Hindawi Publishing Corporation
Interdisciplinary Perspectives on Infectious Diseases
Volume 2012, Article ID 465717, 7 pages
Epidemiologyof Rhodotorula: AnEmergingPathogen
Section of Infectious Diseases, Hospital de Cl´ ınicas de Porto Alegre, Universidade Federal do Rio Grande do Sul Ramiro Barcelos 2350,
90640-002 Porto Alegre, RS, Brazil
Correspondence should be addressed to Luciano Z. Goldani, email@example.com
Received 7 August 2012; Accepted 7 September 2012
Academic Editor: Mary E. Marquart
Copyright © 2012 F. Wirth and L. Z. Goldani. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
Previously considered nonpathogenic, Rhodotorula species have emerged as opportunistic pathogens that have the ability to
colonise and infect susceptible patients. Rhodotorula species are ubiquitous saprophytic yeasts that can be recovered from many
environmental sources. Several authors describe the isolation of this fungus from different ecosystems, including sites with
unfavourable conditions. Compared to R. mucilaginosa, R. glutinis and R. minuta are less frequently isolated from natural
environments. Among the few references to the pathogenicity of Rhodotorula spp. in animals, there are several reports of an
outbreak of skin infections in chickens and sea animals and lung infections and otitis in sheep and cattle. Most of the cases of
infection due to Rhodotorula in humans were fungemia associated with central venous catheter (CVC) use. The most common
underlying diseases included solid and haematologic malignancies in patients who were receiving corticosteroids and cytotoxic
drugs, the presence of CVC, and the use of broad-spectrum antibiotics. Unlike fungemia, some of the other localised infections
caused by Rhodotorula, including meningeal, skin, ocular, peritoneal, and prosthetic joint infections, are not necessarily linked to
the use of CVCs or immunosuppression.
Rhodotorula is a common environmental yeast that is
found in air, soil, lakes, ocean water, milk, and fruit juice.
Rhodotorula species, part of the Basidiomycota phylum,
colonise plants, humans, and other mammals. The genus
Rhodotorula includes eight species, of which R. mucilaginosa,
R. glutinis, and R. minuta are known to cause disease in
humans . Rhodotorula produces pink to red colonies
and blastoconidia that are unicellular lacking pseudohyphae
and hyphae. Several authors have isolated Rhodotorula in
different ecosystems and environments as well as described
infections in animals. Rhodotorula spp. have been recognised
as emerging yeast pathogens in humans in the last two
decades. While no cases of Rhodotorula infection were
reported in the medical literature before 1985, the number
of infections increased after that time, most likely because
of the wider use of intensive treatments and central venous
catheters (CVCs) .
This is an updated concise paper focusing on the general
epidemiological aspects of Rhodotorula in humans, animals,
and the environment.
2.Rhodotorula inthe Environment
Rhodotorula species are ubiquitous saprophytic yeasts that
can be recovered from many environmental sources. This
yeast has a strong affinity for plastic, having been isolated
from various medical equipments, such as dialysis equip-
ment, fibre-optic bronchoscopes, and other environmental
sources, including shower curtains, bathtubs, and tooth-
Several authors describe the isolation of this fungus from
different ecosystems, including sites with unfavourable con-
ditions, such as the depths of the Baltic Sea, the high-altitude
Lake Patagonia, the soil and vegetation of Antarctica and
2Interdisciplinary Perspectives on Infectious Diseases
aquatic, hypersaline, and high-temperature environments
such as the Dead Sea (Israel), Lake Enriquillo (Dominican
Republic), the Great Salt Lake (USA), and beaches located
in northern Brazil. In this study, R. mucilaginosa was the
third most isolated yeast in seawater. Two other studies have
reported the occurrence of Rhodotorula species in marine
waters polluted by household waste [6–10].
R. mucilaginosa is commonly isolated from foods and
beverages. Several studies have reported the presence of R.
mucilaginosa in peanuts, apple cider, cherries, fresh fruits,
fruit juice, cheese, sausages, edible molluscs, and crustaceans
[11–17]. Although the consumption of food contaminated
infections, there is growing concern that food may be an
underestimated source of environmental pathogens .
