Clostridium difficile in Discharged Inpatients, Germany

fungal pathogens could be isolated from sputum by classic and molecular methods. After 4–5 days, his temperature was 40°C, a productive cough with dyspnea was noted, and his condition deteriorated. A chest radiograph showed progression of the infiltrates, and a computed tomography scan of the abdomen and chest showed infiltrates near the pleura, suggesting encapsulated fluid (Figure). An ultrasound-guided lung biopsy was performed, and mucoid material was aspirated. Microscopy and a culture from the aspirate showed a cryptococcal isolate. This isolate was further identified by internal transcribed spacer and D1/D2 sequencing, as well as amplified fragment-length polymorphism analysis (2). In addition, detailed genotyping was performed by using sequences of 7 genes (IGS, CAP10, GPD1, LAC1, MPD1, PLB1, and TEF1; GenBank accession nos. DQ861593–DQ861599) (5). Extensive molecular research showed that this isolate belonged to the highly virulent AFLP genotype 6A (VGIIa) of Cryptococcus gattii, which is the major genotype involved in the Vancouver Island C. gattii outbreak (1–4). All 7 sequenced genes had a complete match with the sequence types specific for isolates involved in the Vancouver Island outbreak (5). Thus, we conclude that the pathogen was acquired during the patient’s visit to Vancouver Island and imported to Denmark. The presence of 3 cryptococcal masses of more or less equal size suggests that the patient was exposed to a high concentration of infectious cells of C. gattii. The observed incubation time of 6 weeks is shorter than that was previously reported for infections related to the Vancouver Island outbreak (2–11 mo) (4). These observations, in combination with the absence of any known predisposing factor in this patient, such as smoking or treatment with corticosteroids, suggest that this specific AFLP6 genotype of C. gattii is highly virulent (4,5). This case suggests a potential risk of tourists acquiring cryptococcosis while visiting Vancouver Island. Therefore, we recommend tourists and medical staff of healthcare centers worldwide be alert for symptoms of cryptococcosis after travel to Vancouver Island.