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Introduction

Acremonium is a fungal species which is present in the soil, air and decayed vegetation. This fungus can cause multisystem disseminated infections through hematogenous spread and is resistant to routinely used antifungals [1]. A case report of Indian male who presented with polytrauma with probable disseminated infection and the causative agent as Acremonium species is discussed.

Case presentation

A 39-year-old male, with no previous comorbidities reported to hospital with polytrauma due to road traffic accident with blunt injury to chest and penetrating injury to abdomen, bilateral lower limb weakness, bowel and bladder incontinence. He was admitted to the ICU, KIMS Hospital, Secunderabad. Chest X ray AP view suggested patchy consolidation in the right lung. Computed Tomography (CT) whole abdomen suggested patchy sub capsular non enhancing area in the IV a segment of the liver (Figure 1).

Figure 1: CT ABDOMEN suggestive of mixed echogenic lesion.

Patient had fever, malaise and his Glasgow Coma Scale (GCS) deteriorated with increased drowsiness. CT and Magnetic Resonance Imaging (MRI) brain were done which suggested a ring enhancing lesion. Pus from the right liver lobe was evacuated and was sent to microbiology for gram staining, Ziehl-Neelsen staining, modified Ziehl-Neelsen staining, 10% KOH mount, culture and sensitivity and to pathology for histopathology examination. The specimen was processed as per the standard laboratory practices.

Gram stain showed moderate pus cells. Ziehl-Neelsen stain was negative for Acid fast bacilli. Modified Ziehl-Neelsen was negative for Nocardia species. 10% KOH mount showed thin filamentous hyphae with cylindrical, one-celled conidia arising from short unbranched single phialide.

Figure 2: Photomicrograph (40x) showing septate filamentous hyphae with ellipsoidal conidia arising from short unbranched single phialide.

Under strict aseptic conditions, specimen was inoculated onto Sabouraud Dextrose Agar (SDA) with antibiotics which were incubated at room temperature and at 37°C. Gross morphology of culture after 96 hours of incubation had a white-gray with a velvety to cottony appearance on the obverse and grey-black on the reverse (Figure 3).

Figure 3a,b: Obverse and reverse of SDA at 37 °C.

Microscopic examination using lactophenol cotton blue (LPCB) mount revealed thin, septate, and hyaline hyphae. The conidia were single-celled, originating from short, unbranched, tapered, awl-shaped phialides and forming clusters at their apex. Macroscopic analysis showed colonies characteristic of Acremonium species, displaying a cottony, white to grayish appearance with a velvety or powdery texture, features typical of this opportunistic fungal pathogen.

Patient was initiated on IV amphotericin B 30mg once daily and voriconazole 4mg/kg for four days. His neurological status improved in due course and was discharged on oral voriconazole 200 mg twice a day for 2 months and IV amphotericin B 30mg once daily for next two months with stable hemodynamics. Patient was asymptomatic at review after two months.

Discussion

The non-dermatophytic molds (NDMs) or yeasts have a worldwide prevalence of 5.5% [1]. Acremonium, opportunistic fungus being one among them belongs to the genus cephalosporium which is a saprophytic hyaline fungal mold causing infections. Acremonium is ubiquitous in nature and an environmental contaminant. Acremonium species are being reported in both systemic and localised infections. Acremonium infections are well recognized as aetiologic agents in causing subcutaneous infections followed by penetrating trauma [2]. Majority of the reports on diseases caused by this fungus were reported from tropical and subtropical areas [3]. Acremonium can cause disseminated and multiple organ involvement causing a variety of clinical manifestations like mycetoma, mycotic keratitis, onychomycosis, arthritis, osteomyelitis, endocarditis, peritonitis and meningitis [4-7].

Conclusion

Acremonium species are opportunistic fungal pathogens capable of causing severe, life-threatening infections, especially in immunocompromised individuals, leading to high morbidity and mortality if not promptly diagnosed and treated. A multidisciplinary team, including infectious disease specialists, and microbiologists, is crucial for effective management. Timely antifungal therapy, surgical intervention when required, and vigilant monitoring significantly improve recovery outcomes and reduce complications.

Conflicts of interest

Authors declare no conflicts of interest.