Compared to R. mucilaginosa, R. glutinis and R. minuta
are less frequently isolated in natural environments. These
species have been detected in air, seawater (including
deep environments), freshwater, and goat’s milk [19–21].
Environmental studies have documented the presence of
Rhodotorula sp. in tropical fruits, sugar cane, and shrimp
in the waters of Sepetiba Bay in Brazil [22–24]. Toms´ ıkov´ a
reported, Rhodotorula sp. contamination of food that is
provided to immunocompromised patients in hospitals.
. In addition, environmental monitoring of yeasts in
specific areas of two tertiary local hospitals revealed the
Rhodotorula in the hospital environment, patients who have
a depressed immune system can develop Rhodotorulosis,
causing a variety of systemic infections. In fact, Rhodotorula
spp. is the most common microorganism isolated from
the hands of hospital employees and patients . Further
studies are needed to clarify the role of food contamination
by Rhodotorula and the development of opportunistic fungal
infections. These future studies should focus on the survival
and growth of Rhodotorula in the gastrointestinal system
and its potential ability to transfer from the gastrointestinal
tract to bloodstream and should seek to better understand
the ecology of Rhodotorula in hospitals and healthcare envi-
ronments . In this aspect, Rhodotorula spp. have been
isolated from stool samples, indicating that these yeasts can
and it is still uncertain whether Rhodotorula is capable of
passing from the gastrointestinal tract into the bloodstream
Among the few references about the pathogenicity of
Rhodotorula spp. in animals, there are several reports of
an outbreak of skin infections in chickens and a report of
a lung infection in sheep, both caused by R. mucilaginosa
[31, 32]. Rhodotorula was reported as the causative agent of
epididymitis, skin lesions in a sea lion, and dermatitis in a cat
that had crusted lesions and mastitis [33–36]. Interestingly,
this fungus can also be found in pools where sea animals
are kept in captivity . Duarte et al. have shown the
presence of fungi in the ear canal of 45 cattle with external
parasitic otitis. The 45 cultures in Sabouraud dextrose
medium revealed the growth of the genus Malassezia in 31
(68.9%) of the 45 cultures, seven (15.5%) yeasts of the genus
Candida, five (11.1%) R. mucilaginosa, and two (4.4%) fungi
Rhodotorula genus as a colonising agent in the oropharynx
and cloaca of ostriches, in faecal samples and the cloaca
of wild birds and pigeons in urban and suburban areas, in
the ear canals of adult cattle with parasitic otitis, in healthy
rhesus monkeys, genital tract of healthy female camels, and
in healthy cats [39–44].
Animal models have been used to study the mechanisms
of pathogenesis of different human fungal diseases. Recently,
Wirth and Goldani conducted the first experimental study
in an animal model of disseminated Rhodotorula infection
described in the literature . Organs such as lungs,
spleen, and especially the liver were the most affected organs
presented severe degree of infection. Considering that the
animals were highly immunocompromised, histopathology
of the involved organs revealed few epitelioidcellsand multi-
nuclear giant cells in association with abundant yeast forms
with occasional granuloma formation.
Previously considered nonpathogenic, Rhodotorula species
have emerged as opportunistic pathogens with the ability
to colonise and infect susceptible patients. Recent studies
have demonstrated that the incidence of fungemia caused
by Rhodotorula was between 0.5% and 2.3% in the USA
[46, 47] and Europe . Most cases of infection with
Rhodotorula fungemia are associated with central catheters
in patients with haematologic malignancies. [46, 47, 49–52].
Considering that Rhodotorula is an ubiquitous and sapro-
phytic fungus, the isolation of Rhodotorula from nonsterile
human sites, especially from the mucous membranes, has
often been of questionable clinical significance. Localised
infections without fungemia including endophthalmitis,
onychomycosis, meningitis, prosthetic joint infections, and
peritonitis (usually associated with continuous peritoneal
dialysis) have been reported in immunocompromised and
The first report of fungemia caused by Rhodotorula
was made by Louria et al. in 1960 . Subsequently, an
increasing number of cases have been published, especially
in the last two decades. However, this increase may be
a publication bias after recognition of Rhodotorula as a
pathogen . Another possible explanation is the dramatic
medicine and transplantation.
