Combinatory effect of ALA-PDT and itraconazole in the treatment of cutaneous protothecosis.

BACKGROUND: As a rare subcutaneous infection, protothecosis is easily misdiagnosed. Similar to other subcutaneous infection, there is no unified standard for treatment, for cases not suitable for surgery, clinicians often use antifungal drugs based on their experience, and the course of treatment varies from several months to several years. Based on the fact that there are few relevant materials and researches on photodynamic therapy (PDT), we conducted a study based on a clinical case that used oral itraconazole combined with 5-aminolevylinic acid photodynamic therapy (ALA-PDT) to treat a patient with cutaneous protothecosis caused by Prototheca wicherhamii. METHODS: Different concentrations of ALA and different light doses were used to investigate the effects of ALA-PDT on the growth inhibition of P. wickerhamii in vitro with Colony-counting Methods. And we used transmission electron microscopy (TEM) to visualize the structural changes and the effects of ALA-PDT treating on cellular structures of the P. wickerhamii. Futher, we performed the susceptibility test of P. wickerhamii to itraconazole before and after ALA-PDT in vitro. RESULTS: We have successfully treated a patient with cutaneous protothecosis caused by P. wickerhamii by using combination therapy in a total of 9-week course of treatment. In vitro, ALA-PDT can inhibit the growth of P. wickerhamii when the ALA concentration was 5 mg/mL (P < 0.01), and this effect became stronger as the concentration of ALA or light dose is increased. Using TEM, we confirmed that ALA-PDT can disrupt the cell wall structure and partition structure of P. wickerhamii, which may contribute to its inhibitory effect. Further studies showed that the MIC of itraconazole for P. wickerhamii was decreased after ALA-PDT. CONCLUSIONS: ALA-PDT combined with oral itraconazole can be used to treat cutaneous protothecosis. Accordingly, ALA-PDT can destroy the cell wall and partition structure of P. wickerhamii leading to an inhibitory effect on it in vitro, and the effect is enhanced with the increase of ALA concentration and light dose. Also, the sensitivity of P. wickerhamii to itraconazole is observed increased after ALA-PDT. So our study provides a theoretical basis for the promising treatment against cutaneus protothecosis.

Successful Treatment of Cutaneous Protothecosis Due to Prototheca wickerhamii with Terbinafine.

Protothecosis, an infrequent human infection, is caused by achlorophyllic algae belonging to the genus Prototheca, particularly Prototheca wickerhamii. The skin stands as the most commonly affected organ. This report documents a case involving an 82-year-old male with Protothecosis. Histopathological analysis revealed granulomatous inflammation in the dermis, exhibiting necrotic features and hosting numerous non-budding spherical organisms. These organisms were positively stained using methenamine silver and periodic acid-Schiff stains, confirming identification as P. wickerhamii after validation through tissue culture and sequencing procedures. Initially, the patient received oral itraconazole at a dosage of 200 mg daily, accompanied by topical 1% naftifine-0.25% ketoconazole cream for a duration of 4 weeks, resulting in significant improvement. Subsequently, due to gastrointestinal discomfort presumably linked to itraconazole, terbinafine was administered. Over a span of 3 months, the patient received oral terbinafine at a dosage of 250 mg/day alongside the application of topical 1% naftifine-0.25% ketoconazole cream, leading to complete healing of the skin lesion, leaving behind a fibrotic scar.

Simultaneous infection with Fusarium proliferatum and Prototheca wickerhamii localized at different body sites.

2012 Elsevier Ltd. All rights reserved. Subcutaneous infections caused by two unusual fungi are rare. Here we report an elderly woman with long-term glucocorticoid use who was infected with Fusarium proliferatum on the right dorsum of the hand presenting with a verrucous plaque and Prototheca wickerhamii on the left dorsum of the hand presenting with geographic ulcers with erythematous plaques. The diagnosis was made through histopathological examination of skin samples and fungal culture, with identification through molecular examination. She was successfully treated with voriconazole.

