infectious disease specialists and other physicians who care for patients at risk of severe fungal infections.

The goal of this activity is to describe clinical and mycologic characteristics of infection with K bovina.

Upon completion of this activity, participants will:

  • Distinguish mammals that can be infected with Kazachstania bovina
  • Assess clinical characteristics of persons with positive testing for Kazachstania spp.
  • Analyze the antifungal resistance pattern of Kazachstania spp.
  • Evaluate potential risk factors for a positive test for Kazachstania spp.


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Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Faculty

  • Charlotte Kaeuffer, MD

    CHU de Strasbourg
    Université de Strasbourg
    Strasbourg, France

    Disclosures

    Disclosure: Charlotte Kaeuffer, MD, has disclosed no relevant financial relationships.

  • Mathieu Baldacini, MD

    CHU de Strasbourg
    Université de Strasbourg
    Strasbourg, France

    Disclosures

    Disclosure: Mathieu Baldacini, MD, has disclosed no relevant financial relationships.

  • Tiffany Ruge, MD

    CHU de Strasbourg
    Université de Strasbourg
    Strasbourg, France

    Disclosures

    Disclosure: Tiffany Ruge, MD, has disclosed no relevant financial relationships.

  • Yvon Ruch, MD

    CHU de Strasbourg
    Université de Strasbourg
    Strasbourg, France

    Disclosures

    Disclosure: Yvon Ruch, MD, has disclosed no relevant financial relationships.

  • Yves-Jean Zhu, BS

    CHU de Strasbourg
    Université de Strasbourg
    Strasbourg, France

    Disclosures

    Disclosure: Yves-Jean Zhu, BS, has disclosed no relevant financial relationships.

  • Manon De Cian, MD

    CHU de Strasbourg
    Université de Strasbourg
    Strasbourg, France

    Disclosures

    Disclosure: Manon De Cian, MD, has disclosed no relevant financial relationships.

  • Guillaume Philouze, MD

    CHU de Strasbourg
    Université de Strasbourg
    Strasbourg, France

    Disclosures

    Disclosure: Guillaume Philouze, MD, has disclosed no relevant financial relationships.

  • Philippe Bachellier, MD

    CHU de Strasbourg
    Université de Strasbourg
    Strasbourg, France

    Disclosures

    Disclosure: Philippe Bachellier, MD, has disclosed no relevant financial relationships.

  • Julie Denis, PharmD

    CHU de Strasbourg
    Université de Strasbourg
    Strasbourg, France

    Disclosures

    Disclosure: Julie Denis, PharmD, has disclosed no relevant financial relationships.

  • Nicolas Lefebvre, MD

    CHU de Strasbourg
    Université de Strasbourg
    Strasbourg, France

    Disclosures

    Disclosure: Nicolas Lefebvre, MD, has disclosed no relevant financial relationships.

  • Francis Schneider, MD, PhD

    CHU de Strasbourg
    Université de Strasbourg
    Strasbourg, France

    Disclosures

    Disclosure: Francis Schneider, MD, PhD, has disclosed no relevant financial relationships.

  • Yves Hansmann, MD

    CHU de Strasbourg
    Université de Strasbourg
    Strasbourg, France

    Disclosures

    Disclosure: Yves Hansmann, MD, has disclosed no relevant financial relationships.

  • Valérie Letscher-Bru, PhD

    CHU de Strasbourg
    Université de Strasbourg
    Strasbourg, France

    Disclosures

    Disclosure: Valérie Letscher-Bru, PhD, has disclosed no relevant financial relationships.

  • Raoul Herbrecht, MD

    Institut de Cancérologie Strasbourg Europe (ICANS)
    Strasbourg, France

    Disclosures

    Disclosure: Raoul Herbrecht, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Astellas Pharma, Inc.; Basilea Pharmaceutica Ltd.; Gilead Sciences, Inc.; Merck Sharp & Dohme GmbH; Pfizer Inc.
    Served as a speaker or a member of a speakers bureau for: Amgen Inc.; Gilead Sciences, Inc.; Pfizer Inc.
    Received grants for clinical research from: Gilead Sciences, Inc.; Novartis Pharmaceuticals Corporation

  • Marcela Sabou, MD, PhD

    CHU de Strasbourg
    Université de Strasbourg
    DIHP - UR 7292
    Fédération de Médecine Translationnelle
    Strasbourg, France

    Disclosures

    Disclosure: Marcela Sabou, MD, PhD, has disclosed no relevant financial relationships.

