First report of a clinical isolate of Candida haemulonii in Brazil

Almeida Jr., João Nobrega de; Motta, Adriana Lopes; Rossi, Flávia; Abdala, Edson; Pierrotti, Ligia Camera; Kono, Adriana Satie Gonçalves; Diz, Maria Del Pilar Estevez; Benard, Gil; Del Negro, Gilda Maria Barbaro

doi:10.6061/clinics/2012(10)18

CASE REPORT

First report of a clinical isolate of Candida haemulonii in Brazil

João Nobrega de Almeida Jr.^I; Adriana Lopes Motta^I; Flávia Rossi^I; Edson Abdala^II; Ligia Camera Pierrotti^II; Adriana Satie Gonçalves Kono^II; Maria Del Pilar Estevez Diz^II; Gil Benard^III; Gilda Maria Barbaro Del Negro^III

^IHospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Microbiology Section, Divisão de Laboratório Central, São Paulo/SP, Brazil

^IIInstituto do Cancer, Faculdade de Medicina da Universidade de São Paulo, São Paulo/SP, Brazil

^IIIHospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo e Instituto de Medicina Tropical da Universidade de São Paulo, Laboratory of Medical Mycology (LIM-53) - Clinical Dermatologic Division, Sao Paulo/SP, Brazil

INTRODUCTION

The spectrum of Candida species associated with invasive fungal infections is evolving. New microbiology diagnostic tools, the increasing number of immunosuppressed patients with invasive devices and the use of prophylaxis with fluconazole could contribute to this phenomenon (1). In recent years, an increasing number of rare species with reduced susceptibility to antifungal molecules have been described, including C. ciferrii, C. inconspicua, C. guilliermondii, C. humicola, C. lambica, C. lipolytica, C. norvegensis, C. palmioleophila, C. rugosa, C. valida, C. fermentati, and C. lusitaniae (2-5). Data from the SENTRY Antimicrobial Surveillance Program-Fungal Objective (5) concerning bloodstream infections from 2008 and 2009 show that 4.5% of 348 episodes from 10 centers in Latin America were caused by species other than C. albicans, C. glabrata, C. parapsilosis, C. tropicalis, and C. krusei.

In 1984, Lavarde et al. (6) reported the first clinical isolate of C. haemulonii from a blood culture. Since then, rare cases of human infections with C. haemulonii have been reported worldwide, including central venous catheter (CVC)-related bloodstream infections in patients from Argentina, Korea, and China (7-11); in preterm neonates receiving parenteral nutrition in Kuwait (12); and in a 37-year-old French patient with osteomyelitis of the left hallux (13). This pathogen has not been identified in previous reports of candidemia from Brazil (14-17).

The present paper reports for the first time a case of fungemia caused by C. haemulonii in a tertiary hospital in the city of São Paulo. Clinical features and laboratory analyses, including phenotypic and molecular identification and antifungal susceptibility testing (AST), are described.

CASE DESCRIPTION

A 26-year-old woman diagnosed with ovarian carcinoma with a low degree of differentiation two months before

hospitalization was admitted to the Institute of Cancer in May 2010 for abdominal pain. The patient was submitted to laparotomy and tumor resection. Four days later, the patient developed fever and low back pain, and a diagnosis of pyelonephritis was established. Piperacillin/tazobactam 4.5 g three times per day was prescribed. Because of persistent clinical deterioration, the antimicrobial therapy was changed to imipenem 0.5 g four times per day and vancomycin 1 g two times per day. After stabilization of the patient's clinical condition and the cessation of antibiotics, chemotherapy comprising carboplatin and paclitaxel was started through a CVC. In June 2010, after the second cycle of chemotherapy, the patient was diagnosed with febrile neutropenia, and two sets of Bactec^TM aerobic bottles (Becton Dickinson Diagnostics, USA) were collected for blood cultures. Imipenem and vancomycin were reinitiated. After two days, a provisional analysis of the blood culture showed the presence of budding yeast cells. Due to the poor prognosis and the lack of response to chemotherapy, all antibiotics were stopped, and no antifungal agent was prescribed. The patient died six days after the positive blood culture.

