Respiratory microsporidiosis caused by Enterocytozoon bieneusi in an HIV-negative hematopoietic stem cell transplant recipient

Accepted Manuscript Title: Respiratory microsporidiosis caused by Enterocytozoon bieneusi in a HIV-negative hematopoietic stem cell transplant recipient Authors: Marta Kicia, Mariola S˛edzimirska, Bohumil Sak, Martin Kv´acˇ , Maria Wesołowska, Andrzej B. Hendrich, ˙ Zaneta Kopacz PII: DOI: Reference:

S1201-9712(18)34482-5 https://doi.org/10.1016/j.ijid.2018.07.021 IJID 3298

To appear in:

International Journal of Infectious Diseases

Received date: Revised date: Accepted date:

4-7-2018 22-7-2018 25-7-2018

Please cite this article as: Kicia Marta, S˛edzimirska Mariola, Sak Bohumil, ˙ Kv´acˇ Martin, Wesołowska Maria, Hendrich Andrzej B, Kopacz Zaneta.Respiratory microsporidiosis caused by Enterocytozoon bieneusi in a HIV-negative hematopoietic stem cell transplant recipient.International Journal of Infectious Diseases (2018), https://doi.org/10.1016/j.ijid.2018.07.021 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Title: Respiratory microsporidiosis caused by Enterocytozoon bieneusi in a HIV-negative hematopoietic stem cell transplant recipient

Names of authors:

IP T

Marta Kicia,1* Mariola Sędzimirska,2 Bohumil Sak,3 Martin Kváč,3,4 Maria Wesołowska,1

1

SC R

Andrzej B. Hendrich,1 Żaneta Kopacz1

Department of Biology and Medical Parasitology, Wroclaw Medical University, Wroclaw,

Poland;

2

Lower Silesian Center for Cellular Transplantations, Wroclaw, Poland; 3 Biology

U

Centre of the Czech Academy of Sciences, Institute of Parasitology, České Budějovice, Czech

N

Republic; 4 University of South Bohemia, Faculty of Agriculture, České Budějovice, Czech

ED

* Corresponding author:

M

A

Republic;

Mailing address: Department of Biology and Medical Parasitology, Wroclaw Medical

PT

University, Wroclaw, Poland, ul. J. Mikulicza-Radeckiego 9, 50-367 Wroclaw; phone: +48 71

CC E

784 15 12; fax +48 71 784 01 07; e-mail: [email protected]

Highlights

A

  

Enterocytozoon bieneusi causes respiratory infection in transplant recipient Symptoms of respiratory E. beineusi microsporidiosis are non-specific Albendazole does not eradicate E. bieneusi infection

Abstract

1

A 23 year-old, HIV-negative women who underwent hematopoietic stem cell transplantation was admitted to the hospital with respiratory failure and symptoms of bronchiolitis obliterans. The chest CT scan revealed diffuse ground glass opacification and fibrous plugs. Due to worsening respiratory failure despite treatment, ventilation through tracheostomy tube was conducted. Molecular examination of bronchoalveolar lavage and urine revealed

IP T

Enterocytozoon bieneusi infection. After treatment with albendazole the patient gradually improved, but pathogen was not eradicated and reappeared in follow-up examination.

SC R

E. bieneusi belongs to the most clinically important microsporidial species infecting humans,

mostly immunocompromised. This fungus tends to infect enterocytes of the intestine, and there are limited studies concerning its extraintestinal location.

U

This report is the first case of disseminated respiratory and urinary E. bieneusi infection in a

A

N

transplant recipient.

M

Keywords: Enterocytozoon bieneusi; respiratory tract infection; hematopoietic stem cell

ED

transplant;

PT

Introduction

Enterocytozoon bieneusi, alongside Encephalitozoon species, is one of the most clinically

CC E

important microsporidial species – a widely distributed intracellular opportunistic fungus able to infect almost all animal phyla (Didier and Weiss, 2006). Since the fecal-oral route of

A

infection is the most frequent, its primary site of infection is enterocytes of the small intestine. Dissemination to another part of the host’s body also cannot be excluded, mostly in immunocompromised individuals; however, it is mainly observed for Encephalitozoons (Didier and Weiss, 2006; Orenstein et al., 1997; Matos et al., 2012). To date, E. bieneusi

2

localization in biliary, urinary, and respiratory tracts has been confirmed (Didier and Weiss, 2006; Kicia et al., 2016). Symptomatic respiratory E. bieneusi infection is rare and has been described in five HIVinfected patients so far, with spores identified in stool, bronchoalveolar lavage (BAL), sputum and/or tracheobronchial biopsy specimens (Sodqi et al., 2004). Among symptoms described in

IP T

these patients the most common were fever, chronic diarrhea, dyspnea, persistent cough and

acute respiratory distress syndrome, with the majority of patients recovered. Nevertheless, no

SC R

infection of the urinary tract was confirmed in these patients.

