116 The yeasts: Malassezia, Rhodotorula, Trichosporon, Saccharomyces

In this episode Alyssa is joined by common host Callum to talk about some less common yeast pathogens: Malassezia spp., Rhodotorula ssp., Trichosporon spp. and Saccharomyces spp. 

Whilst we're calling these "less common" don't let that fool you - these fungi are everywhere! They are just less commonly causing severe disease in us humans!

Show notes for this episode here: https://idiots.notion.site/116-Yeasts-other-yeasts-30a33d6070c84243b3f42edac4a37ec9?pvs=74

Transcript

0:23

Hi everyone. Welcome to the Idiots Podcast. That's infectious disease insights of these specialists. I'm Callum, and that's Alyssa. And we're going to tell you everything you need to know about fungal infection. Soon, may the editing come to discontinue the Tazo sun one day when the S piece done, we'll take our leave and go.

Callum: 0:46

Hello Alyssa!

Alyssa: 0:47

Hi Callum, how've you been?

Callum: 0:50

I've been good. Recently I was doing some nice things for my partner and I noticed, maybe there's a couple of Scots on the podcast and we talk about ma might mean like my, and last is a girl like lass and laddie. So lass is like a girl so yeah, getting back on the point so yeah, I've been trying to do some stuff to make her life a bit simpler. So for her it's ma lass. Malassezia.

Alyssa: 1:16

Ah! Okay, you.

Callum: 1:18

No, I feel the

Alyssa: 1:19

you're

Callum: 1:19

set up needs to be better.

Alyssa: 1:21

malas easier. Yeah. And is that your resolution for the new yeast?

Callum: 1:27

Oh. Make no sense when this is the release, it's Christmas!

Alyssa: 1:32

Today is the 20th of December, so it will be much later when this is released, but we're thinking about having a hyphy Christmas and

Callum: 1:41

I was out wearing my kilt the other day, and I had the thing that you wear in front of the kilt, I don't know if people know what that is, it's called the Sporin. Sporin. It's pronounced Sporan, and I was trying to go on this bike ride. There's actually a trike. And they were like trike, no Sporan. Trike is Sporan. What a coincidence, because what are we talking about today?

Alyssa: 2:04

So today we're going to talk about some less common yeast pathogens. So far we've gone through the main human pathogenic yeast. So candida, And the species that were previously classified as candida, Cryptococcus, and Pneumocystis jiravecii. And today we're going to talk about some less common yeast pathogens particularly Malassezia Rhodotorola, Trichosporum, and Saccharomyces.

Callum: 2:33

this is not a exhaustive list, there are so many organisms, like in any area of infection, that can, rarely, cause human disease. We've picked these out of the sort of rare yeast as things that we have either encountered clinically or, more common or in exams. And before we start, it's worth pointing out that there are ECMM, so European Conference on Medical Mycology joint cooperative guidelines for 2021 about rare yeasts, and they've got a rare yeast website, and that's in the show notes links, but in there introduction, they they go through some of the other rare yeasts, the other main pathogens, such as Geotrichum, Saprochitae, Magneosomiasis, Trichosporon, Codamiae. Barrelling through these and butchering them all. Malassezia, Pseudozyma, Rhododendrola, Saccharomyces, and Sporobolomyces. So we're not covering everything, but if you do come across a yeast that you've never heard of and is rare, that's a good place to go look because they've got quite useful guidance there. So where should we start? Should we start with Malassezia?

Alyssa: 3:45

Yeah, I

Callum: 3:45

What did you say? I think I said it different from you.

Alyssa: 3:49

most people have heard of that one.

Callum: 3:51

Yeah. How do you pronounce it?

Alyssa: 3:53

I call it Malassezia,

Callum: 3:56

Malassezia. Okay, write in which one you think is right. Yeah, I think for each of these we'll go through them quite briefly. And we'll just talk through the clinical features, laboratory diagnostics and treatment and resistance. So rapid fire through those four yeasts. Malassezia.

Alyssa: 4:14

and it's probably worth saying that we're not, experts in treating rare yeasts by any means. if there are any experts out there who would like to, Right in with some pearls of wisdom

Callum: 4:27

I don't think there's many of them, it's a rare, rare yeast expert.