Cutaneous protothecosis in a dog successfully treated with oral itraconazole in pulse dosing.

BACKGROUND: Protothecosis is a rare infectious disease caused by unicellular, achlorophyllous, microalgae of the genus Prototheca, ubiquitously distributed in nature. The algae are emerging pathogens, whose incidence is increasing in both human and animal populations and serious systemic infections related to this pathogen have been increasingly described in humans in recent years. After mastitis in dairy cows, canine protothecosis is the second most prevalent form of the protothecal disease in animals. Here, we report the first case of chronic cutaneous protothecosis due to P. wickerhamii in a dog in Brazil, successfully treated with a long-term therapy with itraconazole in pulse. CASE PRESENTATION: Upon clinical examination, exudative nasolabial plaque, ulcered, and painful lesions in central and digital pads and lymphadenitis were observed in a 2-year-old mixed-breed dog, with a 4-month history of cutaneous lesions and contact with sewage water. Histopathological examination revealed intense inflammatory reaction, with numerous spherical to oval, encapsulated structures stained with Periodic Acid Schiff, compatible with Prototheca morphology. Tissue culture on Sabouraud agar revealed yeast-like, greyish-white colonies after 48 h of incubation. The isolate was subjected to mass spectrometry profiling and PCR-sequencing of the mitochondrial cytochrome b (CYTB) gene marker, leading to identification of the pathogen as P. wickerhamii. The dog was initially treated with oral itraconazole at a dosage of 10 mg/kg once daily. After six months, the lesions resolved completely, yet recurred shortly after cessation of therapy. The dog was then treated with terbinafine at a dose of 30 mg/kg, once daily for 3 months, with no success. The resolution of clinical signs, with no recurrence over a 36-months follow-up period, was achieved after 3 months of treatment with itraconazole (20 mg/kg) in pulse intermittently on two consecutive days a week. CONCLUSIONS: This report highlights the refractoriness of skin infections by Prototheca wickerhamii with therapies proposed in the literature and suggests a new treatment option with oral itraconazole in pulse dosing for long-term disease control successfully performed in a dog with skin lesions.

Systemic protothecosis in an immunocompetent patient.

BACKGROUND: Although uncommon, there is increasing interest and public health concerns of the pathogen Prototheca spp, a ubiquitous achlorophilic microalgae that can affect both humans and animals. High mortality rates have been reported in immunocompromised patients with disseminated infection, but no data is available in the immunocompetent population. CASE PRESENTATION: We present the case of a 59-year-old man from rural area of Colombia who was admitted to the intensive care unit due to decompensated heart failure that was difficult to medically manage, with development of septic shock and isolation of Prototheca wickerhamii from blood culture. Fluconazole and Amphotericin B were given with successful outcome. CONCLUSIONS: To date, protothecosis and its virulence factors and pathogenesis remain to be fully understood, in our case the isolation of this microalga and its implication of exacerbating chronic conditions such as heart failure is unclear. The medical-scientific community is invited to study this microorganism to determine effective management strategies, as well as its timely identification, treatment, and control, to avoid fatal outcomes.

Genome Sequences of Two Strains of Prototheca wickerhamii Provide Insight Into the Protothecosis Evolution.