From 1970 until 1985, no cases of Rhodotorula infection
were reported in haematological patients, but the number
of cases of Rhodotorula infection in these patients increased
after 1985. The increase of Rhodotorula fungemia related to
catheters was associated with an increase of more aggressive
treatment modalities, which include intensive care units
admissions, use of central venous catheters, short- and
long-term parenteral nutrition, broad-spectrum antibiotics,
organ transplants, and chemotherapy . Most of cases
reported in the literature date back to after 1994, when CVCs
and intensive therapies were widely available. Table 1 shows
Interdisciplinary Perspectives on Infectious Diseases3
Table 1: Summary of reports of Rhodotorula fungemia (2000–2011).
Number of described cases
Hematological-solid malignanciesR. mucilaginosa
R. glutinis/R. mucilaginosa
10SBD; LT; AIDS
Hematological-solid malignancies; LC; SCA; SBD; CLD
Lymphoma; solid tumor
Acute myeloid leukemia
Acute myeloid leukemia
Broad spectrum antibiotics
Systemic lupus erythematous
Solid organ transplant
Acute lymphoid leukemia
Multiple abdominal surgeries; ovarian cancer; bowel necrosis
SCA: sickle cell anemia; SOT: solid organ transplant.
a summary of reported cases of fungemia related to CVC
use between 2000 and 2011 [46–68]. In all cases listed, the
patients were using CVC, short- or long-term CAPD, and
umbilical catheter. Zaas et al.  published a large number
of cases of CVC-related fungemia by Rhodotorula spp. that
occurred in a USA hospital . The most prevalent species
was R. mucilaginosa, followed by R. glutinis. Most of the
patients had an underlying disease, such as congenital heart
disease, AIDS, cancer, or chronic intestinal disease, and two
patients were transplant recipients (one lung and one bone
marrow). Two patients were neutropenic at the time of the
development of fungemia, and five patients were receiving
parenteral nutrition. All the patients received antifungal
treatment. Only in three patients the CVC was not removed.
There were no reports of death or relapse of infection.
Perniola et al.  reported four cases of CVC-related
fungemia by R. mucilaginosa in a neonatal intensive care
unit (NICU) in an Italian hospital . All the newborns
infected with fungemia by R. mucilaginosa were premature;
three had bacteremia prior to fungemia, and 3 received
prophylactic fluconazole. All 4 neonates had venous access
(a CVC, an umbilical venous catheter, or both) since birth,
but early removal or replacement of the catheter followed
by confirmation of sepsis by R. mucilaginosa was possible
in only two newborns. Blood cultures performed at the end
of antifungal therapy were negative. Another retrospective
study reviewed the demographics, risk factors, treatment,
and outcome of seven patients with Rhodotorula fungemia
over the years from 2002 to 2005 in a Brazilian hospital .
Risk factors included solid and haematologic malignancies
in patients who were receiving corticosteroids and cytotoxic
drugs, the presence of CVCs, and the use of broad-spectrum
antibiotics. Three of the seven patients died, with an overall
mortality rate of 42%. The result was favourable for patients
who had just had the CVC removed. Duboc de Almeida et al.
described 25 cases of fungemia by R. Mucilaginosa . The
majority of patients had a CVC, and 10 patients (40%) had
undergone bone marrow transplantation. Amphotericin B
deoxycholate was the most commonly antifungal used, and
the CVC was removed in 89.5% of patients. Four (17%)
patients died .
In a recent paper covering the cases of fungemia by
Rhodotorula spp. associated with catheters between the years
1966 and 2006, Tuon et al. analysed 66 patients with
Rhodotorula fungemia. R. mucilaginosa was responsible for
most of the cases, followed by R. glutinis . The most
prevalent underlying diseases were haematologic malignan-
and gastrointestinal disorders as well as the use of CVCs
for parenteral nutrition were also considered predisposing
A recent literature review published in 2010 by Garc´ ıa-
Su´ arez et al. analysed 29 cases of Rhodotorula fungemia
in patients with haematological disorders . This study
showed that 100% of patients who developed fungemia
by Rhodotorula had some form of central venous access,
such as a Hickman catheter. In 2008, Tuon and Costa
performed the first systematic review of infections caused
4Interdisciplinary Perspectives on Infectious Diseases
Table 2: Summary of reports of Rhodotorula infections other than fungemia from 2000 to 2011.