We present the first case of both respiratory E. bieneusi infection in a HIV-negative patient as well as disseminated respiratory and urinary tracts infection with this fungus.

U

Case report

N

A 23 year-old, HIV-negative women, with a history of hepatitis B and C, was admitted to the

A

Lower Silesian Center for Cellular Transplantations unit in September 2012 with severe

M

aplastic anemia. In December 2012 the patient underwent hematopoietic stem cell

ED

transplantation (HSCT) from an unrelated donor followed by immunosuppressive regimen with cyclosporine (initially 5 mg/kg/day, then corrected according to the drug levels in the

PT

serum) and mycophenolate mofetil (3 × 500 mg/day). Also sulfamethoxazole + trimethoprim (5:1, co-trimoxazole) treatment was applied (initially 2 × 960 mg/day, four days/week, 2 ×

CC E

480 mg/day, four days/week afterwards). No graft versus host disease (GvHD) symptoms were observed. The patient was discharged at day +37, fully hematologically reconstituted,

A

and admitted again in February 2013 with symptoms of dehydration and malnutrition (weight loss 5 kg) as a result of nausea, vomiting and diarrhea. Malabsorption syndrome with proteinlosing enteropathy was confirmed and the patient was qualified for total parenteral nutrition (March-April). Based on histopathological examination of the stomach and large intestine, drug toxicity was considered as the most probable cause of this malabsorption. In April 2013

3

symptoms of bronchitis, diarrhea and dehydration appeared. Therefore, antibiotic, fluid and caloric treatment was implemented, but in June 2013 she was admitted to the hospital again due to symptoms recurrence and liver failure. Since no changes suggesting GvHD were still seen and anti-CMV IgM antibodies were found, viral infection was considered as the most likely cause of hyperbilirubinemia and features of liver cell damage. During admission in

IP T

October 2013, spirometry examination showed respiratory failure and symptoms of

bronchiolitis obliterans (vital capacity 1000 ml). The chest CT scan revealed diffuse ground

SC R

glass opacification and fibrous plugs. The patient was qualified for treatment with dexamethasone (8 mg i.v.), one dose of etanercept and 300 mg of rituximab. Central puncture to the left subclavian vein resulted in left-sided pneumothorax; therefore securing drainage

U

was performed. After six days pneumothorax reappeared and repeat drainage was necessary.

N

The drain was removed after five days, but due to respiratory failure with CO2 retention above

A

100 mm Hg, non-invasive ventilation was conducted. From November 2013 ventilation was

M

continued by a tracheostomy tube. After exclusion of other infectious causes of changes in the

ED

lungs and respiratory failure (Chlamydia pneumoniae, Mycoplasma pneumoniae, Legionella pneumophila), in December both sputum and BAL were examined by molecular techniques

PT

for the presence of Pneumocystis jirovecii, Cryptosporidium spp., Encephalitozoon spp. and E. bieneusi. Total DNA was extracted with a commercially available kit after sample

CC E

homogenization. Genus-specific nested-PCR protocols amplifying a partial sequence of the mitochondrial large-subunit (mtLSU) rRNA gene of P. jirovecii (Maitte et al., 2013), a partial

A

sequence of the small-subunit (SSU) rRNA of Cryptosporidium spp. (Jiang et al., 2005), a partial sequence of 16S rRNA gene, the entire ITS (internal transcribed spacer) region, and a partial sequence of 5.8S rRNA gene of Encephalitozoon spp. and E. bieneusi (KatzwinkelWladarsch et al., 1996; Buckholt et al., 2002) were performed. Genotyping revealed presence of E. bieneusi genotype D in both samples. Encephalitozoon spp., P. jirovecii, and