The Prototheca alga is the only chlorophyte known to be involved in a series of clinically relevant opportunistic infections in humans and animals, namely, protothecosis. Most pathogenic cases in humans are caused by Prototheca wickerhamii. In order to investigate the evolution of Prototheca and the genetic basis for its pathogenicity, the genomes of two P. wickerhamii strains S1 and S931 were sequenced using Nanopore long-read and Illumina short-read technologies. The mitochondrial, plastid, and nuclear genomes were assembled and annotated including a transcriptomic data set. The assembled nuclear genome size was 17.57 Mb with 19 contigs and 17.45 Mb with 26 contigs for strains S1 and S931, respectively. The number of predicted protein-coding genes was approximately 5,700, and more than 96% of the genes could be annotated with a gene function. A total of 2,798 gene families were shared between the five currently available Prototheca genomes. According to the phylogenetic analysis, the genus of Prototheca was classified in the same clade with A. protothecoides and diverged from Chlorella ~500 million years ago (Mya). A total of 134 expanded genes were enriched in several pathways, mostly in metabolic pathways, followed by biosynthesis of secondary metabolites and RNA transport. Comparative analysis demonstrated more than 96% consistency between the two herein sequenced strains. At present, due to the lack of sufficient understanding of the Prototheca biology and pathogenicity, the diagnosis rate of protothecosis is much lower than the actual infection rate. This study provides an in-depth insight into the genome sequences of two strains of P. wickerhamii isolated from the clinic to contribute to the basic understanding of this alga and explore future prevention and treatment strategies.

Protothecosis in the mucosa of the pharynx mimicking pharyngeal cancer in an immunocompetent individual: a case report.

BACKGROUND: Protothecosis is a rare infection in humans and animals caused by the achlorophyllic algae Prototheca species. More than half of the protothecosis cases are cutaneous infections, and most cases are observed in immunocompromised individuals. CASE PRESENTATION: We report a case of Prototheca wickerhamii infection in the mucosa of the pharynx in a 53-year-old immunocompetent woman with an incidentally found mass lesion at the left tongue base. Histopathological findings of the mass lesion suggested cryptococcosis, but P. wickerhamii was identified from the oropharynx scrape culture based on DNA sequencing. After surgical resection, fosfluconazole treatment was initiated, and subsequently, treatment was switched to topical amphotericin B. The residual mass lesion did not deteriorate during the 4-month antifungal treatment and 1-year observational period. CONCLUSIONS: Prototheca species can be easily misdiagnosed as yeasts because of their morphological and pathological similarities. Prototheca, in addition to Cryptococcus should be considered if slow-growing, large Gram-positive organisms are encountered. Lactophenol cotton blue staining of the colony helps distinguish these organisms. Further study is needed to determine the appropriate treatment according to the infection focus.

Prototheca wickerhamii breast implant infection after reconstructive surgery: a new level of complexity.

We report the first published case of Prototheca wickerhamii breast implant infection. This occurred after mastectomy, chemotherapy, radiotherapy, breast reconstruction, implant revisions and breast seroma aspirations and was preceded by polymicrobial infection. Definitive treatment required implant removal and intravenous liposomal amphotericin B. The management of breast prosthesis infections is discussed.

Cutaneous Protothecosis with Meningitis Due to Prototheca wickerhamii in an Immunocompetent Teenager: Case Report and Literature Review.

Human protothecosis is a rare infection caused by Prototheca spp., which are environmental achloric algae ubiquitously existing in nature. Members of the genus of Prototheca usually cause localized infection that affects the skin or wounds. Systemic infection is extremely rare and tends to occur in immunocompromised patients. Here, we report a case of cutaneous protothecosis and meningitis due to Prototheca wickerhamii in an immunocompetent teenager who obtained full-body tattoos at the time of infection. To the best of our knowledge, this is the first description of P. wickerhamii isolated from both skin tissue and cerebrospinal fluid. The data contained in this report will increase our understanding of this pathogen and elucidate the most optimal treatment.

A first insight into the genome of Prototheca wickerhamii, a major causative agent of human protothecosis.

