title: Outbreak of intestinal infection due to Rhizopus microsporus.
abstract: Sinopulmonary and rhinocerebral zygomycosis has been increasingly found in patients with hematological malignancies and bone marrow transplantation, but intestinal zygomycosis remains very rare in the literature. We investigated an outbreak of intestinal infection due to Rhizopus microsporus in 12 patients on treatment for hematological malignancies over a period of 6 months in a teaching hospital. The intake of allopurinol during hospitalization (P < 0.001) and that of commercially packaged ready-to-eat food items in the preceding 2 weeks (P < 0.001) were found to be independently significant risk factors for the development of intestinal zygomycosis. A total of 709 specimens, including 378 environmental and air samples, 181 food samples, and 150 drug samples, were taken for fungal culture. Among them, 16 samples of allopurinol tablets, 3 prepackaged ready-to-eat food items, and 1 pair of wooden chopsticks were positive for Rhizopus microsporus, which was confirmed by ITS1-5.8S-ITS2 rRNA gene cluster (internal transcribed spacer [ITS]) sequencing. The mean viable fungal counts of allopurinol obtained from wards and pharmacy were 4.22 x 10(3) CFU/g of tablet (range, 3.07 x 10(3) to 5.48 x 10(3)) and 3.24 x 10(3) CFU/g of tablet (range, 2.68 x 10(3) to 3.72 x 10(3)), respectively, which were much higher than the mean count of 2 x 10(2) CFU/g of food. Phylogenetic analysis by ITS sequencing showed multiple clones from isolates of contaminated allopurinol tablets and ready-to-eat food, of which some were identical to patients' isolates, and with one isolate in the cornstarch used as an excipient for manufacture of this drug. We attempted to type the isolates by random amplification of polymorphic DNA analysis, with limited evidence of clonal distribution. The primary source of the contaminating fungus was likely to be the cornstarch used in the manufacturing of allopurinol tablets or ready-to-eat food. Rhizopus microsporus is thermotolerant and can multiply even at 50 degrees C. The long holding time of the intermediates during the manufacturing process of allopurinol amplified the fungal load. Microbiological monitoring of drugs manufactured for highly immunosuppressed patients should be considered.
authors.affiliation: Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China.
authors.forename: Vincent C C
authors.initials: VC
authors.lastname: Cheng
authors.forename: Jasper F W
authors.initials: JF
authors.lastname: Chan
authors.forename: Antonio H Y
authors.initials: AH
authors.lastname: Ngan
authors.forename: Kelvin K W
authors.initials: KK
authors.lastname: To
authors.forename: S Y
authors.initials: SY
authors.lastname: Leung
authors.forename: H W
authors.initials: HW
authors.lastname: Tsoi
authors.forename: W C
authors.initials: WC
authors.lastname: Yam
authors.forename: Josepha W M
authors.initials: JW
authors.lastname: Tai
authors.forename: Samson S Y
authors.initials: SS
authors.lastname: Wong
authors.forename: Herman
authors.initials: H
authors.lastname: Tse
authors.forename: Iris W S
authors.initials: IW
authors.lastname: Li
authors.forename: Susanna K P
authors.initials: SK
authors.lastname: Lau
authors.forename: Patrick C Y
authors.initials: PC
authors.lastname: Woo
authors.forename: Anskar Y H
authors.initials: AY
authors.lastname: Leung
authors.forename: Albert K W
authors.initials: AK
authors.lastname: Lie
authors.forename: Raymond H S
authors.initials: RH
authors.lastname: Liang
authors.forename: T L
authors.initials: TL
authors.lastname: Que
authors.forename: P L
authors.initials: PL
authors.lastname: Ho
authors.forename: K Y
authors.initials: KY
authors.lastname: Yuen
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D015169:Colony Count, Microbial; D004271:DNA, Fungal / Q000235:genetics; D004275:DNA, Ribosomal / Q000235:genetics; D021903:DNA, Ribosomal Spacer / Q000235:genetics; D004196:Disease Outbreaks; D004783:Environmental Microbiology; D005260:Female; D005516:Food Microbiology; D005838:Genotype; D019337:Hematologic Neoplasms / Q000150:complications / Q000188:drug therapy; D006784:Hospitals, Teaching; D006801:Humans; D016867:Immunocompromised Host; D007410:Intestinal Diseases / Q000453:epidemiology* / Q000382:microbiology*; D008297:Male; D008875:Middle Aged; D017720:Molecular Epidemiology; D009091:Mucormycosis / Q000175:diagnosis* / Q000453:epidemiology*; D016533:Mycological Typing Techniques / Q000379:methods; D012340:RNA, Ribosomal, 5.8S / Q000235:genetics; D012233:Rhizopus / Q000302:isolation & purification*; D012307:Risk Factors; D055815:Young Adult
chemical_list: D004271:DNA, Fungal; D004275:DNA, Ribosomal; D021903:DNA, Ribosomal Spacer; D012340:RNA, Ribosomal, 5.8S