BOYD 11 ISOLATED FROM A PATIENT WITH CHRONIC PROSTATITIS

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1 THE AMERICAN JOURNAL OF CLINICAL PATHOLOGY Vol. 35, No. 2, pp February, 1961 Copyright 1961 by The Williams & Wilkins Co. Printed in U.S.A. ALLESCHERIA BOYD 11 ISOLATED FROM A PATIENT WITH CHRONIC PROSTATITIS ESTHER MEYER, PH.D., AND RUSSELL D. HERROLD, M.D. Department of Microbiology, University of Illinois College of Medicine, and Department of Surgery, University of Illinois, Research and Educational Hospitals, Chicago 12, Illinois Allescheria hoydii was cultured first by Boyd and Crutchfield 6 from a case of maduromycosis. They enlisted the assistance of Shear, 11 a mycologist, who studied it in detail and believed it to be an undescribed species belonging to the Ascomycetes, and named it A. hoydii. Emmons, 9 in 1944, demonstrated A. hoydii to be the sexual stage (perfect stage) of the more widely known fungus Monosporium apiospermum. A. hoydii produces perithecia containing ascospores (sexual spores) in addition to ovoid conidia, which are observed in each of the stages. Of the 2, M. apiospermum, the imperfect form, has been reported most often as the cause of maduromycosis. Conant 7 attributes this to the fact that the majority of isolates do not produce the perfect stage in culture. Benham and Georg 4 have published data to demonstrate that perithecia developed when they used dextrose agar with 0.2 per cent asparagin as the sole source of nitrogen. These findings emphasize that M. apiospermum and A. hoydii are merely stages of the same fungus. Although these 2 stages are usually associated with maduromycosis, Belding and Umanzio 3 and Blank and Stuart 6 reported M. apiospermum as the cause of otomycosis. Benham and Georg 4 reported A. hoydii as the etiologic agent in a case of meningitis, and Creitz and Harris 8 observed it in the sputum of a patient suffering from a chronic pulmonary infection. Although it is well known that a single fungus may cause more than 1 clinical condition, to our knowledge this is the first report covering a case of chronic prostatitis Received, May 24, 1960; revision received, June 25; accepted for publication October 6. Dr. Meyer is Associate Professor of Microbiology, and Dr. Herrold is Clinical Associate Professor of Surgery. 155 presumably complicated by the secondary invasion of A. hoydii* Case history. W. B. C, a 57-year-old white man, resides in Chicago but spends part of each year in Florida. He is engaged in the wholesale lumber business. He has suffered from chronic prostatitis for many years, but has difficulty urinating only during exacerbation of a complicating cystitis. An enterococcus has been routinely isolated from the urine and prostatic secretions. During periods of relapse he was treated with two 50-mg. doses of either erythromycin or Achromycin 4 times daily. As soon as the symptoms subsided, antibiotics were discontinued. Although the patient has not suffered any acute episodes for the past several months, cultures were prepared 2 or 3 times monthly. Each yielded the same enterococcus, but in addition we observed several colonies of the mold, A. hoydii. We are currently finding an increased number of colonies of the fungus. Physical examination. Some loss in weight has occurred during the past year. The chest x-rays and electrocardiogram were normal; basal metabolism, plus 5; cholesterol from 275 mg. to 315 mg. per 100 ml. of serum; blood urea nitrogen, 19.5 mg. per 100 ml.; and the protein bound iodine was too elevated to read. MATERIALS AND METHODS Slides. A drop of sediment from a centrifuged specimen of urine was placed on a slide, gently covered by a coverslip, and examined microscopically for fungal cells. A similar mount was prepared directly from the prostatic secretions, except that it was * The authors wish to express their appreciation to Dr. Chester W. Emmons for verification of the culture.

