Infection
Aortic Homograft Endocarditis Caused by
Rhodotorula mucilaginosa
M. Maeder, P.R. Vogt, G. Schaer, A. von Graevenitz, H.F. Günthard
Abstract
Serious infections caused by Rhodotorula spp. are rare and
usually occur in immunocompromised people, especially in
patients with tumors and long-time use of indwelling central
venous catheters. We report a case of Rhodotorula
mucilaginosa homograft endocarditis in an otherwise healthy
man, which was successfully treated by surgery in
combination with amphotericin B and subsequently
intraconazole.
Infection 2003; 31: 181–183
DOI 10.1007/s15010-002-3155-1
Introduction
Rhodotorula is a yeast that belongs to the family Crypto-
coccaceae and is characterized by production of a coral-red
pigment. Rhodotorula spp. have been isolated from the
skin, nails, conjunctiva as well as from the respiratory and
gastrointestinal tract [1]. They are usually considered com-
mensals but may rarely be found as external contaminants
[1]. Serious infections in humans are rare but have been re-
ported. Immunocompromised individuals are at greatest
risk. Potential hosts are patients with solid tumors, lym-
phoproliferative diseases, AIDS, diabetes mellitus and
chronic renal failure [2]. Septicemia [3–5], endocarditis [6,
7], meningitis, ventriculitis, peritonitis, keratitis, endoph-
thalmitis, dacryocystitis and pneumonia have been reported
[1, 8]. Few reports exist describing infections in the im-
munocompetent host. In general, indwelling vascular
catheters are considered to be the major risk factor for in-
fection [8]. So far, only two unambigously documented
cases of endocarditis have been described in the English lit-
erature [6, 7]. Louria et al. [6] described a case of native aor-
tic valve endocardits in a 47-year-old woman with underly-
ing rheumatic heart disease. Rhodotorula was isolated from
several blood cultures and from valve tissue. The report of
Naveh et al. [7] concerns a 7-year-old boy with a clinical
course of fever and congestive heart failure. Several blood
cultures revealed Rhodotorula. Furthermore, there are
cases of proven bacterial endocarditis complicated by
Rhodotorula fungemia in whom valve involvement could
Infection 31 · 2003 · No. 3 © URBAN & VOGEL
Case Report
not be demonstrated [4, 5]. With the exception of flucona-
zole, most antifungal agents have been found useful in treat-
ing infections caused by Rhodotorula spp. [1].
Case Report
A 53- year-old otherwise healthy man was diagnosed with infec-
tive endocarditis (IE) of a bicuspid aortic valve in 1991. Coagu-
lase-negative staphylococci were isolated from four blood cultures
and the patient was treated for 4 weeks with flucloxacillin (4

2 g/d iv) and gentamicin (3
80 mg/d iv) before undergoing ur-
gent valve replacement due to rupture of the non-coronary sinus
with severe aortic regurgitation and an annular abscess on the an-
terior mitral cusp. The native valve was replaced by an aortic ho-
mograft (European Homograft Bank, Brussels, Belgium).The pro-
cedure was uneventful (aortic cross-clamp time, 55 min; car-
diopulmonary bypass time, 80 min).Aminoglycoside-impregnated
fibrin glue was used to seal the suture lines and fill up debrided
abscess cavities.After valve replacement, antibiotic treatment was
continued for another 6 weeks consisting of vancomycin (2
1 g/d
iv) plus rifampicin (2
450 mg/d iv). Thereafter he was free of
symptoms and could fully continue his work as a farmer for almost
10 years.
At the beginning of the year 2000, dyspnea, weakness, night
sweats and chest pain during physical efforts developed. The pa-
tient was admitted for cardial workup. On admission he was
afebrile, the heart rate was 68 and blood pressure 130/55 mmHg.
Cardiovascular examination revealed diminished heart sounds, a
grade 3/6 systolic ejection murmur radiating to the carotids with a
maximum at the Erb spot and a decrescendo diastolic murmur at
Erb’s area. No skin abnormalities were found and the spleen was
not enlarged.Transthoracic echocardiography showed severe aor-
tic regurgitation. The sinus portion and the ascending aorta (di-
ameter 4.5 cm) were dilated. An eccentric hypertrophic left ven-
tricle with an almost normal ejection fraction and dilated atria
M. Maeder, P. Vogt
Dept. of Surgery, Clinic of Cardiovascular Surgery, University Hospital
Zürich, Zürich, Switzerland
G. Schaer, A. von Graevenitz
Dept. of Medical Microbiology, University of Zurich, Zurich, Switzerland
H.F. Günthard (corresponding author)
Dept. of Medicine, Division of Infectious Diseases and Hospital Epidemi-
ology, University Hospital Zürich, Rämistr. 100, CH-8091 Zürich, Switzer-
land; Phone: (+41/01) 255-3450, Fax: -3291,
e-mail: huldrych.guenthard@usz.ch
Received: September 9, 2002 • Revision accepted: November 9; 2002
181
M. Maeder et al. Rhodotorula mucilaginosa and Endocarditis
were seen. These signs were consistent with homograft degenera-
tion and at this time IE was not suspected. Furthermore, there
were no laboratory abnormalities indicating generalized infection:
hemoglobin was 15.5 g/dl, thrombocytes 203
109/l, WBC
5.69
109/l, C-reactive protein < 3 mg/l. Preoperative coronary an-
giography revealed the additional diagnosis of a three vessel coro-
nary disease.
