Open Access Case
Report
DOI: 10.7759/cureus.7616
Geotrichosis Presenting As Funguria and
Asymptomatic Urinary Tract Infection in a
Patient with Renal Cyst
Venkataramana Kandi 1 , Ritu Vaish 2 , Padmajakshi Gurrapu 3 , Sri Sandhya Koka 2 , Mohan Rao
Bhoomigari 2
1. Clinical Microbiology, Prathima Institute of Medical Sciences, Karimnagar, IND 2. Microbiology,
Prathima Institute of Medical Sciences, Karimnagar, IND 3. Microbiology, Rural Medical College, Pravara
Institute of Medical Sciences (Deemed University)/Prathima Institute of Medical Sciences, Karimnagar,
IND
Corresponding author: Venkataramana Kandi, ramana20021@gmail.com
Abstract
Fungi are a versatile group of microorganisms that exist in three morphological forms, which
include the yeasts (oval/spherical budding cells), true fungi (produce long filamentous,
branching structures called as hyphae/mycelia), and dimorphic fungi (show both yeast at
370C and hyphal forms at room temperature). Most fungi are present in the environment and
live as saprophytes. Some fungal species like the Candida are present in the human respiratory,
intestinal, and genitourinary tract as commensals. Some fungi cause infections in humans and
animals (dermatophytes). Few other fungal species are responsible for opportunistic infections,
mostly in debilitated and immunosuppressed individuals. Geotrichum is one such fungus, which
is present in the soil, dead, and decomposing organic matter, and may contaminate food, fruits,
and vegetables. Geotrichosis is the infection caused by Geotrichum species. Due to its similarity
in morphology, clinical features, and the pathogenicity with common fungi like the Candida
species, and others, its clinical significance is undermined. This report presents a case of
funguria and asymptomatic urinary tract infection caused by Geotrichum species in a patient
with a renal cyst.
Categories: Pathology, Infectious Disease, Nephrology
Keywords: fungi, yeasts, saprophytes, infections in humans and animals, opportunistic infections,
immunosuppressed individuals, geotrichum, geotrichosis, urinary tract infection, funguria
Introduction
Received 04/02/2020
Review began 04/07/2020
Review ended 04/07/2020
Published 04/10/2020
© Copyright 2020
Kandi et al. This is an open access
article distributed under the terms of
the Creative Commons Attribution
License CC-BY 4.0., which permits
unrestricted use, distribution, and
reproduction in any medium, provided
Geotrichum is a yeast-like fungus, which is ubiquitous and present in the environment as a
saprophyte. Geotrichum may contaminate the food, fruits, and vegetables and in turn, cause a
human infection called geotrichosis, a rare opportunistic mycotic infection. Geotrichum is also
called as a machinery mold because of its ability to grow on various surfaces like the walls of the
equipment, moist building walls, floors, and gutters. They adhere to the surfaces and produce
slimy films. There is a debate about the categorization of Geotrichum as a yeast because of the
appearance of long filamentous and branching structures which break into arthroconidia, as
well as the characteristic growth of the colonies on agar surface (pit within the agar as mycelia
penetrate under the surface). Some Geotrichum species (spp.) are also used in the preparation of
cheese [1].
the original author and source are
credited.
Although a saprophyte, Geotrichum spp. are found as commensals in the mouth, skin,
How to cite this article
Kandi V, Vaish R, Gurrapu P, et al. (April 10, 2020) Geotrichosis Presenting As Funguria and
Asymptomatic Urinary Tract Infection in a Patient with Renal Cyst. Cureus 12(4): e7616. DOI
10.7759/cureus.7616
respiratory tract (upper, and lower), gastrointestinal tract, and genitourinary tract of humans
and animals [2]. Opportunistic infections with Geotrichum spp. were reported previously among
patients suffering from leukemia, neutropenia, and renal transplant patients [3,4]. Urinary tract
infection (UTI) after catheterization in an otherwise immunocompetent young female patient
and a case of UTI in a geriatric patient who was undergoing cancer treatment were reported
previously [5,6]. Other infections associated with Geotrichum spp. include septicemia, renal
bezoar (fungal ball), non-invasive sinusitis, and burns wound infections [7-10]. The present
report reviews a case funguria with asymptomatic UTI in a 65-year-old male patient who
presented to the emergency department with insidious onset of weakness and slurring of
speech.
