Phaeohyphomycosis caused by Exophiala moniliae

We studied two cases of phaeohyphomycosis that occurred in Japan. Histopathologic examination of biopsy material showed the presence of dematiaceous catenulate fungal cells and mycelium characteristic of phaeohyphomycosis. In detailed mycologic study of the two cultures isolated from the patients we found that both formed conidiogenous cells with proximal swellings with long, neck-like extensions bearing distinct annellations and clusters of conidia at their apices. The isolates were identified as Exophiala moniliae de Hoog. These two Japanese cases are the second and third known cases of phaeohyphomycosis caused by E. moniliae and the first recorded in that country.     

Cutaneous and Bone Marrow Histoplasmosis After 18 Years of Renal Allograft Transplant

The frequency of histoplasmosis among solid organ transplant (SOT) recipients appears to be low where there are only a few case series, mostly among renal and liver transplant recipients. Herein we report a case of a 44-year-old woman who underwent a living-related renal transplant 18 years prior to evaluation, developed a nodule after followed by ulceration upon her posterior right leg and a second one upon her left leg 3 months and 2 months before her hospitalisation, respectively. The biopsy of lesion revealed the presence of Histoplasma spp. Bone marrow aspiration was performed and also revealed the same organism. She had initially received itraconazole without improvement of lesions, while a new lesion appeared on her left arm. Healing of all lesions could be observed after 40 days of liposomal amphotericin B when she was submitted to skin grafts on the legs and a surgical treatment on the arms, and the myelosuppression improved simultaneously. Histoplasmosis seems to be very uncommon among patients who underwent to organ solid transplantation. Most cases occur within 12–18 months after transplantation, although unusual cases have been presented many years post-transplant. There are cases reported in the literature, occurring from 84 days to 18 years after organ transplantation, but without cutaneous involvement. Our patient developed lesions on limbs and myelosuppression after 18 years of chronic immunosuppression medication. This case suggests that besides cutaneous histoplasmosis is an uncommon infection following iatrogenic immunosuppression and even rarer over a long period after the transplantation. Clinicians who care SOT recipient patients must bear in mind histoplasmosis infection as differential diagnosis in any case of cutaneous injury with prolonged fever and try to use as many tools as possible to make the diagnosis, once this disease presents a good prognosis if it is diagnosed and treated promptly.     

Phaeohyphomycosis caused by Alternaria infectoria presenting as multiple vegetating lesions in a renal transplant patient

The genus Alternaria is one of the most common black moulds and appears to be increasing as a causative agent of subcutaneous phaeohyphomycosis, particularly among immunosuppressed patients. A 53-year-old patient who had received a kidney transplant presented with multiple verrucous lesions on the distal extremities. Positive histopathology and cultures, in addition to rDNA ITS region sequencing, identified the fungal isolate as Alternaria infectoria. Oral itraconazole was administered for 10 months. A follow-up at 15 months demonstrated no signs of infection. Clinical manifestations of cutaneous alternariosis vary significantly and only a few cases have been described in the literature. Although optimal treatment options remain controversial, this case of phaeohyphomycosis was successfully treated with itraconazole monotherapy.     

Exacerbated inflammatory reaction to <Emphasis Type="Italic">Trichophyton rubrum</Emphasis> infection on an HIV-positive patient successfully treated with fluconazole

A 33 year-old HIV-positive Brazilian female patient was diagnosed with a cutaneous inflammatory reaction on her left forearm. The lesion spread rapidly affecting most of her forearm. The clinical diagnosis of tinea corporis (ringworm) was confirmed by wet mount preparations on 20% KOH and by the isolation of Trichophyton rubrum on pure cultures. Treatment with Fluconazole for a period of four weeks successfully cured the infection.     

Successful Posaconazole Therapy of Disseminated Alternariosis due to <Emphasis Type="Italic">Alternaria infectoria</Emphasis> in a Heart Transplant Recipient

We report a case of phaeohyphomycosis caused by Alternaria infectoria in a 61-year-old heart transplant recipient with multiple skin lesions and pulmonary infiltrates. The infection spread via the haematogenous route from the primary cutaneous lesions into the lungs. The diagnosis was based on the histopathological examination, direct microscopy, skin lesion cultures and detection of Alternaria DNA in the bronchoalveolar lavage fluid using molecular methods. The treatment consisted of a combination of surgical excision and systemic antifungal therapy. Voriconazole was the first agent used but had a weak effect. Posaconazole was subsequently used to achieve a successful response. The isolate was identified as A. infectoria by sequencing of the rDNA ITS region and the partial β-tubulin gene.     