Alyssa: 4:32

So thinking about going back to the grouping of different fungal pathogens the fungal kingdom is enormous and human fungal pathogens are grouped into three different phyla your Basidiomycota, Ascomycota, and Mucomycota. Malassezia, Rhodotorola, and Trichosporin are all Basidiomycetes. So, In the same group with Cryptococcus. Whereas Saccharomyces is an Ascomycete. so in that main group of fungal pathogens and Saccharomyces is quite similar genetically to Candida glabrata,

Callum: 5:13

So they're basidiomyces. Where do they live? What, are they in the environment or?

Alyssa: 5:20

So Malassezia are part of our normal skin flora. The Malassezia genus has about 16 species. And these include Malassezia furfur Malassezia sympodialis.

Callum: 5:36

Malassezia restrictica.

Alyssa: 5:38

And a range of skin conditions are associated with Malassezia. So I think this is where most of us have probably heard of Malassezia. So either caused by or exacerbated by Malassezia. So these include Versicolor, Seborrheic Dermatitis, dandruff, atopic eczema, and folliculitis. And from an exam perspective, it's worth knowing that the majority, say 15 of the 16 species, are lipid dependent, so they will only grow in culture in the presence of certain fatty acids. So we'll come on to why that's important when we get on to the diagnostics.

Callum: 6:24

Okay. So clinical features, so skin manifestations. You talked about some of these clinical syndromes, which I think are generally things that are presenting to primary care. Yeah. Or dermatology. And so the first one that people working in that setting would be familiar with their is pits s of color. So this is a superficial skin infection. It's characterized by these sort of hypopigmented lesions and it's non itchy, and it's usually confined to the trunk and the proximal limbs. So I guess there's a differential for hypopigmented lesions, but it's got quite a classic appearance. There's pictures from DermNet that, that show what you're looking for. And they're usually called by Malassezia globosa or for,

Alyssa: 7:07

Yeah, and then there's Malassezia folliculitis, which is inflammation around the hair follicle caused by Malassezia. that presents as small, itchy papules or pustules at the hair follicle areas. So particularly on the back and the upper chest.

Callum: 7:27

And then finally we've got seborrheic dermatitis and dandruff, which are, hugely common. They cause, chronic dermatitis involving oily regions of the scalp, so areas where there's a lot of suspicious glands and that's generally the scalp, face, and trunk. So it makes sense that these are lipid dependent organisms and one subset of this is cradle cap in infants

Alyssa: 7:52

It's like the, it's like seborrheic dermatitis, but on the head of baby, newborn babies,

Callum: 7:58

right?

Alyssa: 7:59

infants. Yeah, you get this oily scaling. On their head.

Callum: 8:05

There's a huge amount more you could say about all those conditions, but we're not a dermatology podcast. We're an infection podcast. Predisposing factors really include things that would increase the oil available in the skin, so things like high humidity, setting, sweating, having generally oily skin. And then other things that might impair your response, so immune deficiency states or immune suppression, but that's just the superficial side. Can they cause invasive disease?

Alyssa: 8:31

Yeah, so rarely Malassezia can cause invasive infection in the form of, Fungimia. And Fungimia with, remember that these are predominantly lipid dependent organisms, so they usually occur in patients with, central lines. Who are receiving TPN, that's lipid rich, so often lipid supplemented parenteral therapy and fungemia of these lipid dependent malassezia is most commonly seen in neonates, in infants. So I think that it's one thing of if, you know you've got somebody with a line who's receiving TPN that's lipid supplemented, who then develops a fungemia. And other risk factors for invasive infection include immunosuppression and peritoneal dialysis.

Callum: 9:20

Cool. So how do you diagnose it? Essentially these conditions are generally clinical diagnosis. They're very common. You can take samples sent to the lab. Direct microscopy of skin scrapings on pitta rice is versicolor. This really, depends on how much there is. You need quite a large amount of tissue to be able to do it when it gets to the lab. And essentially, when you look at it under the lab microscope, you see yeasts and hyphae. And I think it's meant to resemble spaghetti and meatballs, which has put me off spaghetti and meatballs. There's a picture in the prep notes from the Adelaide Mycology site. Does that look like spaghetti and meatballs to you?