4

Cryptosporidium spp. were not found. Since E. bieneusi may also cause intestinal and urinary tract infections, urine and stool examinations were performed. As a result, DNA of E. bieneusi genotype D was confirmed in urine only. The patient began receiving albendazole 2 × 400 mg per day for 21 days and subsequently levofloxacin for 21 days and gradually improved: the respiratory system stabilized, diarrhea

IP T

subsided and absorption improved. She was qualified for non-invasive ventilation at home and specialized dietary management. In follow-up examination in January 2014, BAL and

SC R

sputum were repetitively negative for E. bieneusi, but urine samples remained positive in

three of four independent samplings. Subsequent examination in March revealed E. bieneusi in urine and again in BAL, but no symptoms of infection reappeared and the patient remains

U

in good general condition. Stool samples remained negative during the entire diagnostic

N

process. Since the patient has been discharged from the hospital and subsequently ceased to

A

appear for the routine check-up, no subsequent follow-up was conducted.

M

Discussion

ED

Even though transplant recipients, alongside HIV-infected patients, are the most important risk groups of microsporidial infection, little is known about extraintestinal, especially

PT

respiratory, infections in these patients. It is noteworthy that in transplant recipients microsporidial infections more often manifested more severe symptoms than in HIV-positive

CC E

ones and the majority of them died from cardiopulmonary failure preceded by acute respiratory distress syndrome. Although the causative agents of these infections were

A

Encephalitozoons, the worsening respiratory failure observed in our patient suggests that E. bieneusi respiratory infection can manifest in a similar way. Therapeutic agents for treating microsporidiosis are albendazole and fumagillin, with fumagillin

being more

effective

against

E.

bieneusi.

Nevertheless,

in

severely

immunocompromised patients these drugs are poorly effective against both Encephalitozoon

5

spp. and E. bieneusi. However, in case of pharmacologically immunosuppressed patients with microsporidiosis, dose reduction or temporary withdrawal of the immunosuppressant leads to immunity improvement and may result in symptoms resolution and elimination of the pathogen (Galvan et al., 2011; Kicia et al., 2014). In immunocompromised patients with intestinal E. bieneusi infections fumagillin was able to eradicate effectively the pathogen but

IP T

bone marrow toxicity was observed as a side-effect (Costa and Weiss, 2000; Molina et al., 2002). Moreover, aseptic meningoencephalitis was reported as a result of fumagillin treatment

SC R

of E. bieneusi-infected renal transplant recipients, in whom albendazole failed to treat (Audemard et al., 2012). In turn, in some of HIV-infected patients with E. bieneusi infections with respiratory tract involvement, albendazole treatment was shown to lead to patients’

U

improvement (del Aguila et al. 1997). Indeed, albendazole, as a systemic agent, is effective in

N

patients with disseminated infections, including respiratory tract (Costa and Weiss, 2000).

A

Since fumagillin is not registered for human treatment in Poland and albendazole appears to

M

be well tolerated in immunocompromised patients, this drug has been administered in our

ED

patient. Nevertheless, according to some studies, treatment with albendazole resulted in clinical improvement in up to 50% of patients infected with E. bieneusi (Costa and Weiss,

PT

2000). Moreover, the presence of E. bieneusi persisted during treatment in all patients but a decrease in pathogen burden has been observed (Dieterich et al., 1994). It might explain the

CC E

resolution of symptoms in our patient with simultaneous lack of pathogen eradication and its reappearance in follow-up examination.

A

Microsporidial spores can be ingested or inhaled, so the transmission route remains unclear in the case of our patient. Nevertheless, the lack of pathogen in the patient’s stool makes inhalation more probable. Subsequent hematogenous dissemination from a focus of infection explains the presence of E. bieneusi also in the urinary tract. Moreover, reactivation of latent infection acquired prior to immunosuppression cannot be excluded.

6

This unusual finding highlights that respiratory E. bieneusi infection, although rare, should be considered in the differential diagnosis in transplant patients suffering from respiratory failure with unexplained aetiology. Moreover, as E. bieneusi colonized asymptomatic individuals might serve as a source of infection, there should be increased awareness of the risk of infection and/or pathogen burden increase in immunocompromised patients.

IP T

Conflicts of interest: None.

SC R

Financial support:

This work was supported by the National Science Centre, Poland [grant number DEC-

decision to publish, or preparation of the manuscript.