Case Presentation
A 65-year-old male patient presented to the emergency/casualty department attached to the
Prathima Institute of Medical Sciences with complaints of weakness of the right upper and
lower limbs for the past four days. He also gave a history of slurring speech for four days with a
deviation of the mouth towards the left side. The patient was otherwise healthy before the
presentation of the symptoms. There was no history of trauma, fever, headache, nausea, and
neck stiffness. He was also not a known case of hypertension, diabetes mellitus, tuberculosis,
and asthma. On clinical examination, the patient was found to be drowsy and incoherent. The
clinical examination revealed a pulse rate of 88 beats/minute and a blood pressure of 150/90
mmHg. The patient was provisionally diagnosed as a case of hemiplegia and was admitted for
further evaluation and medical management. On day 2, when the patient complained of turbid
and dark-colored urine, an ultrasound abdomen was advised and a midstream urine sample was
sent to the clinical microbiology laboratory for further evaluation. The ultrasound abdomen
revealed a distended gall bladder with multiple calculi with an average size of 7 mm. Evidence
of an 8X8 mm sized cortical cyst in the mid pole of the right kidney with grade 1 renal
parenchymal changes was also noted as shown in Figure 1.
FIGURE 1: The ultrasound image showing the renal cyst
(yellow arrow) in the right kidney (star border)
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The urine on macroscopic observation was found to be turbid and dark colored. Microscopic
examination of the urine showed normal pH and specific gravity, traces of albumin, plenty of
red blood cells and pus cells, and occasional epithelial cells. On a simple wet mount of urine,
few oval budding yeast cells were noted as shown in Figure 2.
FIGURE 2: Direct wet mount of the urine showing budding
yeast cells (black arrow)
The urine was routinely processed for bacterial culture on blood agar and MacConkey's agar. On
day 2, the blood agar revealed the growth of chalky white-colored stellate colonies as shown in
Figure 3.
FIGURE 3: Growth of chalky white-colored stellate colonies on
2020 Kandi et al. Cureus 12(4): e7616. DOI 10.7759/cureus.7616
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blood agar on the first isolation
The colonies were characteristically revealing pitting (growth of colonies within the agar), with
grayish hairy bottom/undersurface and the chalky white superficial/central region as shown in
Figure 4.
FIGURE 4: Characteristic pitting colonies (fluorescent green
arrow) with grayish hairy bottom/undersurface (fluorescent
pink arrow) and the chalky white superficial/central region
Similar growth was also observed on MacConkey's agar. Gram's stain of the growth on blood
agar revealed Gram-positive oval budding yeast cells with occasional hyphal forms as shown in
Figure 5.
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FIGURE 5: Gram's stain of the growth on blood agar showing
Gram-positive oval budding yeast cells with occasional hyphal
forms (yellow arrow)
After an extended period of incubation, the Gram's stain of the colonies revealed Gram-positive
long filamentous structures, which later break off to form arthroconidia as shown in Figure 6.
FIGURE 6: Gram's stain of the colonies showing Gram-positive
long filamentous structures that break off to form
arthroconidia
Antifungal susceptibility testing was performed using the disk diffusion method. The antifungal
agents tested included amphotericin B, fluconazole, nystatin, and clotrimazole. The isolated
fungus was sensitive to all the antifungal drugs tested. Based on the cultural (stellate colonies
with pitting), morphological (presence of arthroconidia), and biochemical (negative urease
test) characteristic features, the organism was identified as Geotrichum species.
Although the UTI was asymptomatic, considering the age of the patient, and the results of the
antifungal susceptibility profile, the patient was treated with amphotericin B (0.6 mg/kg/day)
Discussion
Fungi, based on their ability to cause infections, are classified as primary pathogens,
opportunistic pathogens, and environmental pathogens. The fungi which possess virulence
factors and which cause infections even in a healthy individual are called as primary pathogens.
Blastomyces dermatitidis, Coccidioides immitis, Histoplasma capsulatum, and others are a few
examples of primary pathogens. The opportunistic fungi, which include Cryptococcus spp.,
Candida spp., Torulopsis spp., Aspergillus spp., and others, are either present in the
environment as saprophytes or as commensals in humans. These fungi take advantage of the
host factors like the immunological deficiency including abnormal phagocytic function,
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neutropenia, granulocytopenia, metabolic dysfunction, chronic steroid/immunosuppressive
therapy, and others to cause infection. The third group of fungi, which comprise the
environmental pathogens like Geotrichum spp., Penicillium spp., Rhinosporidium spp., Sporothrix
spp., and others, causes accidental/occasional/rare human infections, which are worth
reporting as rare clinical cases to improve the understanding concerning their virulence,
potential predisposing factors, and complications associated with them [11-13].
Yeast and yeast-like fungi are a versatile group of microorganisms which consists of several
genera like the Candida, Geotrichum (G.), Saccharomyces, Torulopsis, Rhodotorula, Trichosporon,
Malassezia, and Cryptococcus [13,14]. They are present in the environment as saprophytes, and
as commensals in humans/animals. They can cause mild self-limiting infections to severe
invasive, and disseminated infections in debilitated, and immunosuppressed individuals.