HIV; HCV; NU
HIV, SOT; chronic renal failure
Oral ulcers, dermatitis
Arotic homograft endocarditis
R. rubra; R. minuta
R. rubra; R. glutinis; R. mucilaginosa
R. mucilaginosa; R. minuta
HCV: chronic hepatitis C; NU: no underlying disease described; SOT: solid organ transplant.
by Rhodotorula in 128 patients . The authors analysed
all papers about Rhodotorula infections published until
January 2006 . The most common Rhodotorula species
found by the authors was R. mucilaginosa, followed by
R. glutinis and R. minuta. Immunosuppression was found
in 40% of patients, and the most common underlying
condition associated with Rhodotorula infection was the use
of CVCs. In a recent paper, Spiliopoulou et al. described a
patient who developed Rhodotorula fungemia in an intensive
care unit. The authors reviewed the risk factors associated
with the development of disseminated Rhodotorula infection
published in several reports including presence of central
venous catheters, solid organ neoplasm, abdominal surgery,
and administration of antibiotics. In addition, the authors
pointed out that Rhodotorula is reliably resistant to flucona-
zole and echinocandins . On the other hand, in vitro
susceptibility studies revealed that Rhodotorula is generally
susceptible to amphotericin B and flucytosine.
Unlike fungemia, some of the other infections caused
by Rhodotorula were not necessarily linked to the use of
CVCs or an underlying disease. Table 2 lists a summary of
cases of localized Rhodotorula infection that did not cause
fungemia occurring between the years 2000 and 2011 [70–
90]. Meningitis and endophthalmitis by Rhodotorula species
have been reported as nosocomial infections especially in
human immunodeficiency virus- (HIV-) infected persons
[70–78]. Prosthetic joint infections caused by Rhodotorula
sp. have been reported in an HIV-infected patient and
patients without any known immunosuppression [79–81].
Goyal et al. described a case of infection caused by R.
mucilaginosa that had been unionised as a fracture of the
femur (the femoral nonunion). The patient was treated with
amphotericin B and required a bone graft . Savini et al.
reported a similar case, but the patient was seropositive
for HIV and had fractured their left femur . The
infection manifested as a chronic coxitis after the patient
had undergone surgery for internal fixation. Antifungal
therapy was performed using liposomal amphotericin B,
which eradicated the infection, and a surgical replacement
of the femoral prosthesis was indicated. Peritonitis caused
Rhodotorula species which have been reported in patients
undergoing continuous ambulatory peritoneal dialysis [82–
86]. Most of the patients were successfully treated with
The first case of onychomycosis caused by R. mucilagi-
nosa was described by Cunha et al., which shows that these
yeasts should also be considered as primary agents that
can cause opportunistic onychomycosis . The patient
was immunocompetent, and the onychomycosis affected
the nail of the hallux. In addition to aortic homograft
endocarditis, dermatitis, oral ulcers, and lymphadenitis
Rhodotorula species are ubiquitous saprophytic yeasts that
can be recovered from many environmental sources. R.
mucilaginosa is commonly isolated in foods and beverages.
Several studies have reported the presence of R. mucilagi-
nosa in peanuts, apple cider, cherries, fresh fruits, fruit
juice, cheese, sausages, edible molluscs, and crustaceans.
Rhodotorula was reported as the causative agent in some
papers, including dermatitis in sea lions, chickens, and cats,
can also be found in pools where sea animals are kept in
captivity. Previously considered nonpathogenic, Rhodotorula
species have emerged as opportunistic pathogens with
the ability to colonise and infect susceptible patients.
Rhodotorula in humans primarily cause bloodstream infec-
tions that are associated with central venous catheter (CVC)
use. Risk factors include solid and haematologic malignan-
cies in patients who receive corticosteroids and cytotoxic
drugs, the presence of CVCs, and the use of broad-spectrum
antibiotics. Unlike fungemia, localised infections caused by
Rhodotorula, including skin, ocular, meningeal, prosthetic
joint, and peritoneal infections, are not necessarily linked to
the use of CVCs or an immunosuppression.
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