2 156 MEYER AND HERROLD Vol. 35 cleared by adding a drop of 10 per cent potassium hydroxide. Cultures. Portions of the same materials were cultured routinely on brain-heart infusion agar plates and incubated at 37 C. When colonies of mold developed, they were transferred to Sabouraud's agar slants which were incubated at room temperature for several days. Agglutination tests. Prior to the work of Seeliger 10 no useful procedures were available for the serologic diagnosis of infections caused by M. apiospermum-a. boydii. The technics used in this work were essentially the same as those described by him. Agglutination reactions were performed with conidial suspensions of the A. boydii organism isolated from the patient (W. B. C.) and from another culture as indicated later. The suspension was prepared by washing the surface of Sabouraud's dextrose agar slants with 0.3 per cent formalized saline solution after maximal development of conidia. It was filtered through a few layers of sterile gauze to remove fungal filaments, and the antigen was killed by incubating the formalized suspension for 2 days at 37 C. For agglutination tests it was diluted to a density corresponding to the McFarland No. 3 standard, and 0.5 ml. was added to each tube of a serial 2-fold dilution of the patient's serum. As serum controls, we used 3 different samples of blood serum obtained from normal persons. After shaking well, the antigen-antiserum mixtures and an antigensaline control were centrifuged for 15 min. at 3000 r.p.m. The results were read after gentle agitation of the tubes. At the same time these tests were being performed, a patient (H. C.) suffering from maduromycosis-ilf. apiospermum etiology, entered University of Illinois Research and Educational Hospitals. Blood serum was obtained and similar agglutination studies were performed on this sample. RESULTS Occasional ovoid spores resembling those produced in cultures were seen in slides prepared from urine sediments and prostatic FIG. 1. Allescheria boydii; growth on Sabouraud's glucose agar after 12 days at 25 C. Actual size.

3 Feb ALLESCHERIA BOYDII AND P R O S T A T I T I S FIG. 2 (upper). Allescheria boydii; slide culture indicating pyriform, asexual conidia. X 500. FIQ. 3 (lower). Allescheria boydii; ruptured mature perithecia, and also ascospores. X

4 158 MEYER AND HERROLD Vol. 35 TABLE 1 AGGLUTINATION TITERS OF SEKUMS OBTAINED PROM THE Two PATIENTS AS COMPARED WITH THREE NORMAL HUMAN SERUMS; BOTH ANTIGENS, STANDARDIZED CONIDIAL SUSPEN SIONS PREPARED FROM THE ISOLATED FUNGI Source of Antigen Allescheria boydii (patient W. B.C.) Monosporium apiospermum. (patient H. C.) Patients' Serums* 1. (W. B. C.) 160f 2 (H. C.) Normal Human Serums* * All tests were performed in triplicate. f Figures refer to reciprocals of serum titers. X Not performed, inasmuch as conidial suspensions were difficult to obtain because of poor sporulation. secretions, but no mycelial filaments were seen. Benham and Georg 4 similarly observed only spores of A. boydii in centrifuged spinal fluid. Histopathologic studies have not been made, inasmuch as biopsy material was not available. Cultures of the fungus on Sabouraud's dextrose agar revealed white to gray cottony aerial mycelia, with a dark gray color on the under side. Initially the fungus was isolated in the imperfect stage but, upon continued incubation, perithecia typical of A. boydii were produced. Slides prepared, using lactophenol cotton blue stain, revealed pyriform asexual conidia 5 to 7 n wide, and 9 to 10 n long, produced singly at the ends of conidiophores of various lengths and laterally from the hyphae. Abundant dark brown perithecia from 50 to 200 n in diameter, filled with subglobose asci containing elliptical, brown-walled ascospores 4 to 5 n in diameter, were observed (Figs. 1, 2, and 3). The results of the agglutination tests are listed in Table 1. It is apparent that serum from both patients agglutinated antigens obtained from either A. boydii or M. apiospermum to titers of 1: to 1:160, whereas control serums revealed titers of 1:10 to t :20. No spontaneous agglutination occurred in the conidial-saline controls. DISCUSSION The summation of clinical experience to date indicates that there is an increased incidence of mycotic infections. Zimmerman 12 reviewed the literature and attributes this to a combination of 3 factors: (1) debilitating disease or poor resistance; (2) existence of a local lesion; and (3) an ecologic disturbance between fungi and bacteria, resulting from various antibiotics and hormones used in therapy. He comments that Aspergillus and Candida infections, particularly in their disseminated form, are more frequently encountered in the present era of modern therapeutics. Baker 1 ' 2 has recognized mucormycosis as a new disease and believes that the increased incidence, like that of candidiasis, is probably owing to the use of antibiotics which reduce the number of bacterial infections, but permit fungus invasion. In the case reported in this paper, it is possible that A. boydii may be superimposed on an existing enterococcal infection, and; also that antibiotic therapy produced an environment favorable to growth of the fungus. Proof of the etiologic agent could best be obtained by histopathologic examination, but unfortunately the patient was unwilling to submit to the necessary procedure. Creitz and Harris 8 reported a somewhat similar situation regarding a problem case in which the patient was suffering from a chronic suppurative pneumonia with multiple abscesses, and had been treated with several antibiotics over a long period, but manifested no change in symptoms. When sputum specimens were submitted for fungus culture, A. boydii was isolated repeatedly. They also believed that proof of the etiologic agent could be obtained only by histopathologic examination of the lung tissue, which was not available. They did express the opinion that the evidence at hand favored fungus etiology. Results of the agglutination tests substantiate those obtained by Seeliger, 10 with the exception that control serums in his