Microbial growth was detected after 24 hours in Bactec 9249 incubator (Becton Dickinson Diagnostics, USA). Gram staining of the positive blood cultures showed the presence of yeast. The samples were seeded on CHROMagar Candida^TM medium (Becton Dickinson Diagnostics, USA). Pink colonies grew after 24 hours of incubation at 37ºC. After 72 hours, the colonies developed darker violet central pigmentation. Further phenotypic identification was conducted using API 20C AUX panels (BioMérieux, Marcy-L'Etoile, France) but was inconclusive. A VITEK 2 ^{T M} system (BioMérieux, Marcy-L'Etoile, France) identified the isolate as C. haemulonii with 97% certainty.

The DNA from the isolate was extracted as described by Loffler et al. (18) using 250 U/mL of recombinant lyticase (L-4276, Sigma-Aldrich, St. Louis, MO, USA) and the QIAamp DNA Mini kit (QIAGEN, Hilden, Germany) according to the manufacturer's protocol. Amplification targeted the Candida ITS sequence and was performed in a total volume of 25 µl containing 1 x enzyme buffer, 200 mM dNTPs, 0.4 mM each of the ITS1 and ITS4 primers (19), 2 mM MgCl₂, 2.5 U of Taq DNA polymerase (Invitrogen, São Paulo, Brazil) and 5 ng of the template DNA from the Candida isolate. The PCR was conducted in a thermocycler (Veriti, Applied Biosystems, Carlsbad, CA, USA) with an initial denaturation step at 95 ºC for 5 minutes; 30 cycles of 1 minute at 95ºC, 1 minute at 55ºC and 1 minute at 72ºC; and a final extension at 72 ºC for 5 minutes. The amplification product was purified using the PureLink^TM PCR purification kit (Invitrogen, Carlsbad, CA, USA) and sequenced in both directions in a MegaBace-1000 analyzer (GE Healthcare, Buckinghamshire, UK). The sequences were compared with the reference sequences available in GenBank using BLAST (http://blast.ncbi.nlm.nih.gov).

The results of the phenotypic and molecular analyses are summarized in Table 1. Molecular methods confirmed the identity of C. haemulonii.

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Antifungal susceptibility testing (AST) was performed using Sensititre YeastOne^TM colorimetric plates (Trek Diagnostic Systems, Cleveland, USA) according to the manufacturer's instructions, and interpretation was performed according to the breakpoints established by the Clinical Laboratory Standards Institute (CLSI) (20). The drugs included in these panels and their concentrations were as follows: posaconazole (0.004-8 mg/L), fluconazole (0.125-256 mg/L), itraconazole (0.008-16 mg/L), ketoconazole (0.008-16 mg/L), voriconazole (0.008-16 mg/L), 5-flucytosine (0.03-64 mg/L), caspofungin (0.008-16 mg/L) and amphotericin (0.008-16 mg/L). Reference strains (C. parapsilosis ATCC 22019 and C. krusei ATCC 6258) were used for quality control purposes. The AST results are summarized in Table 2. The isolate had elevated minimal inhibitory concentrations (MICs) for amphotericin and flucytosine.

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DISCUSSION

Sunyong Kim et al. (11) identified reports of C. haemulonii bloodstream infections in the literature and summarized the clinical characteristics of the patients who developed these infections. These authors found that among ten cases, nine were related to CVCs. Most isolates had elevated MICs for amphotericin, fluconazole and itraconazole, and treatment failure occurred when one of these drugs was prescribed (11). Among four patients treated with an echinocandin, only one experienced treatment failure (11).

Mi-Na Kim et al. (9) described eight cases of fungemia caused by C. haemulonii and C. pseudohaemulonii in five hospitals in Korea. Four of these patients had received previous antifungal therapy, and all of the patients had a severe underlying disease and a CVC (9).

Oh et al. (21) investigated the in vitro production of biofilms by C. haemulonii and C. pseudohaemulonii. The formation of biofilms reflects the potential of these two species to cause catheter-related bloodstream infections. In accordance with these previous reports, our patient had a severe underlying disease and a CVC when candidemia was diagnosed.

The darker violet central pigmentation of the colonies after 72 hours of incubation in chromogenic medium is not a characteristic specific to C. haemulonii. Hospenthal et al. (22) studied the appearance of 83 isolates of different Candida species on CHROMagar^TMCandida medium (CHROMagar Microbiology, Paris, France) and found that C. glabrata also developed darker violet pigmentation after three or four days of incubation.