Chronic Disfiguring Facial Lesions in an Immunocompetent Patient Due to Exophiala spinifera: A Case Report and Review of Literature

Exophiala spinifera is a rare fungus causing chromoblastomycosis or different types of phaeohyphomycosis (cutaneous, subcutaneous, disseminated and cyst phaeohyphomycosis). We report a case of a young male with phaeohyphomycosis due to E. spinifera, who had multiple itchy painful papular lesions disfiguring his face for 4?years. His diagnosis was delayed and had received antibacterial and antileishmanial therapy elsewhere without any improvement. While he reported to our hospital, the histopathology of the biopsy collected from the lesion demonstrated acute on chronic inflammation with granuloma formation and darkly pigmented fungal elements. The isolate grown on culture was identified as E. spinifera on the basis of morphological characters. The identification of the isolate was further confirmed by sequencing of the ITS region of ribosomal DNA. After treatment with oral itraconazole, he had marked clinical improvement.     

Phialophora verrucosa-induced subcutaneous phaeohyphomycosis. Fine needle aspiration findings

A 34-year-old woman on immunosuppressive therapy presented with a subcutaneous, cystic lesion on the dorsum of the right foot. Cytologic examination of material obtained by fine needle aspiration (FNA) revealed a mixture of acute and granulomatous inflammation as well as brown-pigmented fungi in the form of budding yeast, pseudohyphae and septate hyphae. The findings suggested subcutaneous phaeohyphomycosis (phaeomycotic cyst). Culture grew Phialophora verrucosa. The cytologic, histologic and cultural findings are given. This case demonstrates that phaeohyphomycosis can be diagnosed by FNA but that fungal culture is necessary to establish the identity of the etiologic agent. This appears to be the first case of P. verrucosa-induced subcutaneous phaeohyphomycosis reported in the Western Hemisphere.     

Fine needle aspiration cytology diagnosis of cutaneous leishmaniasis in a 6-month-old child: a case report.

BACKGROUND: Skin biopsy and scrape smear examination are the two most commonly employed investigatory techniques in the diagnosis of cutaneous leishmaniasis. Although cases Leishmania lymphadenitis are reliably diagnosed with fine needle aspiration (FNA) cytology, it has not attained popularity in the diagnosis of cutaneous leishmaniasis, and only a few reports are available. CASE: A 6-month-old Kuwaiti child presented with a skin lesion on her left forearm of five months' duration. Both scrape smears and FNA were performed from the lesion. FNA cytology smears showed a rich population of inflammatory cells predominating in lymphocytes and histiocytes and epithelioid cell granulomas. The amastigote forms of Leishmania were noted on the smears. The scrape smears were nondiagnostic. CONCLUSION: FNA cytology can be reliably used in the diagnosis of cutaneous leishmaniasis, especially in dry lesions, where scrape smears are likely to be nondiagnostic.     

Fine needle aspiration cytology diagnosis of a cutaneous granular cell tumor in a 7-year-old child. A case report

BACKGROUND: Granular cell tumors are neoplasms of uncertain histogenesis, although a neural origin is favored. Most reports on the cytologic features of granular cell tumors have been on lesions from the breast or respiratory tract. However, there are only a few reports on fine needle aspiration (FNA) cytologic diagnosis of cutaneous or soft tissue granular cell tumors. CASE: A 7-year-old girl presented with a skin lesion on her right forearm of one year's duration. The FNA smears showed sheets and clusters of oval to polygonal cells with an abundant amount of granular cytoplasm. Many single, scattered cells with similar morphology were seen in the background. Immunostaining for S-100 protein showed granular cytoplasmic positivity. The tumor was diagnosed as a benign granular cell tumor. The histopathology report on the excised lesion confirmed the FNA diagnosis. CONCLUSION: The cytopathologic features of granular cell tumors presenting as skin lesions are distinctive enough to allow a correct diagnosis on FNA cytology.     

Tinea corporis due to Trichophyton rubrum in a Woman and Tinea capitis in her 15-Day-Old Baby: Molecular Evidence of Vertical Transmission

We report a case of a 40-year-old Caucasian woman who came under our observation with a 7-year history of a chronic erythematous scaly dermatitis, diagnosed as psoriasis, involving gluteal area and thighs, and treated with topical steroids without benefit. During pregnancy, a progressive worsening of her condition and an extension of cutaneous lesions were observed. Her newborn, a 15-day-old girl, presented a similar scaly and squamous lesion on her scalp. Mycological examination was positive for Trichophyton rubrum in both cases, and random amplified polymorphic DNA analysis confirmed the isogenicity of the two isolates. We performed a diagnosis of T. rubrum tinea corporis and tinea capitis. The case we describe illustrates an unusual clinical presentation of tinea corporis with remarkable extension of cutaneous lesions due to the diagnostic delay and the continuous use of local steroids, together with a rare tinea capitis in the newborn. Our experience highlights the possibility of mother-child transmission and the importance of an early diagnosis.     

