title: First Case of Trichoderma longibrachiatum CIED (Cardiac Implantable Electronic Device)-Associated Endocarditis in a Non-immunocompromised Host: Biofilm Removal and Diagnostic Problems in the Light of the Current Literature.
abstract: BACKGROUND
  Trichoderma species are saprophytic filamentous fungi producing localized and invasive infections that are cause of morbidity and mortality, especially in immunocompromised patients, causing up to 53% mortality. Non-immunocompromised patients, undergoing continuous ambulatory peritoneal dialysis, are other targets of this fungus. Current molecular diagnostic tools, based on the barcode marker ITS, fail to discriminate these fungi at the species level, further increasing the difficulty associated with these infections and their generally poor prognosis.
  
  
  METHODS
  We report on the first case of endocarditis infection caused by Trichoderma longibrachiatum in a 30-year-old man. This patient underwent the implantation of an implantable cardioverter defibrillator in 2006, replaced in 2012. Two years later, the patient developed fever, treated successfully with amoxicillin followed by ciprofloxacin, but an echocardiogram showed large vegetation onto the ventricular lead. After CIED extraction, the patient had high-grade fever. The culturing of the catheter tip was positive only in samples deriving from sonication according to the 2014 ESCMID guidelines, whereas the simple washing failed to remove the biofilm cells from the plastic surface. Subsequent molecular (ITS sequencing) and microbiological (macromorphology) analyses showed that the vegetation was due to T. longibrachiatum.
  
  
  CONCLUSIONS
  This report showed that T. longibrachiatum is an effective threat and that sonication is necessary for the culturing of vegetations from plastic surfaces. Limitations of the current barcode marker ITS, and the long procedures required by a multistep approach, call for the development of rapid monophasic tests.
authors.affiliation: Infectious Diseases Unit, Azienda Ospedaliera Universitaria Pisana, Via Paradisa 2, Cisanello, 56100, Pisa, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Tascini
authors.affiliation: Department of Pharmaceutical Sciences - Microbiology, University of Perugia, Borgo 20 Giugno 74, 06121, Perugia, Italy. gianluigi.cardinali@unipg.it.|Department of Chemistry, Biology and Biotechnology, CEMIN, Centre of Excellence on Nanostructured Innovative Materials, University of Perugia, Via Elce di Sotto 8, 06123, Perugia, Italy. gianluigi.cardinali@unipg.it.
authors.forename: Gianluigi
authors.initials: G
authors.lastname: Cardinali
authors.affiliation: Cardiovascular Medicine Unit 2, Azienda Ospedaliera Universitaria Pisana, Via Paradisa 2, Cisanello, 56100, Pisa, Italy.
authors.forename: Valentina
authors.initials: V
authors.lastname: Barletta
authors.affiliation: Division of Pharmacology, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, 56126, Pisa, Italy.
authors.forename: Antonello
authors.initials: A
authors.lastname: Di Paolo
authors.affiliation: Infectious Diseases Unit, Azienda Ospedaliera Universitaria Pisana, Via Paradisa 2, Cisanello, 56100, Pisa, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Leonildi
authors.affiliation: Cardiovascular Medicine Unit 2, Azienda Ospedaliera Universitaria Pisana, Via Paradisa 2, Cisanello, 56100, Pisa, Italy.
authors.forename: Giulio
authors.initials: G
authors.lastname: Zucchelli
authors.affiliation: Department of Pharmaceutical Sciences - Microbiology, University of Perugia, Borgo 20 Giugno 74, 06121, Perugia, Italy.
authors.forename: Laura
authors.initials: L
authors.lastname: Corte
authors.affiliation: Department of Pharmaceutical Sciences - Microbiology, University of Perugia, Borgo 20 Giugno 74, 06121, Perugia, Italy.
authors.forename: Claudia
authors.initials: C
authors.lastname: Colabella
authors.affiliation: Department of Pharmaceutical Sciences - Microbiology, University of Perugia, Borgo 20 Giugno 74, 06121, Perugia, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Roscini
authors.affiliation: Infectious Diseases Unit, "Spirito Santo" Hospital, Pescara, Italy.
authors.forename: Augusta
authors.initials: A
authors.lastname: Consorte
authors.affiliation: Infectious Diseases Unit, Department of Medicine, University of Perugia, Piazzale Gambuli, 1, 06132, Perugia, Italy.
authors.forename: Maria Bruna
authors.initials: MB
authors.lastname: Pasticci
authors.affiliation: Infectious Diseases Unit, Azienda Ospedaliera Universitaria Pisana, Via Paradisa 2, Cisanello, 56100, Pisa, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Menichetti
authors.affiliation: Cardiovascular Medicine Unit 2, Azienda Ospedaliera Universitaria Pisana, Via Paradisa 2, Cisanello, 56100, Pisa, Italy.
authors.forename: Maria Grazia
authors.initials: MG
authors.lastname: Bongiorni
mesh_terms: D000328:Adult; D000666:Amphotericin B / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use*; D001483:Base Sequence; D018441:Biofilms / Q000187:drug effects*; D021901:DNA, Intergenic / Q000235:genetics; D017147:Defibrillators, Implantable / Q000009:adverse effects*; D004696:Endocarditis / Q000188:drug therapy* / Q000382:microbiology; D006321:Heart / Q000382:microbiology*; D006801:Humans; D008297:Male; D009181:Mycoses / Q000188:drug therapy* / Q000382:microbiology; D017422:Sequence Analysis, DNA; D014242:Trichoderma / Q000145:classification / Q000187:drug effects* / Q000235:genetics; D065819:Voriconazole / Q000627:therapeutic use
chemical_list: D000935:Antifungal Agents; D021901:DNA, Intergenic; D000666:Amphotericin B; D065819:Voriconazole
keywords: CIED; Endocarditis; Molecular diagnosis; Trichoderma longibrachiatum