Ruan et al. (10) described three C. haemulonii infections that were identified by VITEK 2^TM and confirmed by ITS1 and 18S rRNA sequencing. However, Mi-Na Kim et al. (9) showed that most isolates obtained from blood cultures that are identified as C. haemulonii by VITEK 2 ^TM were determined to be C. pseudohaemulonii based on the sequences of D1/D2 regions of the rRNA gene. These authors also reported that these two species are closely related according to phylogenetic analysis (9). Genotypic identification of the present isolate by ITS sequencing showed 100% identity with C. haemulonii but only 94% identity with C. pseudohaemulonii, thus confirming the identification of our isolate as the former species according to the CLSI MM-18A guidelines (23). Fluconazole, caspofungin, voriconazole, and posaconazole showed good in vitro activity. According to other reports, most isolates of C. haemulonii related to candidemia are resistant to amphotericin and fluconazole (10). Table 3 summarizes the antifungal susceptibility profile of C. haemulonii isolates from Argentina, Korea, Kuwait, China, and Brazil.

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To our knowledge, this is the first report of a clinical isolate of C. haemulonii in Brazil. VITEK2^TM correctly identified the etiologic agent, but DNA sequencing was necessary for final identification. Echinocandins and voriconazole should be empirical treatment options when C. haemulonii infection is suspected and an antifungigram is not available.

ACKNOWLEDGMENTS

We thank Vagner Oliveira Carvalho for his assistance with the sequencing of the isolate and Fundação de Amparo a Pesquisa do Estado de São Paulo (FAPESP) for financial support (grant #2010/09715-4).

AUTHOR CONTRIBUTIONS

Almeida Junior JN, Motta AL and Del Negro GM provided experimental data. Rossi F, Abdala E, Bernard G and Del Negro GM designed the study. Pierroti LC, Kono ASG and Diz Mdel P provided clinical data. Almeida Junior JN, Bernard G and Del Negro GM wrote the paper.

REFERENCES

1. Miceli MH, Diaz JA, Lee SA. Emerging opportunistic yeast infections. The Lancet infectious diseases. 2011;11(2):142-51, http://dx.doi.org/10.1016/S1473-3099(10)70218-8.

2. Lockhart SR, Messer SA, Pfaller MA, Diekema DJ. Identification and Susceptibility Profile of Candida fermentati from a worldwide collection of Candida guilliermondii clinical isolates. J Clin Microbiol. 2009;47(1):242-4, http://dx.doi.org/10.1128/JCM.01889-08.

3. Chen SC, Marriott D, Playford EG, Nguyen Q, Ellis D, Meyer W, et al. Candidaemia with uncommon Candida species: predisposing factors, outcome, antifungal susceptibility, and implications for management. Clin Microbiol Infect. 2009;15(7):662-9, http://dx.doi.org/10.1111/j.1469-0691.2009.02821.x.

4. Pfaller MA, Diekema DJ, Gibbs DL, Newell VA, Ellis D, Tullio V, et al. Results from the ARTEMIS DISK Global Antifungal Surveillance Study, 1997 to 2007: a 10.5-year analysis of susceptibilities of Candida Species to fluconazole and voriconazole as determined by CLSI standardized disk diffusion. J Clin Microbiol. 2010;48(4):1366-77, http://dx.doi.org/10.1128/JCM.02117-09.

5. Pfaller MA, Moet GJ, Messer SA, Jones RN, Castanheira M. Geographic variations in species distribution and echinocandin and azole antifungal resistance rates among Candida bloodstream infection isolates: report from the SENTRY Antimicrobial Surveillance Program (2008 to 2009). J Clin Microbiol. 2011;49(1):396-9, http://dx.doi.org/10.1128/JCM.01398-10.

6. Lavarde V, Daniel F, Saez H, Arnold M, Faguer B. Peritonite mycosique a Torulopsis haemulonii. Bul Soc Fr Mycol Med. 1984;13:173-6.

7. Rodero L, Cuenca-Estrella M, Córdoba S, Cahn P, Davel G, Kaufman S, et al. Transient fungemia caused by an amphotericin B-resistant isolate of Candida haemulonii. J Clin Microbiol. 2002;40(6):2266-9, http://dx.doi.org/10.1128/JCM.40.6.2266-2269.2002.

8. Giusiano G, Magianterra M, Garcia Saito V, Rojas F, Gómez V, Días MC. Fluconazole and itraconazole resistance of yeasts isolated from the bloodstream and catheters of hospitalized pediatric patients. Chemotherapy. 2006;52(5):254-9, http://dx.doi.org/10.1159/000094867.