Alyssa: 10:02

I think I can see spaghetti and meatballs. They're quite small meatballs relative to the size of the spaghetti, but essentially what you see with these Malassezia on direct microscopy from skin scrapings is the round fairly thick walled yeasts and then these sort of short hyphal forms.

Callum: 10:21

I've, I'm going to explore, because I live right next to the sea, and I really like food from the sea. I think I'm going to rename this and say it looks like caviar and samphire

Alyssa: 10:33

oh yes.

Callum: 10:35

Yeah, if you add samphire, It's really nice.

Alyssa: 10:38

Sunfire.

Callum: 10:41

what, that's definitely what it looks like. Yeah, we'll rename that for you all. Yeah. So this podcast is getting real fancy now. Yeah, That's the direct microscopy. As I say, you can't take skin scrapings from all areas, like sensitive areas. And it depends on if it's really flaky skin, that can be quite easy, but it's not always that, that easy. And then in terms of transport to the lab. So I don't know if we talked about this in Fungal Diagnostics episode, but I'll maybe just repeat it if we did. You ideally want specific fungal transport media, so they're like little cardboard boxes that we use. They fold over and the idea is it dries, liquid comes out and it allows, basically inhibits the growth of bacteria and allows the fungi to survive. So culture, because they're lipid dependent, they don't grow in normal media. So you need oil. So I've, I think I've seen this before. It's quite cool, isn't it?

Alyssa: 11:38

so you can either, yeah, you can either take your standard sabrose dextrose agar and then overlay it with some olive oil and then inoculate the plate, you can use a specialized media that, that is already oil supplemented. So there's one called Dixon's Media and there's a nice picture of Malassezia growing on Dixon's Media on Adelaide Mycology that I've included. And for the exam, the way I remembered it was think fatty fur fur. So, Malassezia fur fur, fatty fur fur, need the oil. Oh,

Callum: 12:14

hobbit name. So the the picture is really quite beautiful. It just looks like a normal yeast, isn't it? It's it is a yeast, it just that's really interesting. Okay. That's the diagnostics.

Alyssa: 12:23

So we've already said that if you get yeasts in blood culture from someone with a line in TPN, but also if you get yeasts in blood culture in a patient who's has risk factors, but then it fails to grow on Sabros dextrose agar, it is really important to think about Malassezia and make sure that you that supplemented agar. And once you've grown them, the multi TOF is reliable for identifying them to species level.

Callum: 12:50

So cutaneous is generally with topical antifungal agents. So you might use something like a topical azole say, or might cream, or you might use ketoconazole shampoo, say that's scalp or you might use topical terbenephine. You can treat with oral azoles, so fluconazole, itraconazole, if it's severe, or if topical treatment has failed, but obviously they have significant side effects. One thing to mention here is that seborrheic dermatitis is an indicator condition for HIV testing. Remember to do that. It's quite a common condition, so I guess, not saying everybody with seborrheic dermatitis has HIV, but rather, Particularly the more severe end of it higher risk with HIV.

Alyssa: 13:30

And then if your patient's got fungimia or a line infection with Malassezia, like a lot of yeasts, they can form biofilms. So removal of the central line is key as well as if possible, discontinuing that lipid supplemented parenteral therapy. And then moving on to treat antifungal treatment so fluconazole or amphotericin B are your main options. As these fungi have in vitro resistance to fluocytosine and echinocandins.

Callum: 14:00

So that's Malassezia. Should we move on to Rhodotorula? Rhodotorula?

Alyssa: 14:07

I call it Rhodotorola, but I don't know how

Callum: 14:11

Not sure. Yeah, I guess the Romans are dead. Or actually, is it Roman at all?

Alyssa: 14:20

coloured, and the origin of that word is Greek. Rhodon is Greek for rose. Rhodotorola colonies are red or salmon pink in colour. similar to Rhodococcus,

Callum: 14:32

Oh okay, yeah.

Alyssa: 14:33

And these are environmental yeasts. And I was so excited when finally discovered, when I was in a student house the tile grout and the shower curtain always have this disgusting pinky orangey scum on it. And that is Rhodotorola. What the

Callum: 14:56

I never had that because my student accommodation was always pristine and there was never any problems. There's a little mycology lab, mold growing in the plates. Yeah, there's a lot of different species. species within this genera. So there's 46 species of Rhodotorola. Now only three of them have been described as human pathogens. So that's Rhodotula Mukulaganosa.