Aortic valve replacement with a Carbo Medics Aortic 23 mm
prosthesis (Sulzer Carbo-Medics Inc, Austin, TX, USA) and coro-
nary arterial bypass grafting were performed. Intraoperatively, a
ruptured left coronary aortic cusp of the allograft was seen. Sur-
prisingly, the non-coronary cusp was filled with a yellow, creamy
viscous material. The surgeon, suspecting an infection, sent mate-
rial for microbiological examination. Empiric antibiotic treatment
was started including vancomycin (2
1g iv), gentamicin
(3
80 mg iv) plus rifampicin (2
450 mg iv). Direct microscopy
of the grounded valve revealed yeast cells and after 3 days two of
three agar plates (sabouraud agar with gentamicin and chloram-
phenicol and brain heart infusion agar without antibiotics) and the
enrichment yielded growth of yeast colonies. Subsequently, flu-
conazole 400 mg/d was added after two blood cultures (fungal cul-
tures) were drawn which, however, remained negative. There was
no growth of bacteria and 16S ribosomal bacterial broad-spectrum
PCR was negative. Histopathology of the homograft material re-
vealed parts of the aortic valve with severe fibrosis and consider-
able fibrin insudations. There were no vegetations and no signs of
infiltration by inflammatory cells. Subsequently, the yeast was
identified as Rhodotorula mucilaginosa (formerly Rhodotorula
rubra) based on the red color of the yeast colonies, a positive ure-
ase test, the assimilation profile in the ID 32 C system (API Bio-
Mérieux, La Balme-Les Grottes, France; code 54716501) and the
lack of nitrate assimilation which differentiated Rhodotorula mu-
cilaginosa from Rhodotorula glutinis.
Since Rhodotorula spp. are resistant to fluconazole, antifun-
gal treatment was changed to amphotericin B. A total dose of 2 g
was administered iv over 28 days. Thereafter the patient was
treated for a further month with itraconazole 2
200 mg/d. An-
tibacterial treatment was stopped 1 month after surgery.
Three months after surgery the patient presented in good
health; transthoracic echocardiography showed a normal left ven-
tricular ejection fraction and only minimal aortic regurgitation.
The patient did not encounter any relapse of infective endocardi-
tis during a follow-up period of 2 years after surgery.
Discussion
Rhodotorula is known to be a potential pathogenic yeast in
immunocompromised individuals. Our patient, however,
was not immunocompromised in any known way. He did
not have diabetes, had no renal failure, was not HIV posi-
tive, nor did he have any known malignancies. Since the last
cardiac surgery 9 years previously, he had never been ad-
mitted to a hospital and no central catheters were placed
during this period.Yet, despite the absence of common pre-
disposing factors for fungal infections, he presented three
risk factors for fungal IE which have been identified in the
most comprehensive meta-analysis of fungal IE; previous
valve surgery, antibiotic use and bacterial endocarditis [9].
We can only speculate on the port of entry for this rare or-
ganism. One hypothesis is that the homograft, implanted 9
years earlier, became colonized by Rhodotorula at the time
of the first operation. It has been documented that Candida
182
IE can relapse up to 9 years after antifungal treatment [9],
suggesting that the yeast can survive for years attached to
the aortic valves without causing progressive disease. An-
other possibility is that he had a Rhodotorula fungemia at
some time which leads to colonization of the homograft.
The fact that only two proven cases of endocarditis caused
by Rhodotorula spp. have been found in the English litera-
ture (1960 – present) so far [6, 7] also warrants careful ex-
clusion of external contamination of the sample or the
plates used.The strongest argument against contamination
was detection of yeast in the PAS stain of ground-up valve.
Furthermore, the fact that the surgeon found a focus which
looked infected, that growth of yeast on two of three plates
in the absence of bacterial growth and negative broad-spec-
trum PCR was observed and that the patient was not pre-
treated with antibiotics, makes contamination highly un-
likely. In addition, in our laboratory, Rhodotorula spp. are
encountered rarely as contaminants from skin, nail and
stool specimens and in less than one case per year from ster-
ile body sites. Histopathologic staining of the valves showed
much fibrinogen but no inflammatory cells. These findings
are nonspecific and do not prove or disprove endocarditis.
Yet, it is known that bioprosthetic valves do not necessar-
ily show invasion of the valves by inflammatory cells be-
cause the tissue has been devitalized before use as a pros-
thesis and therefore granulocytes cannot invade the devi-
talized tissue easily [10]. In addition, sampling error may
also have occurred because the surgeon has sent the mate-
rial, which looked infected, to microbiology and therefore
this foci may not have been sampled by pathology. More-
over, lack of systemic inflammatory symptoms and the ab-
sence of classical signs of endocarditis also do not rule out
IE, since fungal IE with atypical symptoms, signs and labo-
ratory findings have been documented [9].
Cryopreserved homografts are believed to have a low
incidence of late endocarditis due to their resistance to in-
fection. In a large series of 680 patients who had received
homografts for different underlying valve diseases, 94% did
not show endocarditis after 15 years [11]. If homografts are
implanted as an emergency because of progressive conges-
tive heart failure (as was the case in our patient) or persis-
tent sepsis, their freedom from late endocarditis after 5
years was reported to be 85% [12]. Reports of homograft
infections include rare cases of fungal endocarditis [13].
Candida spp. were found to be the predominant causal
agents. In one case a contaminated donor aortic valve was
shown to be the source of infection [14].
To our knowledge, we report the first case of a
Rhodotorula homograft endocarditis in the English litera-
ture.
It remains to be determined whether reports of infec-
tive prosthetic valve endocarditis caused by Rhodotorula
spp. will increase in the future, in parallel with the ever in-
creasing frequency of valve replacements in recent years
and the wide use of fluconazole, which might, in theory, se-
lect for Rhodotorula spp.
Infection 31 · 2003 · No. 3 © URBAN & VOGEL

Acknowledgment
We thank Dr. B. Bode for carefully reviewing the histopathology.
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