9. Kim MN, Shin JH, Sung H, Lee K, Kim EC, Ryoo N, et al. Candida haemulonii and closely related species at wsniversity hospitals in Korea: identification, antifungal susceptibility, and clinical features. Clin Infect Dis. 2009;48(6):e57-61, http://dx.doi.org/10.1086/597108.

10. Ruan SY, Kuo YW, Huang CT, Hsiue HC, Hsueh PR. Infections due to Candida haemulonii: species identification, antifungal susceptibility and outcomes. Int J Antimicrob Agents. 2010;35(1):85-8, http://dx.doi.org/10.1016/j.ijantimicag.2009.08.009.

11. Kim S, Ko KS, Moon SY, Lee MS, Lee MY, Son JS. Catheter-related Candidemia Caused by Candida haemulonii in a Patient in Long-term Hospital Care. J Korean Med Sci. 2011;26(2):297-300, http://dx.doi.org/10.3346/jkms.2011.26.2.297.

12. Khan ZU, Al-Sweih NA, Ahmad S, Al-Kazemi N, Khan S, Joseph L, et al. Outbreak of fungemia among neonates caused by Candida haemulonii resistant to amphotericin B, itraconazole, and fluconazole. J Clin Microbiol. 2007;45(6):2025-7, http://dx.doi.org/10.1128/JCM.00222-07.

13. Crouzet J, Sotto A, Picard E, Lachaud L, Bourgeois N. A case of Candida haemulonii osteitis: clinical features, biochemical characteristics and antifungal resistance profile. Clin Microbiol Infect. 2011;17(7):1068-70, http://dx.doi.org/10.1111/j.1469-0691.2011.03471.x.

14. Colombo AL, Nucci M, Park BJ, Nouér SA, Arthington-Skaggs B, da Matta DA, et al. Brazilian Network Candidemia Study. Epidemiology of candidemia in Brazil: a nationwide sentinel surveillance of candidemia in eleven medical centers. J Clin Microbiol. 2006;44(8):2816-23, http://dx.doi.org/10.1128/JCM.00773-06.

15. Colombo AL, Guimarães T, Silva LR, de Almeida Monfardini LP, Cunha AK, Rady P, Alves T, et al. Prospective observational study of candidemia in São Paulo, Brazil: incidence rate, epidemiology, and predictors of mortality. Infect Control Hosp Epidemiol. 2007;28(5):570-6, http://dx.doi.org/10.1086/513615.

16. Motta AL, Almeida GM, de Almeida Júnior JN, Burattini MN, Rossi F. Candidemia epidemiology and susceptibility profile in the largest Brazilian teaching hospital complex. Braz J Infect Dis. 2010;14(5):441-8, http://dx.doi.org/10.1590/S1413-86702010000500004.

17. Pereira GH, Müller PR, Szeszs MW, Levin AS, Melhem MS. Five-year evaluation of bloodstream yeast infections in a tertiary hospital: the predominance of non-C. albicans Candida species. Med Mycol. 2010;48(6):839-42, http://dx.doi.org/10.3109/13693780903580121.

18. Loffler J, Hebart H, Schumacher U, Reitze H, Einsele H. Comparison of different methods for extraction of DNA of fungal pathogens from cultures and blood. J Clin Microbiol 1997;35:3311-2.

19. Luo G, Mitchell TG. Rapid identification of pathogenic fungi directly from cultures by using multiplex PCR. J Clin Microbiol. 2002;40(8):2860- 5, http://dx.doi.org/10.1128/JCM.40.8.2860-2865.2002.

20. Clinical Laboratory Standards Institute. Reference Method for Broth Diluiton Antifungal Susceptibility Testing of Yeasts; Approved Standard-Third Edition. CLSI document M27-A3. Wayne, PA: CLSI, 2008.

21. Oh BJ, Shin JH, Kim MN, Sung H, Lee K, Joo MY, et al. Biofilm formation and genotyping of Candida haemulonii, Candida pseudohaemulonii, and a proposed new species (Candida auris) isolates from Korea. Med Mycol. 2011;49(1):98-102, http://dx.doi.org/10.3109/13693786.2010.493563.

22. Hospenthal DR, Murray CK, Beckius ML, Green JA, Dooley DP. Persistence of pigment production by yeast isolates grown on CHROMagar Candida medium. J Clin Microbiol. 2002;40(12):4768-70, http://dx.doi.org/10.1128/JCM.40.12.4768-4770.2002.

