LAUSR

We report the case of a 57-year-old man with a 3-month history of intermittent pyrexia. He received irregular antibacterial therapy and thrombolysis in a local hospital due to occlusion of the right distal popliteal artery. His medical history included multiple fractures, allergic purpura, and hypertension. His medications included prednisone (30 mg orally per day), metoprolol, and amlodipine. On physical examination, breath sounds were clear and a 3/6 pansystolic murmur was auscultated at the right sternal border. Swelling of the right leg and gangrene at the fifth toe were found. Abdominal palpation revealed mild splenomegaly. The following abnormal laboratory results were identified: white cell count, 3.20 10/L; platelet count, 30 10/L; hemoglobin, 8.80 g/dL; albumin, 2.99 g/dL; erythrocyte sedimentation rate, 42 mm/h; C-reactive protein, 13.30 mg/L; and ferritin, 674 mg/L. Three blood cultures were positive and a gram stain showed budding yeast cells. The isolate, after being subcultured on CHROMagar (Becton Dickinson, Paris, France), showed membranous colonies that changed color from pink to blue within 48 hours (Figure A). On corn meal agar (Becton Dickinson), pseudohyphae and blastoconidia were seen 24 hours later (Figure B). The yeasts were identified as Kodamaea ohmeri (K. ohmeri). Drug sensitivity testing showed that this strain was susceptible to voriconazole, fluconazole, itraconazole, and amphotericin B. Bone marrow aspiration, performed due to the cytopenia, showed phagocytosis of hematopoietic cells by activated macrophages (Figure C). Thoracoabdominal computed tomography revealed splenomegaly and mild bilateral pleural effusion. Transthoracic echocardiography showed a large vegetation (30 mm 12 mm) on the aortic valve with mild regurgitation and stenosis. On hospital day 5, the patient developed persistent pyrexia with a temperature of 39 8C despite antifungal therapy with intravenous voriconazole. Urgent surgery was performed and a large fragile and loose vegetation was found on the aortic valve that almost