BACKGROUND: Colourless microalgae of the Prototheca genus are the only known plants that have consistently been implicated in a range of clinically relevant opportunistic infections in both animals and humans. The Prototheca algae are emerging pathogens, whose incidence has increased importantly over the past two decades. Prototheca wickerhamii is a major human pathogen, responsible for at least 115 cases worldwide. Although the algae are receiving more attention nowadays, there is still a substantial knowledge gap regarding their biology, and pathogenicity in particular. Here we report, for the first time, the complete nuclear genome, organelle genomes, and transcriptome of the P. wickerhamii type strain ATCC 16529. RESULTS: The assembled genome size was of 16.7 Mbp, making it the smallest and most compact genome sequenced so far among the protothecans. Key features of the genome included a high overall GC content (64.5%), a high number (6081) and proportion (45.9%) of protein-coding genes, and a low repetitive sequence content (2.2%). The vast majority (90.6%) of the predicted genes were confirmed with the corresponding transcripts upon RNA-sequencing analysis. Most (93.2%) of the genes had their putative function assigned when searched against the InterProScan database. A fourth (23.3%) of the genes were annotated with an enzymatic activity possibly associated with the adaptation to the human host environment. The P. wickerhamii genome encoded a wide array of possible virulence factors, including those already identified in two model opportunistic fungal pathogens, i.e. Candida albicans and Trichophyton rubrum, and thought to be involved in invasion of the host or elicitation of the adaptive stress response. Approximately 6% of the P. wickerhamii genes matched a Pathogen-Host Interaction Database entry and had a previously experimentally proven role in the disease development. Furthermore, genes coding for proteins (e.g. ATPase, malate dehydrogenase) hitherto considered as potential virulence factors of Prototheca spp. were demonstrated in the P. wickerhamii genome. CONCLUSIONS: Overall, this study is the first to describe the genetic make-up of P. wickerhamii and discovers proteins possibly involved in the development of protothecosis.

Sequencing and Analysis of the Complete Organellar Genomes of Prototheca wickerhamii.

Of the Prototheca genus, Prototheca wickerhamii has the highest clinical significance in humans. However, neither nuclear nor organellar genomes of this species were sequenced until now. The hitherto determined and analyzed mitochondrial and plastid genomes of the alleged P. wickerhamii species belong in fact to another species, recently named Prototheca xanthoriae. This study provides a first insight into the organellar genomes of a true P. wickerhamii (type strain ATCC 16529). The P. wickerhamii mitochondrion had a 53.8-kb genome, which was considerably larger than that of Prototheca ciferrii (formerly Prototheca zopfii gen. 1) and Prototheca bovis (formerly Prototheca zopfii gen. 2), yet similarly functional, with the differences in size attributable to a higher number of introns and the presence of extra unique putative genes. The 48-kb plastid genome of P. wickerhamii, compared to autotrophic Trebouxiophyceae, was highly reduced due to the elimination of the photosynthesis-related genes. The gene content of the plastid genome of P. wickerhamii was, however, very similar to other colorless Prototheca species. Plastid genome-based phylogeny reinforced the polyphyly of the genus Prototheca, with Helicosporidium and Auxenochlorella branching within clades of Prototheca species. Phylogenetic reconstruction also confirmed the close relationship of P. wickerhamii and P. xanthoriae, which is reflected in the synteny of their organellar genomes. Interestingly, the entire set of atp genes was lost in P. wickerhamii plastid genome while being preserved in P. xanthoriae.

Multiple cutaneous infections caused by Prototheca wickerhamii.

BACKGROUND: Prototheca species are a group of organisms ubiquitously existing in nature but have become a pathogenic threat to public health, which has aroused wide attention. Species identification and antifungal susceptibility have essential and valuable meanings to clinical diagnosis and treatment. METHODS: A case of an 84-year-old patient who had suffered from multiple cutaneous infections was reported. Tissue samples of the damaged skin were collected from the patient and used for microscopic examination and tissue culture. Staining methods, the VITEK system with YSD card and the molecular identification method based on partial mitochondrion-encoded cytochrome b (cytb) gene amplification and sequencing were used for species identification. Antifungal susceptibility testing was completed by using YeastOne plate. RESULTS: The patient had type II diabetes mellitus. Round, grape-like, and scattered morula forms were observed under the microscope in bright blue with lactophenol cotton blue staining and in green fluorescence with fungus fluorescence staining. Yeast-like colonies were grown on both the blood plates and the Sabouraud agar. P wichehamii was identified and presented resistance to three echinocandins, fluconazole, and 5-fluorocytosine, while was susceptible to amphotericin B, posaconazole, itraconazole, and voriconazole. CONCLUSION: Our result revealed that an old patient with diabetes mellitus might be a dangerous population of cutaneous protothecosis. It also highlighted the contribution to microbial methodology on the diagnosis and treatment of such rare fungus infection.

