[The first case of persistent vaginitis due to Aspergillus protuberus in an immunocompetent patient]

The vast majority of vaginal fungal infections are caused by Candida species. However, vaginitis cases caused by molds are extremely rare. Aspergillus protuberus is previously known as a member of Aspergillus section Versicolores which can cause opportunistic infections in immunocompromised patients, however it has recently been described as a seperate species. Although the members of Aspergillus section Versicolores have been isolated rarely in cases of pulmonary infections, eye infections, otomycosis, osteomyelitis and onycomycoses, to the best of our knowledge, there is no published case of human infection caused by A.protuberus. In this report, the first case of persistent vaginitis due to A.protuberus in an immunocompetent patient was presented. A 42-year-old female patient was admitted to our hospital with the complaints of pelvic pain, vaginal itching and discharge during one month. Her symptoms had been persistant despite of the miconazole nitrate and clotrimazole therapies for probable candidal vaginitis. Fungal structures such as branched, septate hyphae together with the conidial forms were seen in microscopic examination as in the cervical smear. Thereafter, a vaginal discharge sample was taken for microbiological evaluation and similar characteristics of fungal structures were observed in the microscopic examination as of cervical smear. Then, preliminary result was reported as Aspergillus spp. At the same time, the sample was plated on Sabouraud dextrose agar (SDA) in duplicate and incubated at room temperature and at 37°C. After 5 days, white, powdery and pure-looking fungal colonies were observed in SDA which was incubated at room temperature, while the other medium remained sterile. The culture was submitted to the CBS-KNAW Fungal Biodiversity Center for further characterization. Phenotypic identification showed that the isolated strain belonged to the Aspergillus section Versicolores. The strain was grown for 7 days on malt extract agar and then ITS regions were amplified and sequenced from isolated DNA for genomic characterization. The obtained sequences were compared with the NCBI database and internal databases of the CBS-KNAW Fungal Biodiversity Centre and confirmed as Aspergillus section Versicolores. As a result of recent changes in classification of fungi, analysis of partial β-tubulin and calmodulin sequences have also been used to obtain a detailed and precise characterization. Eventually, the strain has been identified as A.protuberus which is a recently accepted species distinct from Aspergillus section Versicolores. As the patient could not be contacted after the preliminary report, detailed demographical information, probable origin and route of transmission of the agent and prognosis of infection remained obscure. In conclusion, the first case of vaginitis caused by A.protuberus was described in this report with the support of clinical, pathological, microbiological and molecular data.