P490 Fatal secondary fungemia due to Trichosporon asahii onychomycosis in a diabetic patient

POSTER SESSION 1, SEPTEMBER 21, 2022, 12:30 PM - 1:30 PM: OBJECTIVES: We describe a fatal case of trichosporonosis caused by Trichosporon asahii. The aim was to molecularly characterize the T. asahii strains from blood and foot tissue samples to investigate their genetic relatedness. CASE: An 85-year-old morbidly obese female with a prior cerebrovascular accident, hypertension, and diabetes mellitus was admitted to a peripheral hospital with type II respiratory failure, metabolic acidosis, and chronic anemia. Three weeks post-hospitalization the patient remained febrile, physical examination showed that the patient had paronychia, nail pigmentation, subungual onychomycosis, and a diabetic foot ulcer. Blood culture, as well as nail and ulcer samples, became positive for Trichosporon yeasts. METHODS: Trichosporon yeasts were subjected to molecular identification by sequencing the intergenic spacer (IGS1) region. Minimal inhibitory concentrations (MICs) were determined by the EUCAST microdilution method. Long-read nanopore sequencing was performed for the three clinical strains, the type-strain of T. asahii (CBS2479), and two IGS-genotype 7 strains (CBS2936, CBS7632) using the native barcoding kit v12 (SQK-LSK112; Oxford Nanopore Technologies). Raw data were basecalled with Guppy v6, Flye v2.9 was used to de novo assemble the genome of CBS2479, this was used as a reference for variant calling using the genomic reads of all strains. RESULTS: The three clinical strains were found to belong to the rare IGS-genotype 7 and had similar MICs for amphotericin B (4 µg/ml), 5-fluorocytosine and fluconazole (2 µg/ml), voriconazole (≤ 0.015 µg/ml), posaconazole (0.0625 µg/ml), itraconazole (0.125 µg/ml), caspofungin (8 µg/ml), anidulafungin and micafungin (> 16 µg/ml). Strains from the ulcer and nail were genetically very closely related with 10 836 SNPs differences, the blood-derived strain differed more from these two strains with 94 729 SNPs and 94 913 SNPs, respectively. Strains CBS2936 and CBS7632 were only distantly related to CBS2479 with 328 221, and 436 060 SNPs, respectively. CONCLUSION: The T. Asahii IGS-genotype 7 strain causing fatal fungemia was genetically nearly identical to that obtained from nail and foot ulcers, making it highly likely that this was the port d'entrée for T. asahii.