Alyssa: 15:26

Glutinous.

Callum: 15:28

and Rhodotorola minuta.

Alyssa: 15:31

And I think Rhodotorola mucilaginosa is certainly the one that, that I've most commonly encountered and it is the most common species isolated in human infection and it, I do, I always get confused with this because there's also rothia mucilaginosa, isn't there? Which is a gram positive cocker back

Callum: 15:51

yeah, and I think Rothy are gram positive coccyx, they're anaerobic.

Alyssa: 15:55

So it is

Callum: 15:56

Yeah.

Alyssa: 15:57

rothiomucilaginosa, rhodotorolemucilaginosa, it does all get a bit confusing.

Callum: 16:04

So why do we care about Rhodotula?

Alyssa: 16:06

So these are environmental yeasts, but they're opportunistic pathogens in immunocompromised patients. The most common risk factors being having a line and hematological malignancy. So they can cause bloodstream infection, disseminated infection, and line infection in that context.

Callum: 16:31

And the other, context that they can cause infection is fungal peritonitis in patients undergoing peritoneal dialysis. Essentially, it colonizes the dialysis catheter and equipment, and then causes the peritonitis from that, which is not what you want. And rarely things like endocarditis and meningitis have been reported although obviously very rare.

Alyssa: 16:52

And then moving on how to diagnose them. So is the mainstay of diagnosing invasive infection by rhodotorola. So blood cultures, CDC line tips, peritoneal dialysis fluid. can all be cultured. And rhodotorola species are really easily recognized in the laboratory by the red salmon pink color of the colonies. And then if you were to gram it, you'd see the budding yeasts under the microscope.

Callum: 17:22

And then once you've grown it, you can identify using the I guess you'll have the classic color. So that may well be enough. But if you can do the moldy tough. And that's a reliable method of identification. If you don't have a moldy tough, then I guess you're looking at your microscopic and macroscopic appearances to make a likely diagnosis. Plus then maybe sending it to a reference lab if you've got one to send it to.

Alyssa: 17:44

And then treatment can be quite challenging because they're intrinsically resistant to azoles and echinocandins but generally susceptible to amphotericin being free cytosine. So generally, liposomal amphotericin B is going to be your treatment of choice. And if it's a case of PD peritonitis, this can be given intraperitoneally. And then removing the peritoneal dialysis catheter or central line that's associated with the infection is really important for clearing the infection.

Callum: 18:16

Yes. I wonder if there's some link between. Obviously it's an environmental contaminant in that sort of wet environment. I wonder, people with lines, I always wonder having a shower in that environment is contaminating. Is that we talk about bacterial organisms that are in the water, like often when people have line related infection, it's some sort of, pseudomonad or some similar organism. You just wonder, and I, it was when you get these weird organisms from lines, you think what's the line care like, what was the patient counseling about lines and so on? Because I think in general life, because if you're immune competent, then, you have a shower and you didn't think about any risk. And as soon as you're immune compromised and you've got this prosthetic material and like things that you never, like tap water, there's no risk of tap water, but it's full of fungi and

Alyssa: 19:01

Yeah,

Callum: 19:02

microorganisms that, could potentially be really problematic. Yeah, just that re evaluation of what is and isn't safe is so important, isn't it?

Alyssa: 19:10

And we do a lot of infection prevention and control in the hospital and clinical setting. But, you feel when patients with risk factors for invasive, bacterial and fungal disease, a discharged home, that they then enter an unregulated environment, don't they?

Callum: 19:28

Yeah, and you don't know, I feel like it's almost an episode of House, which I haven't really watched much of, but the odd snippets and there's that classic thing where they go to the person's house and like snoop around and they're like, oh there's this hat. They must have lead poisoning or something. And it's like they sneak in, they go into their bathroom, like their bathroom's moldy, they've got a rhodochorola, so maybe we should be doing domiciliary infection control visits. Maybe that's happening in some parts of the world, let us know if it is. So we'll move on to our penultimate rare yeast, so trichosporon.