N

Support:

U

2012/05/D/NZ6/00615]. The funders had no role in study design, data collection and analysis,

A

This study has been approved by the Human Research Ethics Committee of Wroclaw Medical

Acknowledgement:

A

CC E

PT

None.

ED

from the patient prior to examination.

M

University according to agreement No. KB-549/2012. Written informed consent was obtained

7

References Audemard A, Le Bellec ML, Carluer L, Dargère S, Verdon R, Castrale C, et al. Fumagillininduced

aseptic

meningoencephalitis

in

a

kidney

transplant

recipient

with

microsporidiosis. Transpl Infect Dis 2012; 14: E147-9. Buckholt MA, Lee JH, Tzipori S. Prevalence of Enterocytozoon bieneusi in swine: an 18-

IP T

month survey at a slaughterhouse in Massachusetts. Appl Environ Microbiol 2002; 68: 2595-99.

SC R

Costa SF, Weiss LM. Drug treatment of microsporidiosis. Drug Resist Updat 2000; 3(6): 384-99.

del Aguila C, Lopez-Velez R, Fenoy S, Turrientes C, Cobo J, Navajas R, et al. Identification

U

of Enterocytozoon bieneusi spores in respiratory samples from an AIDS patient with a 2-

N

year history of intestinal microsporidiosis. J Clin Microbiol 1997; 35(7): 1862-6.

A

Didier ES, Weiss LM. Microsporidiosis: current status. Curr Opin Infect Dis 2006; 19(5):

M

485–92.

ED

Dieterich DT, Lew EA, Kotler DP, Poles MA, Orenstein JM. Treatment with albendazole for intestinal disease due to Enterocytozoon bieneusi in patients with AIDS. J Infect Dis

PT

1994; 169(1): 178-83.

Galván AL, Sánchez AM, Valentín MA, Henriques-Gil N, Izquierdo F, Fenoy S, et al. First

CC E

cases of microsporidiosis in transplant recipients in Spain and review of the literature. J Clin Microbiol 2011; 49: 1301-6.

A

Jiang J, Alderisio KA, Xiao L. Distribution of cryptosporidium genotypes in storm event water samples from three watersheds in New York. Appl Environ Microbiol 2005; 71(8): 4446-54. Katzwinkel-Wladarsch S, Lieb M, Helse W, Löscher T, Rinder H. Direct amplification and species determination of microsporidian DNA from stool specimens. Trop Med Int

8

Health 1996; 1: 373-78. Kicia M, Wesolowska M, Jakuszko K, Kopacz Z, Sak B, Květonova D, et al. Concurrent infection of the urinary tract with Encephalitozoon cuniculi and Enterocytozoon bieneusi in a renal transplant recipient. J Clin Microbiol 2014; 52(5): 1780-2. Kicia M, Wesolowska M, Kopacz Z, Jakuszko K, Sak B, Kvetonová D et al. Prevalence and

transplant recipients. Clin Microbiol Infect 2016; 22(5): 462.e5-462.e9.

IP T

molecular characteristics of urinary and intestinal microsporidia infections in renal

SC R

Maitte C, Leterrier M, Pape P Le, Miegeville M, Morio F. Multilocus sequence typing of

Pneumocystis jirovecii from clinical samples: how many and which loci should be used? J Clin Microbiol 2013; 51(9): 2843–49.

U

Matos O, Lobo ML, Xiao L. Epidemiology of Enterocytozoon bieneusi infection in Humans. J

N

Parasitol Res 2012; 2012:981424. doi: 10.1155/2012/981424.

A

Molina JM, Tourneur M, Sarfati C, Chevret S, de Gouvello A, Gobert JG, et al. Fumagillin

M

treatment of intestinal microsporidiosis. N Engl J Med 2002; 346(25): 1963-9.

ED

Orenstein JM, Gaetz HP, Yachnis AT, Frankel SS, Mertens RB, Didier ES. Disseminated microsporidiosis in AIDS: are any organs spared? AIDS 1997; 11(3): 385–86.

PT

Sodqi M, Brazille P, Gonzalez-Canali G, Cornet M, Piketty C, Weiss L. Unusual pulmonary Enterocytozoon bieneusi microsporidiosis in an AIDS patient: case report and review.

A

CC E

Scand J Infect Dis 2004; 36(3): 230-31.

9