23. Clinical Laboratory Standards Institute. Interpretative Criteria for Identification of Bacteria and Fungi by DNA Target Sequencing; Approved Guideline. CLSI document MM18-A.: Wayne, PA: CLSI, 2008.

No potential conflict of interest was reported.

Email: jnaj99@gmail.com

Tel.: 55 11 2661-6136

References

2. Lockhart SR, Messer SA, Pfaller MA, Diekema DJ. Identification and Susceptibility Profile of Candida fermentati from a worldwide collection of Candida guilliermondii clinical isolates. J Clin Microbiol. 2009;47(1):242-4, http://dx.doi.org/10.1128/JCM.01889-08
3. Chen SC, Marriott D, Playford EG, Nguyen Q, Ellis D, Meyer W, et al. Candidaemia with uncommon Candida species: predisposing factors, outcome, antifungal susceptibility, and implications for management. Clin Microbiol Infect. 2009;15(7):662-9, http://dx.doi.org/10.1111/j.1469-0691.2009.02821.x
4. Pfaller MA, Diekema DJ, Gibbs DL, Newell VA, Ellis D, Tullio V, et al. Results from the ARTEMIS DISK Global Antifungal Surveillance Study, 1997 to 2007: a 10.5-year analysis of susceptibilities of Candida Species to fluconazole and voriconazole as determined by CLSI standardized disk diffusion. J Clin Microbiol. 2010;48(4):1366-77, http://dx.doi.org/10.1128/JCM.02117-09
5. Pfaller MA, Moet GJ, Messer SA, Jones RN, Castanheira M. Geographic variations in species distribution and echinocandin and azole antifungal resistance rates among Candida bloodstream infection isolates: report from the SENTRY Antimicrobial Surveillance Program (2008 to 2009). J Clin Microbiol. 2011;49(1):396-9, http://dx.doi.org/10.1128/JCM.01398-10
6. Lavarde V, Daniel F, Saez H, Arnold M, Faguer B. Peritonite mycosique a Torulopsis haemulonii. Bul Soc Fr Mycol Med. 1984;13:173-6.
7. Rodero L, Cuenca-Estrella M, Córdoba S, Cahn P, Davel G, Kaufman S, et al. Transient fungemia caused by an amphotericin B-resistant isolate of Candida haemulonii. J Clin Microbiol. 2002;40(6):2266-9, http://dx.doi.org/10.1128/JCM.40.6.2266-2269.2002
8. Giusiano G, Magianterra M, Garcia Saito V, Rojas F, Gómez V, Días MC. Fluconazole and itraconazole resistance of yeasts isolated from the bloodstream and catheters of hospitalized pediatric patients. Chemotherapy. 2006;52(5):254-9, http://dx.doi.org/10.1159/000094867
9. Kim MN, Shin JH, Sung H, Lee K, Kim EC, Ryoo N, et al. Candida haemulonii and closely related species at wsniversity hospitals in Korea: identification, antifungal susceptibility, and clinical features. Clin Infect Dis. 2009;48(6):e57-61, http://dx.doi.org/10.1086/597108
10. Ruan SY, Kuo YW, Huang CT, Hsiue HC, Hsueh PR. Infections due to Candida haemulonii: species identification, antifungal susceptibility and outcomes. Int J Antimicrob Agents. 2010;35(1):85-8, http://dx.doi.org/10.1016/j.ijantimicag.2009.08.009
11. Kim S, Ko KS, Moon SY, Lee MS, Lee MY, Son JS. Catheter-related Candidemia Caused by Candida haemulonii in a Patient in Long-term Hospital Care. J Korean Med Sci. 2011;26(2):297-300, http://dx.doi.org/10.3346/jkms.2011.26.2.297
12. Khan ZU, Al-Sweih NA, Ahmad S, Al-Kazemi N, Khan S, Joseph L, et al. Outbreak of fungemia among neonates caused by Candida haemulonii resistant to amphotericin B, itraconazole, and fluconazole. J Clin Microbiol. 2007;45(6):2025-7, http://dx.doi.org/10.1128/JCM.00222-07
13. Crouzet J, Sotto A, Picard E, Lachaud L, Bourgeois N. A case of Candida haemulonii osteitis: clinical features, biochemical characteristics and antifungal resistance profile. Clin Microbiol Infect. 2011;17(7):1068-70, http://dx.doi.org/10.1111/j.1469-0691.2011.03471.x
14. Colombo AL, Nucci M, Park BJ, Nouér SA, Arthington-Skaggs B, da Matta DA, et al. Brazilian Network Candidemia Study. Epidemiology of candidemia in Brazil: a nationwide sentinel surveillance of candidemia in eleven medical centers. J Clin Microbiol. 2006;44(8):2816-23, http://dx.doi.org/10.1128/JCM.00773-06
15. Colombo AL, Guimarães T, Silva LR, de Almeida Monfardini LP, Cunha AK, Rady P, Alves T, et al. Prospective observational study of candidemia in São Paulo, Brazil: incidence rate, epidemiology, and predictors of mortality. Infect Control Hosp Epidemiol. 2007;28(5):570-6, http://dx.doi.org/10.1086/513615
16. Motta AL, Almeida GM, de Almeida Júnior JN, Burattini MN, Rossi F. Candidemia epidemiology and susceptibility profile in the largest Brazilian teaching hospital complex. Braz J Infect Dis. 2010;14(5):441-8, http://dx.doi.org/10.1590/S1413-86702010000500004
17. Pereira GH, Müller PR, Szeszs MW, Levin AS, Melhem MS. Five-year evaluation of bloodstream yeast infections in a tertiary hospital: the predominance of non-C. albicans Candida species. Med Mycol. 2010;48(6):839-42, http://dx.doi.org/10.3109/13693780903580121
18. Loffler J, Hebart H, Schumacher U, Reitze H, Einsele H. Comparison of different methods for extraction of DNA of fungal pathogens from cultures and blood. J Clin Microbiol 1997;35:3311-2.
19. Luo G, Mitchell TG. Rapid identification of pathogenic fungi directly from cultures by using multiplex PCR. J Clin Microbiol. 2002;40(8):2860- 5, http://dx.doi.org/10.1128/JCM.40.8.2860-2865.2002
²⁰ Clinical Laboratory Standards Institute. Reference Method for Broth Diluiton Antifungal Susceptibility Testing of Yeasts; Approved Standard-Third Edition. CLSI document M27-A3. Wayne, PA: CLSI, 2008.
21. Oh BJ, Shin JH, Kim MN, Sung H, Lee K, Joo MY, et al. Biofilm formation and genotyping of Candida haemulonii, Candida pseudohaemulonii, and a proposed new species (Candida auris) isolates from Korea. Med Mycol. 2011;49(1):98-102, http://dx.doi.org/10.3109/13693786.2010.493563
22. Hospenthal DR, Murray CK, Beckius ML, Green JA, Dooley DP. Persistence of pigment production by yeast isolates grown on CHROMagar Candida medium. J Clin Microbiol. 2002;40(12):4768-70, http://dx.doi.org/10.1128/JCM.40.12.4768-4770.2002
²³ Clinical Laboratory Standards Institute. Interpretative Criteria for Identification of Bacteria and Fungi by DNA Target Sequencing; Approved Guideline. CLSI document MM18-A.: Wayne, PA: CLSI, 2008.