Alyssa: 20:01

Yeah, so Trichosporon are a fairly minor component of normal skin flora. So they're, they're part of the skin microbiome, but not a very big part. And they're also found quite widely in the environment. There's 16 species within the Trichosporon genera. That Are associated with human infection. And 75% of these infections are due to a single species called Trione Asaki. I think that's the main one to remember. Pra.

Callum: 20:36

And trichosporon species, they cause something which are called white piedra of the hair. And so these are small white nodules that are deposited along the hair shaft and they almost look like small stones. There's a picture from DermNet of this. It's quite subtle. Maybe something that you would feel. And I think those nodules are actually where the fungus is growing, isn't it? So that's the most common clinical feature. It can cause the hair shafts to break or itching or pain or just generally gritty or brittle hair.

Alyssa: 21:11

And apparently, Trichosporon ascii can also spread to the nails causing onychomycosis and even to the lungs causing a more allergic or hypersensitivity pneumonitis.

Callum: 21:24

It can also cause disseminated infection in the immune compromised host. So things that have been reported being fungimia, endocarditis, peritonitis and meningitis. And really the people that are at risk of that are those with hematological malignancy, particularly prolonged neutropenia, or those with, neutrophil dysfunction, so something like a chronic granulomatous disease. And these disseminated infections are often fulminant, so you know, severe end of spectrum with widespread sort of foci. So lesions occur in the liver, spleen, lungs, and GI tract, and mortality rates, unfortunately, up to 80%. So some prior relative invasive candidiasis there, because we talk about, candida often going to liver and battle splenic disease. So we acquired a devastating thing, which is normally quite innocuous.

Alyssa: 22:15

With Spoon, think of it, yeah, as causing this white piedra pretty, innocuous but it can cause quite an impressive disseminated infection in immunocompromised hosts. And just of note, do you know what piedra means in Spanish?

Callum: 22:31

I'm gonna guess it's something like feet or shoes or something like that, footprints.

Alyssa: 22:35

It's actually stone,

Callum: 22:37

Oh,

Alyssa: 22:38

so that's why, yeah, it looks like little small stones. That's called white Piedra.

Callum: 22:42

I was pretty far off. Oh, Peter. Actually, Peter is means rock, isn't it? Peter is the rock.

Alyssa: 22:49

Oh, does it? Yeah,

Callum: 22:51

Yeah, so Petrus as well. I love etymology, sidebar. I just, I find it fascinating when you know a word and you find out what it actually means. So how do we diagnose this? The hair bit is pretty easy. You take the hair sample, you send it to the lab, they look under the microscope and they are able to see the yeast there directly. But fungal culture is the gold standard.

Alyssa: 23:14

Is probably again something that's mainly going to be so Piedra's mainly going to be diagnosed by, primary care or by dermatologists. And I think, dermatologists have those little, magnifying glasses

Callum: 23:28

yeah.

Alyssa: 23:29

the skin and also on the hair. So look at the hair under magnification you might be able to see these little deposited white nodules. But yeah, then getting that definitive diagnosis that it's trichosporinosis. Culture would be the gold standard, but I expect it rarely comes to that, does it? It's probably mostly a clinical diagnosis.

Callum: 23:51

So for invasive disease, again, it's direct microscopy of the sterile fluid or the tissue biopsy.

Alyssa: 23:57

Yeah, you see these arthroconidia, so arthroconidia are structures that have broken off from the hyphae, and they're quite thick walled and barrel shaped. So that, you might see that on microscopy.

Callum: 24:10

So yeah, they've got this characteristic appearance on the microscopy. There's a picture of that in the show notes and then on culture, if you're growing them on one of the fungal media, they've got this very characteristic feature appearance where they have raised colonies that form like burrows and folds. So it's almost like, sand dunes? Maybe that's not the right thing. Or if you're on the beach and you see those little bur like, where the sandworms have been, and there's little burrows of sand. A little bit like that, how would you describe it?

Alyssa: 24:40

really wobbly.

Callum: 24:41

Different areas. By the sea, you've got the seaside culture and you've got the agriculture.. And then identification. You can do that on Molotov again, but you, I don't know if you would need to, I guess it's quite a characteristic microscopic and macroscopic appearance. So I can't actually see any reason why you might need to do that unless there was some dubiety or it was important to specifically speciate it.