5 Feb ALLESCHERIA BOYDII AND PROSTATITIS 159 series were negative. In this instance we can not regard the agglutination titers of 1: to 1:160 obtained with the patient's serum (W. B. C.) as diagnostic, but can only say that the fungus seems to be stimulating antibody formation. It is difficult to explain the low titers of 1:10 and 1:20 in the control serums with any degree of certainty, but it is possible that the antibodies developed in response to a common antigen that was shared by some other fungus. SUMMARY Allescheria boydii, as well as its imperfect form, Monosporium apiospermum, have been reported primarily as etiologic agents of maduromycosis, and only rarely in other infections. In this instance, A. boydii was isolated repeatedly from the urine and prostatic secretions of a patient suffering from chronic prostatitis. At present there is inadequate evidence for us to assign a definite etiologic role to the fungus, inasmuch as proof could be gained only by examination of histopathologic sections which were not available. We can only say that A. boydii is resident in the urinary system, reproduces there, but its role in the symptomatology is unknown. SUMMARIO IN INTERLINGUA Allescherichia boydii, como etiam su forma imperfecte, Monosporium apiospermum, se trova reportate primarimente como agentes etiologic de maduromycosis e solo rarmente in altere infectiones. In le presente caso, A. boydii esseva isolate repetitemente ab le urina e le secretiones prostatic de un patiente con prostatitis chronic. Al tempore presente, nostre datos non suffice pro ascribir un definite rolo etiologic a ille fungo in le presente caso. Un prova de iste possibilitate esserea obtenibile solmente super le base del examine de sectiones histopathologic, e tales non esseva disponibile. Nos pote dicer solmente que A. boydii reside in le systema urinari e se reproduce in illo, sed su rolo in le symptomatologia non es cognoscite. REFERENCES 1. BAKER, R. D.: Pulmonary mucormycosis. Am. J. Path., 32: , BAKER, R. D.: Mucormycosis A new disease? J. A. M. A., 163: 5-8, BELDING, D. L., AND UMANZIO, C. B.: A new species of the genus Monosporium associated with chronic otomycosis. Am. J. Path., 11: , BENHAM, R. W., AND GEORG, L. K.: Allescheria boydii, causative agent in a case of meningitis. J. Invest. Dermat., 10: , BLANK, F., AND STUART, E. A.: Monosporium apiospermum Sacc, 1911, associated with otomycosis. Canad. M. A. J., 72: 601, BOYD, M. F., AND CRUTCHFIELD, E. D.: Mycetoma in North America. Am. J. Trop. Med., 1: , CONANT, N. F., SMITH, D. T., BAKER, R. D., CALLAWAY, J. L., AND MARTIN, D. S.: Manual of Clinical Mycology, Ed. 2. Philadelphia: W. B. Saunders Company, 1954, p CREITZ, J., AND HARRIS, H. W.: Isolation of Allescheria boydii from sputum. Am. Rev. Tuberc, 71: , EMMONS, C. W.: Allescheria boydii and Monosporium apiospermum. Mycologia, 36: , SEELIGER, H.: A serologic study of hyphomycetes causing mycetoma in man. J. Invest. Dermat., 26: 81-93, SHEAR, C. L.: Life history of an undescribed ascomycete isolated from a granular mvcetoma of man. Mycologia, 14: , ZIMMERMAN, L. E.: Fatal fungus infections complicating other diseases. Am. J. Clin. Path., 25: 46-65, 1955.