Prototheca wickerhamii prepatellar bursitis in an immunocompetent woman: A case report.

Prototheca wickerhamii is a rare cause of septic prepatellar bursitis. We report a patient who had no apparent immunodeficiency developed P. wickerhamii prepatellar bursitis following intra-bursal corticosteroid injection. Clinical manifestations could not distinguish Prototheca bursitis from septic bursitis caused by other pathogens. Bursal fluid aspiration sent for direct microscopic examination and cultures could give an early diagnosis. Systemic antifungal therapy with complete surgical excision of infected bursa provided a good outcome.

In vitro aminolevulinic acid mediated-antimicrobial photodynamic therapy inactivates growth of Prototheca wickerhamii but does not change antibacterial and antifungal drug susceptibiltity profile.

BACKGROUND: Antimicrobial photodynamic therapy(aPDT) has been used to treat localized cutaneous fungal infections that have an enhanced antifungal susceptibility profile. The aim of this study was to evaluate the effect of ALA aPDT on both the growth and the antimicrobial and antifungal susceptibility of Prototheca wickerhamii. METHODS: Six isolates of P. wickerhamii were used in the present study. The inocula in sterile 6-well microtiter plates were irradiated with narrow band LED (633 ± 10 nm) at the light intensity of 100 mW/cm2 and at a distance of 1 cm for 900 s. The ALA was tested at concentrations of 1, 5, and 10 mmol/l, while 10-µl aliquots of suspensions from each group were inoculated on Sabouraud dextrose agar to test the photoinactivation. Antibiotic susceptibility was investigated by the disc-diffusion method. RESULTS: Our study shows ALA aPDT induced 46% ± 24.23% reduction of the growth of all tested P. wickerhamii strains in T1 group. ALA aPDT induced 50.39% ± 19.88% reduction of the growth of all tested P. wickerhamii strains in T2 group. ALA aPDT induced 52.68 ± 20.22% reduction of the growth of all tested P. wickerhamii strains inT3 group. Single ALA aPDT induced 32.97% ± 1.6% growith reduction of three tested strains(O23d, O23e and 62,207), while repeated ALA aPDT induced 51.65 ± 2.91% reduction of the growth(P value = 0.000). There were no significant difference of the inhibitory zone diameter of both antibacterial and antifungal agents before and after ALA aPDT. CONCLUSIONS: ALA aPDT can inactivate the growth of P. wickerhamii, and repeated aPDT has more photoinactivation of P. wickerhamii. ALA aPDT does not change antibacterial agents and antifungal drugs susceptibility profile of P. wickerhamii.

Outbreak of Prototheca wickerhamii algaemia and sepsis in a tertiary care chemotherapy oncology unit.