Publication Dates

Publication in this collection
10 Oct 2012
Date of issue
Oct 2012

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[2] 2. Lockhart SR, Messer SA, Pfaller MA, Diekema DJ. Identification and Susceptibility Profile of Candida fermentati from a worldwide collection of Candida guilliermondii clinical isolates. J Clin Microbiol. 2009;47(1):242-4, http://dx.doi.org/10.1128/JCM.01889-08

[3] 3. Chen SC, Marriott D, Playford EG, Nguyen Q, Ellis D, Meyer W, et al. Candidaemia with uncommon Candida species: predisposing factors, outcome, antifungal susceptibility, and implications for management. Clin Microbiol Infect. 2009;15(7):662-9, http://dx.doi.org/10.1111/j.1469-0691.2009.02821.x

[4] 4. Pfaller MA, Diekema DJ, Gibbs DL, Newell VA, Ellis D, Tullio V, et al. Results from the ARTEMIS DISK Global Antifungal Surveillance Study, 1997 to 2007: a 10.5-year analysis of susceptibilities of Candida Species to fluconazole and voriconazole as determined by CLSI standardized disk diffusion. J Clin Microbiol. 2010;48(4):1366-77, http://dx.doi.org/10.1128/JCM.02117-09

[5] 5. Pfaller MA, Moet GJ, Messer SA, Jones RN, Castanheira M. Geographic variations in species distribution and echinocandin and azole antifungal resistance rates among Candida bloodstream infection isolates: report from the SENTRY Antimicrobial Surveillance Program (2008 to 2009). J Clin Microbiol. 2011;49(1):396-9, http://dx.doi.org/10.1128/JCM.01398-10

[6] 6. Lavarde V, Daniel F, Saez H, Arnold M, Faguer B. Peritonite mycosique a Torulopsis haemulonii. Bul Soc Fr Mycol Med. 1984;13:173-6.