Alyssa: 25:02

I guess if you, yeah, if you're getting an invasive in infection with a yeast,

Callum: 25:07

That's true. Yeah.

Alyssa: 25:08

you're gonna be seeing that often. You're gonna need identification and susceptibility

Callum: 25:13

Yeah, that's true. If it's invasive, that makes sense. And the other thing, in terms of our fungal antigens, so they share antigens so you've written here in the notes that there's dual positivity of CRAG and Aspergillus galactomanin can be an indicator of invasive trichosporonosis, which is really interesting. I, I guess you get a positive CRAG, you just think it's Cryptococcus, but that's a sort of, Important little nugget of information with the lightbulb next to it on the note. That'd be a great exam question. A patient with,, the fitting clinical picture and then you get those results. I think that would be quite tricky question, but you heard it here. Not that we have any power over what's in the exam, but it's going in.

Alyssa: 25:53

and then treatment resistance. Again, quite quickly to to treat. Trichosporin species are intrinsically resistant to flu cytosine and echinocandins. And then Trichosporin which is the most common. Species to cause disease in humans is also resistant in vitro to amphotericin B. So the mainstay for treatment are your azoles. Topical, you can get ketoconazole shampoo for piedra and superficial infections like the onychomycosis. then is the preferred agent for treating fungimia and disseminated infection.

Callum: 26:34

Yeah, that's, that is definitely tricky to treat. Okay. So that's Trichosporon. And then our final one is Saccharomyces so this I've definitely seen come up and you said at the beginning this isn't Asco Mycete, so the other three that we've talked about in the rare yeasts have all been Basidio Mycete so it's in a different group. And it's phylogenetically very closely related to Nacosiomyces glabratus, or what formerly was called Candida glabratus. And I think people have heard of this because it's, I guess we've talked to quite a few fungal and we're learning a lot about just general life and industry, but it's almost known as baker's yeast or brewer's yeast as it used in fermentation. So if you're somebody who makes bread or beer at home then you'll know about this. And it's often. In probiotics. So certainly if you look at the ingredients of probiotics, saccharomyces and, we had that whole episode on the microbiome before, and I've listened to this there's a podcast called microbiome medics which I would I recommend checking out where they talk about a variety of things, including the evidence base behind probiotics and the sort of difficulties in interpreting that. Okay. And people have looked at using Saccharomyces in these for the prevention treatment of things like infectious and antibiotic associated diarrhea, including C. diff associated diarrhea. So normal, healthy part of the gut microbiome, really useful in industrial. Places and I think some there's, a mix of evidence, some of it quite low quality, but the high quality evidence that there is seems just that things like probiotics might have a role and in some circumstances. So generally pretty harmless and transiently colonizers.

Alyssa: 28:20

Think it's the variety boulardii, saccharomyces boulardii, the one that's used in probiotics, and then I guess because they're, they're in food and probiotics we eat them, and they transiently colonize our GI tract and mucosal surfaces. But can rarely cause infection. And we'll come onto that now, the different types of infection that they can cause so cause the following infection. Vaginitis, this is particularly in women who have been exposed to fluconazole so women with recurrent vulva vaginal candidiasis um, croce sate can cause bloodstream infections. Again, particularly in fluconazole patients. And then a key thing to remember is that bloodstream infection and then subsequent disseminated infection can occur in immunocompromised individuals with, Saccharomyces boulardii. And this has been described following probiotic use. So it is recommended that probiotics to prevent and treat diarrhea is avoided in patients who are immunocompromised.

Callum: 29:41

Yeah, I think that's a really important point because I've certainly seen some people recommending probiotics and I don't know if the science is really there to completely Recommend that, and there's obviously a lot of, conflicts of interest, and it's not a medical product, so the sort of controls about what research is done and published is not, are not there, like they would be for a drug. But the, everything in life has some risks, and if you're in that situation where you're immune compromised, then this actually could make you seriously unwell, so that's a really key point. Okay, so someone has we're worried about invasive Saccharomyces infection. How do we diagnose it? The most common diagnosis, like all these fungi, is microscopy and culture. On microscopy, what we would see is yeast cells that are round oval, but they're generally larger than other yeasts. Now that's going to need a really trained eye. To see that, but, something to be aware of if you're seeing something that's a bit bigger. And then on, on culture so there are white to cream smooth yeast like colonies in standard media, so pretty, hard to differentiate from another yeast. But I think, certainly if we had the yeast in a bud culture, what would happen with it? We'd go straight to the moldy top. And that's thought to be reliable. And you can do DNA sequencing. And I presume there's sort of macroscopic appearances that would differentiate from other yeast as well, but I'm not so familiar with those.