  • François Danion, MD, PhD

    CHU de Strasbourg
    Université de Strasbourg
    Inserm
    UMR-S1109
    Fédération de Médecine Translationnelle
    Strasbourg, France

    Disclosures

    Disclosure: François Danion, MD, PhD, has disclosed the following relevant financial relationships:
    Served as a speaker or a member of a speakers bureau for: Gilead Sciences, Inc.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine

    Disclosures

    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Johnson & Johnson

Editor

  • P. Lynne Stockton Taylor, VMD, MS, ELS(D)

    Copyeditor 
    Emerging Infectious Diseases

    Disclosures

    Disclosure: P. Lynne Stockton Taylor, VMD, MS, ELS(D), has disclosed no relevant financial relationships.

CME Reviewer

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Stephanie Corder, ND, RN, CHCP, has disclosed no relevant financial relationships.

None of the nonfaculty planners for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients.


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    For Physicians

  • Medscape, LLC designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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CME / ABIM MOC

Fungal Infections Caused by Kazachstania spp., Strasbourg, France, 2007–2020

Authors: Charlotte Kaeuffer, MD; Mathieu Baldacini, MD; Tiffany Ruge, MD; Yvon Ruch, MD; Yves-Jean Zhu, BS; Manon De Cian, MD; Guillaume Philouze, MD; Philippe Bachellier, MD; Julie Denis, PharmD; Nicolas Lefebvre, MD; Francis Schneider, MD, PhD; Yves Hansmann, MD; Valérie Letscher-Bru, PhD; Raoul Herbrecht, MD; Marcela Sabou, MD, PhD; François Danion, MD, PhDFaculty and Disclosures

CME / ABIM MOC Released: 12/17/2021

Valid for credit through: 12/17/2022

processing....

Abstract and Introduction

Abstract

Rare fungal pathogens are emerging as agents of invasive fungal infections. We analyzed 13 cases of fungal infections caused by Kazachstania (Arxiozyma) spp. in Strasbourg University Hospital, Strasbourg, France. Among the cases, 4 patients had proven fungal disease (3 cases of invasive fungal disease and 1 mucocutaneous infection) and 9 were colonized by Kazachstania (Arxiozyma) spp. Candida albicans was also isolated from 11 of the 13 patients. None of the patients with proven invasive fungal disease met host criteria, but most had underlying diseases. All strains were identified as K. telluris by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, and 3 were confirmed as K. bovina by internal transcribed spacer sequencing. For all tested strains, the MICs for fluconazole were ≥2 μg/mL. Emergence of this rare fungal infection might be explained by the increasing number of patients with immunocompromised conditions and gastroesophageal diseases.

Introduction

Incidence of invasive fungal infections (IFI) has increased over the past 2 decades, mostly associated with candidemia[1]. Rare fungal pathogens have also emerged as agents causing IFI, notably in immunocompromised persons[2].

Kazachstania (Arxiozyma) spp. are ubiquitous yeasts belonging to the Saccharomycetaceae family. Kazachstania bovina was described as Saccharomyces tellustris in 1957, as Candida bovina in 1958, as Torulopsis bovina in 1970, and finally as K. bovina in 2005 on the basis of multigene phylogenetic analyses[3–5]. K. bovina belongs to the K. telluris species complex, which also includes K. pintolopesii, K. sloofiae, K. heterogenica, and K. telluris[5]. Recently, a case of IFI caused by C. bovina (the former name of K. bovina in humans) was described[6]. We report a case series of fungal infections caused by Kazachstania (Arxiozyma) spp. and classify them as invasive infections, mucocutaneous infections, or colonizations. We also describe the antifungal susceptibility testing and the methods used to identify the species.

This analysis is part of a study of opportunistic infections approved by the institutional ethics committee of the Hôpitaux Universitatires de Strasbourg. According to regulations in France, the database was declared to the Commission Nationale de l’Informatique et des Libertés. The study was registered at ClinicalTrials.gov (no. NCT03920735).