Rhodotorula mucilaginosa Fungemia in an Infected Biloma Patient Following a Traumatic Liver Injury

Abstract

Rhodotorula mucilaginosa fungemia is rare and highly resistant to antifungal therapy. We herein report a case involving a 31-year-old male admitted after a high-velocity road traffic accident. He sustained a grade IV liver injury with right hepatic vein thrombosis, which necessitated an urgent laparotomy. Post-operatively, repeated imaging of the abdomen revealed the presence of a biloma. Percutaneous subdiaphragmatic drainage was carried out but appeared ineffective, prompting a second surgery for an urgent hemi-hepatectomy. The patient was then nursed in the intensive care unit (ICU); however, during his stay in the ICU, he became more sepsis, which was evident by worsening ventilatory support and a rise in septic parameters from the biochemistry parameters. Despite intravenous piperacillin-tazobactam and fluconazole, his septic parameters did not improve and a full septic workup was conducted and was found to be positive for Rhodotorula mucilaginosa from the blood cultures. After discussion with the infectious disease physicians and clinical microbiologists, it was decided to initiate a course of intravenous meropenem and amphotericin B based on minimum inhibitory concentration (MIC) values, considering the patient's extended ICU stay and catheter use. Eventually, after successfully weaning off mechanical ventilation, the patient was discharged from ICU care. This case underscores the necessity of individualized approaches, combining timely imaging, appropriate drainage techniques, and tailored treatments to optimize outcomes for such intricate post-traumatic complications.

Keywords: Rhodotorula mucilaginosa; biloma; fungemia; liver; trauma.

Figure 1

Computed tomography scan of the abdomen non-contrasted phase showing heterogenous areas consisting of hematoma and laceration at segments V, VI, VII, and VIII extending down to the subhepatic region (red arrow). Inferiorly, it extends down to the hepatic flexure, just lateral to the right pararenal space. Another subcapsular collection was seen adjacent to right liver lobe (blue arrow): (a) coronal view, (b) sagittal view, and (c) axial view, with findings as aforementioned.

Figure 1

Computed tomography scan of the abdomen non-contrasted phase showing heterogenous areas consisting of hematoma and laceration at segments V, VI, VII, and VIII extending down to the subhepatic region (red arrow). Inferiorly, it extends down to the hepatic flexure, just lateral to the right pararenal space. Another subcapsular collection was seen adjacent to right liver lobe (blue arrow): (a) coronal view, (b) sagittal view, and (c) axial view, with findings as aforementioned.

Figure 2

Salmon-pink colonies of Rhodotorula mucilaginosa on sheep blood agar (left) and on Sabouraud dextrose agar (right). Sheep blood agar was initially used as it is the standard isolation media used for all positive blood cultured in the bacteriology laboratory. Once the organism was found to be yeast, a subculture onto mycological isolation media such as Sabouraud dextrose agar was carried out.

Figure 3

A Gram stain of the positive blood culture showing budding yeast cells (1000× magnification). The yeast was identified as Rhodotorula mucilaginosa (%ID: 91.9) through biochemical means using the ID 32 C kit (Biomerieux, Marcy-l’Étoile, France). Our isolate’s identity was further confirmed by matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI Biotyper, Bruker-Daltonics, Bremen, Germany), which matched its mass spectral pattern with that of Rhodotorula mucilaginosa DSM 70403 DSM.