[7] 7. Rodero L, Cuenca-Estrella M, Córdoba S, Cahn P, Davel G, Kaufman S, et al. Transient fungemia caused by an amphotericin B-resistant isolate of Candida haemulonii. J Clin Microbiol. 2002;40(6):2266-9, http://dx.doi.org/10.1128/JCM.40.6.2266-2269.2002

[8] 8. Giusiano G, Magianterra M, Garcia Saito V, Rojas F, Gómez V, Días MC. Fluconazole and itraconazole resistance of yeasts isolated from the bloodstream and catheters of hospitalized pediatric patients. Chemotherapy. 2006;52(5):254-9, http://dx.doi.org/10.1159/000094867

[9] 9. Kim MN, Shin JH, Sung H, Lee K, Kim EC, Ryoo N, et al. Candida haemulonii and closely related species at wsniversity hospitals in Korea: identification, antifungal susceptibility, and clinical features. Clin Infect Dis. 2009;48(6):e57-61, http://dx.doi.org/10.1086/597108

[10] 10. Ruan SY, Kuo YW, Huang CT, Hsiue HC, Hsueh PR. Infections due to Candida haemulonii: species identification, antifungal susceptibility and outcomes. Int J Antimicrob Agents. 2010;35(1):85-8, http://dx.doi.org/10.1016/j.ijantimicag.2009.08.009

[11] 11. Kim S, Ko KS, Moon SY, Lee MS, Lee MY, Son JS. Catheter-related Candidemia Caused by Candida haemulonii in a Patient in Long-term Hospital Care. J Korean Med Sci. 2011;26(2):297-300, http://dx.doi.org/10.3346/jkms.2011.26.2.297

[12] 12. Khan ZU, Al-Sweih NA, Ahmad S, Al-Kazemi N, Khan S, Joseph L, et al. Outbreak of fungemia among neonates caused by Candida haemulonii resistant to amphotericin B, itraconazole, and fluconazole. J Clin Microbiol. 2007;45(6):2025-7, http://dx.doi.org/10.1128/JCM.00222-07

[13] 13. Crouzet J, Sotto A, Picard E, Lachaud L, Bourgeois N. A case of Candida haemulonii osteitis: clinical features, biochemical characteristics and antifungal resistance profile. Clin Microbiol Infect. 2011;17(7):1068-70, http://dx.doi.org/10.1111/j.1469-0691.2011.03471.x

[14] 14. Colombo AL, Nucci M, Park BJ, Nouér SA, Arthington-Skaggs B, da Matta DA, et al. Brazilian Network Candidemia Study. Epidemiology of candidemia in Brazil: a nationwide sentinel surveillance of candidemia in eleven medical centers. J Clin Microbiol. 2006;44(8):2816-23, http://dx.doi.org/10.1128/JCM.00773-06

[15] 15. Colombo AL, Guimarães T, Silva LR, de Almeida Monfardini LP, Cunha AK, Rady P, Alves T, et al. Prospective observational study of candidemia in São Paulo, Brazil: incidence rate, epidemiology, and predictors of mortality. Infect Control Hosp Epidemiol. 2007;28(5):570-6, http://dx.doi.org/10.1086/513615

[16] 16. Motta AL, Almeida GM, de Almeida Júnior JN, Burattini MN, Rossi F. Candidemia epidemiology and susceptibility profile in the largest Brazilian teaching hospital complex. Braz J Infect Dis. 2010;14(5):441-8, http://dx.doi.org/10.1590/S1413-86702010000500004

[17] 17. Pereira GH, Müller PR, Szeszs MW, Levin AS, Melhem MS. Five-year evaluation of bloodstream yeast infections in a tertiary hospital: the predominance of non-C. albicans Candida species. Med Mycol. 2010;48(6):839-42, http://dx.doi.org/10.3109/13693780903580121

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