Pulmonary infection due to Acrophialophora fusispora in a patient with underlying mixed connective tissue disease and chronic pulmonary aspergillosis: A case report and review of literature.

Acrophialophora fusispora is a soil-borne fungus rarely implicated in human infections. Here, we report a case of pulmonary infection due to A. fusispora in a 59-year-old male who presented with productive cough and gradually progressive dyspnoea for 20 days. He had a past history of pulmonary tuberculosis and was a known case of chronic obstructive pulmonary disease for past five years. He was diagnosed with mixed connective tissue disease and had been receiving oral azathioprine and prednisolone for three months. CECT thorax revealed an aspergilloma and serum Aspergillus fumigatus-specific IgG levels were raised, suggestive of chronic pulmonary aspergillosis. He was also tested positive for influenza A (H1N1) and received treatment with oral oseltamivir without any clinical benefit. Culture of sputum and bronchoalveolar lavage fluid showed growth of a fungus which was identified as Acrophialophora fusispora based on characteristic microscopic morphology and internal transcribed spacer sequencing of the ribosomal DNA. Antifungal susceptibility testing for six antifungal drugs showed itraconazole to have the most potent in vitro activity (MIC=0.25μg/mL) against A. fusispora in comparison to the other drugs tested. Treatment with itraconazole capsule 200mg twice daily was initiated and favourable clinical response was observed after 10 days of therapy. Follow-up visit after three months showed marked clinical and radiological improvement. A. fusispora is an emerging opportunistic fungus capable of causing invasive infections in immunocompromised hosts. Lack of knowledge about this fungus and confusion with morphologically similar opportunistic fungi have led to its misidentification and hence its prevalence remains largely underestimated. Accurate identification is crucial as it can help initiate early effective antifungal therapy and improve patient outcomes. To our knowledge, this is the first case of pulmonary infection due to A. fusispora reported from India.