Alyssa: 30:59

Yeah. I think generally they just look quite, it's not like something like your rotatorula or your trichosporin um, where you're getting those characteristic laboratory features or the Malassezia where it fails to grow on standard agar. There isn't really anything to flag up that this could be Saccharomyces. And I think generally, remember they're very closely related to Candida glabrata. Quite like a glabrata.

Callum: 31:28

yeah, so that's a tricky one. It's not going to stand out potentially. And then treatment. It's similar to glandular glabrata actually, in terms of it's got elevated azole MICs.

Alyssa: 31:39

So successful treatment has been reported with Freakonazole. Liposomal amphotericin B and combinations of liposomal amphotericin B and pre cytosine. And I guess you'd reserve those latter ones for more severe infection. And then as a general rule, probiotics should be discontinued if the patient's probiotics. and like most other yeasts, these are capable of forming biofilms, so it's important that associated lines are removed. And prosthetic material are removed.

Callum: 32:13

And I think when I've seen this before I have seen it in blood cultures, but I have to say it was in the context of, if I remember now, I, this is quite a long time ago now, but I, I remember getting it and thinking, oh, that's for beer making. And that's odd. And then there's some looking up online and the patient was like, I think they were like not immune compromised, but they had some GI surgery or some other reason that their gut lining might be disturbed. And actually, in the end, I don't think we treated it because The patient didn't really fit the risk characteristics and they weren't unwell in any way. And like many parts of your gut microbiome, sometimes you see these sort of blood cultures with anaerobes and the patient was like very transient fever and is completely well with antibiotics and you get the ID much later on. And these things that live in our gut sometimes end up in our blood and we pick them up in blood cultures. And whilst that's not normal, I don't know if it necessarily always needs treatment. But clearly if the patient is. In a position where they are unwell and they've been compromised and you're going to need to treat this. But I don't think there's much out there to guide what that is. So I guess you could go to the ECM guidance and get some more information, which would highly recommend. So just to wrap up what we've talked about there. So we've, we're wrapping up our yeasts month for our miniseries. And we've picked up a couple of the rare yeasts to talk about. Mal roto, TOA uh, Trico, Sporin, and Croce serve VCA. And in each of those we talked about the clinical features. The laboratory diagnostics and the treatment and resistance We've signed voices due towards the joint ECMM and others guidance. So if you want to learn more, go there. And any closing statements from you, Alyssa?

Alyssa: 34:00

No, I don't think so. actually I'm off on holiday in a minute to an island called Rula. So I need to head off now and get on the road to Rula. Rodeo to rule rodeo.

Callum: 34:15

probably not heard of it, don't look it up. But yeah, lovely place it's a rare holiday destination, very rare, Great, so we'll be back with our Mycology series in the future, and we'll be coming back with the Moulds.

34:30

This Mycology series of episodes is sponsored by the British Society for Medical Mycology. The 59th BSMM annual conference is due to take place in Norwich from the seventh to the 9th of September, and aims to bring together clinicians and researchers in the field of medical mycology. Registration is only two 40 for trainees and includes accommodation and meals. Abstract submission is now open and we welcome abstracts on research, clinical cases and auditing QI projects in medical. Visit www.bsm.org to register and submit your abstract. Thank you for listening to The Idiots Podcast, the UK's premier Infectious Disease podcast. Questions, comments, suggestions. Why don't you send them into Idiots podcasting@gmail.com. Have a five star review in your pocket at Calm, and I would love to have it. Please drop it in your podcast player of choice. We tweet at idiot under pod and if you want to donate to support the show, there's a link to do so in the description. But until next time, I'm Jane. I'm Callum. See you. Now that the episode's done, we hope you learn and had lots of fun. So go forth and treat people with some of what you now know.