BACKGROUND: Prototheca is an emerging, opportunistic, pathogenic, zoonotic achlorophyllous green alga, expanding in pathogenicity and host range, causing localized and disseminated infections. This outbreak of Prototheca wickerhamii algaemia and sepsis in a tertiary care 30-bedded chemotherapy oncology unit is the first human outbreak to the best of our knowledge. METHODS: P. wickerhamii algaemia was confirmed on consecutive isolation. Person to person transmission was hypothesized considering all patients in the unit at risk. Clinico-demographic, diagnostic and treatment profile were correlated. Both manual and automated systems were used for blood culture, isolation, identification and susceptibility of Prototheca. Liposomal amphotericin B was given. Outbreak surveillance of faeces, fingertips and environmental reservoirs, retrospective surveillance during past 15 years and prospective surveillance was continued for two years. RESULTS: The outbreak affected 12 neutropenic patients over 50 days. No specific clinical features were noted. The hypothesis could not be substantiated. P. wickerhamii was isolated as yeast-like colonies revealing Gram positive yeast-like cells without budding and pseudohyphae which were confirmed by automated system. Post amphotericin B blood cultures were negative for Prototheca. Surveillance studies were not contributory. CONCLUSION: P. wickerhamii has no documented reservoirs or transmission. Endogenous colonization in the gut followed by translocation during chemotherapy induced immunosuppression is likely to cause algaemia and sepsis. Outbreaks are difficult to detect and control as incubation period is variable and clinical presentation is muted, emphasizing the need to strengthen hospital and laboratory based surveillance systems to ensure adequate preparedness, rapid detection and response to outbreaks.

Case report of cutaneous protothecosis caused by Prototheca wickerhamii designated as genotype 2 and current status of human protothecosis in Japan.

An 85-year-old Japanese woman presented with infiltrative erythema and ulceration on the extensor surface of her right forearm. Direct microscopic examination demonstrated spherical and morula-like sporangia, while histopathology revealed numerous microorganisms with a mulberry-like appearance in the dermis. Staining of the microorganisms also showed mulberry-like sporangia that resembled the spokes of a wheel. The isolated yeast-like microorganism had been identified as Prototheca wickerhamii genotype 2 in another independent study on the basis of its morphological, biochemical and genetic analysis. This case of protothecosis was recorded in Kyushu, Japan, and oral treatment with itraconazole 200 mg/day for 2 months was effective. Herein, we also summarize and analyze 39 cases of human protothecosis reported in Japan since the first record in 1983.

Protothecosis in a patient with T cell lymphocytic leukemia / Prototecosis en un paciente con leucemia linfocítica de células T

Human protothecosis is a rare infection caused by algae of the genus Prototheca. Prototheca wickerhamii has been recognized as the main species that causes infection in immunocompromised hosts with deficits in innate or cellular immunity. We report a case of persisting subcutaneous protothecosis in a patient with T-cell large granular lymphocyte leukemia, who also presented a history of disseminated histoplasmosis.

La prototecosis humana es una infección rara causada por algas del género Prototheca. Prototheca wickerhamii ha sido reconocida como la principal especie causante de infección en huéspedes inmunocomprometidos, con déficit de inmunidad innata o celular. Presentamos un caso de prototecosis subcutánea persistente en un paciente con leucemia linfocítica granular de células T, con antecedentes de histoplasmosis diseminada.

Prototheca: A Danger Underwater.

Prototheca wickerhamii rarely causes systemic infection in humans but when it occurs, there are coexisting comorbidities. This case illustrated shows the manifestation of this opportunistic microorganism in an immunosuppressed patient. The patient was successfully treated with Liposomal amphotericin B with complete resolution of the lesions.

Protothecosis in a patient with T cell lymphocytic leukemia.

Human protothecosis is a rare infection caused by algae of the genus Prototheca. Prototheca wickerhamii has been recognized as the main species that causes infection in immunocompromised hosts with deficits in innate or cellular immunity. We report a case of persisting subcutaneous protothecosis in a patient with T-cell large granular lymphocyte leukemia, who also presented a history of disseminated histoplasmosis.

Isolation of infectious microalga Prototheca wickerhamii from a carp (Cyprinus carpio) - a first confirmed case report of protothecosis in a fish.

Protothecosis is a rare infection caused by environmentally ubiquitous achlorophyllic microalgae of the genus Prototheca. Here, we describe a first case of protothecosis in a carp (Cyprinus carpio), which is at the same time the first case of protothecosis in a fish, confirmed by phenotype- and molecular-based methods, including PCR sequencing of the rDNA cluster and protein profiling using matrix-assisted laser desorption ionization time-of-flight mass spectrometry.