Therefore, most members of this group are recognized as opportunistic fungi. Geotrichum is a
unique yeast-like fungus, which resents two morphological colony variants, where one type
forms glaborous colonies, and resemble other yeasts like the Candida spp., and the other
variants form fluffy/hairy colonies which resemble the molds/true fungi. Therefore, Geotrichum
spp. are called imperfect fungi and are placed in the class Fungi Imperfecti [14]. The
microscopic appearance of Geotrichum differentiates it from the other common yeasts ( Candida)
owing to the presence of long filamentous, branching structures with septa, which later break
off to form arthroconidia [1].
There are several species of Geotrichum that include G. candidum, G. capitatum, G. klebahnii,
G. pseudocandidum, G. citri-aurantii, G. fermentans, G. decipiens, G. restrictum, G. europaeum,
G. carabidarum, G. cucujoidarum, G. histeridarum, and G. clavatum. Among these species, G.
candidum, and G. capitatum are frequently associated with human infections. Geotrichum spp.
are also associated with granulomatous, and suppurative infections in animals, which include
cattle, pigs, dogs, horses, fowl, and others [1].
G. candidum was noted to cause invasive intestinal infection in a patient with hairy cell
leukemia. The diagnosis, in this case, was made based on histological and cultural
characteristic features. This report proves its invasive capabilities, especially when the host is
immunosuppressed [15]. Pulmonary infection with G. capitatum in a patient with a history of
pulmonary tuberculosis was previously reported [16]. This case report highlights the fact that
the fungus might take advantage of the debilitating conditions of the host to cause infection.
The invasiveness of Geotrichum spp. and its ability to cause disseminated infection were
confirmed by a previous study, which suggested that geotrichosis may in some instances
become invasive and fatal. A case reporting multiple abscesses of the kidney caused by
Geotrichum spp. confirms its potential for tissue invasion [17]. This study had also suggested
that despite such reports, it cannot be hypothesized that geotrichosis alone may result in renal
failure/pathology because the outcome may be influenced both by the organism and host
factors.
G. candidum had been isolated from the vitreous fluid in a case of post-cataract
endophthalmitis. Despite extended treatment with amphotericin B and voriconazole, the
patient suffered enucleation [18].
Infection in the immunocompetent individuals, although rare, was infrequently reported. A
young male patient was found suffering from a suppurative infection of the
metacarpophalangeal joint following a traumatic injury. The joint fluid aspirated from the
patient was noted to be seropurulent and had grown G. candidum. The patient, in this case, was
successfully treated with oral ketoconazole for eight weeks [19].
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The taxonomy of the Geotrichum spp. and its teleomorphs (sexual/perfect stages of fungi) has
been recently revised. Many species have been renamed based on the phenotypic characteristic
features, molecular analysis using the ribosomal deoxyribonucleic acid (DNA) internal
transcribed spacer regions, multilocus sequencing, and amplified fragment length
polymorphism [20]. The uncertainty over the taxonomy, morphological resemblances to other
common yeasts like the Candida spp., and the similar clinical and histopathological features
could have been the reasons for the underreporting of infections caused by Geotrichum spp.
In the present case, the patient was admitted to the casualty/emergency with the symptoms
related to stroke. The patient was later found to be suffering from asymptomatic UTI. Urine
culture revealed the growth of Geotrichum spp., and an ultrasound abdomen showed the
presence of a renal cyst with grade I renal parenchymal changes. It is not clear if the renal cyst
was the predisposing factor for geotrichosis, or the infection was responsible for cyst formation.
The histopathological examination of the renal cyst could have given a clue if the cyst was a
cause or an effect of the infection, which unfortunately was not done in the present case.
Conclusions
Geotrichum spp. are a versatile group of imperfect fungi. Morphologically, they resemble the
most common yeast-like fungus, the Candida spp. Infections caused by Geotrichum spp. are
underreported due to their similar clinical and histopathological features with other fungal
infections. The available literature signifies the pathogenic potential of Geotrichum spp., which
not only is present in the environment as a saprophyte but also can cause infections in both
immunosuppressed and immunocompetent individuals. In the present case, the patient was
over 60-year-old and had asymptomatic UTI. Considering the debilitating conditions of the
patient, and the possibility of dissemination in the future, a decision to treat the patient with
antifungal therapy was made.
Additional Information
Disclosures
Human subjects: Consent was obtained by all participants in this study. Institutional Ethics
Committee of Prathima Institute of Medical Sciences issued approval IEC/PIMS/2019-100192019. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all
authors declare the following: Payment/services info: All authors have declared that no
financial support was received from any organization for the submitted work. Financial
relationships: All authors have declared that they have no financial relationships at present or
within the previous three years with any organizations that might have an interest in the
submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.
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