Stereotactic biopsy and cytological diagnosis of solid and cystic intracranial lesions

Cytological smears from 115 consecutive cases of stereotactic biopsies of intracranial lesions were reviewed. Ninety-five lesions were solid and 20 cystic. Material from 90 solid and 13 cystic lesions was sent both for cytological and histological examination. In 66 of the solid lesions, the cytological diagnosis was confirmed by histology (five were benign lesions and 61 malignant tumours: 56 primary brain tumours, three metastases and two lymphomas). In 24 cases with discrepant cytology and histology, the histology was inconclusive or insufficient in 14 cases, while cytology established the diagnosis of astrocytoma grade II (seven cases), metastases (two cases), gliosis (one case) and benign (four cases). Necrosis of tumour type was observed cytologically in six patients representing glioblastoma (two cases), anaplastic astrocytoma (one case), lymphoma (one case) and normal brain (two cases) histologically. Three cases reported cytologically as benign were primary brain tumour (two cases) and gliosis (one case). One smear of a glioblastoma was insufficient for cytological diagnosis. Cystic lesions were cytologically benign in 17 cases and malignant in three cases. Histology from the cyst wall confirmed the malignant diagnosis in three cases and showed tumour in six more cases, a benign process (two cases), changes induced by radiotherapy for arteriovenous malformation (one case) and insufficient material (one case). In conclusion, cytology from solid brain lesion allows an accurate diagnosis and subtyping of tumours in a majority of cases, and can thus be used to choose type of therapy. In cystic brain tumours, however, examination of the cystic fluid, is often inconclusive and a biopsy from the cyst wall should be performed if there is clinical or radiological suspicion of tumour.     

Effects of 14 days of head-down tilt bed rest on cutaneous vasoconstrictor responses in humans.

This study tested the hypothesis that head-down tilt bed rest (HDBR) reduces adrenergic and nonadrenergic cutaneous vasoconstrictor responsiveness. Additionally, an exercise countermeasure group was included to identify whether exercise during bed rest might counteract any vasoconstrictor deficits that arose during HDBR. Twenty-two subjects underwent 14 days of strict 6 degrees HDBR. Eight of these 22 subjects did not exercise during HDBR, while 14 of these subjects exercised on a supine cycle ergometer for 90 min a day at 75% of pre-bed rest heart rate maximum. To assess alpha-adrenergic vasoconstrictor responsiveness, intradermal microdialysis was used to locally administer norepinephrine (NE), while forearm skin blood flow (SkBF; laser-Doppler flowmetry) was monitored over microdialysis membranes. Nonlinear regression modeling was used to identify the effective drug concentration that caused 50% of the cutaneous vasoconstrictor response (EC(50)) and minimum values from the SkBF-NE dose-response curves. In addition, the effects of HDBR on nonadrenergic cutaneous vasoconstriction were assessed via the venoarteriolar response of the forearm and leg. HDBR did not alter EC(50) or the magnitude of cutaneous vasoconstriction to exogenous NE administration regardless of whether the subjects exercised during HDBR. Moreover, HDBR did not alter the forearm venoarteriolar response in either the control or exercise groups during HDBR. However, HDBR significantly reduced the magnitude of cutaneous vasoconstriction due to the venoarteriolar response in the leg, and this response was similarly reduced in the exercise group. These data suggest that HDBR does not alter cutaneous vasoconstrictor responses to exogenous NE administration, whereas cutaneous vasoconstriction of the leg due to the venoarteriolar response is reduced after HDBR. It remains unclear whether attenuated venoarteriolar responses in the lower limbs contribute to reduced orthostatic tolerance after bed rest and spaceflight.     

Mixed Corticomedullary Carcinoma of the Adrenal Gland: A Case Report

ObjectiveTo report the case of a 78-year-old woman with mixed corticomedullary carcinoma of the adrenal gland, and to review other reported lesions that exhibit clinical and/or histopathologic features of both adrenal cortical and medullary differentiation.MethodsWe describe the patient’s clinical findings and laboratory test results, as well as the gross and histopathologic features of her tumor. We also review the literature pertaining to mixed corticomedullary adenomas and cortical tumors with clinical features of pheochromocytoma, and vice versa.ResultsA 78-year-old woman with a 10-cm left adrenal mass was hospitalized for management of hypertensiveurgency. Laboratory workup revealed elevated urinary metanephrine excretion and elevated serum dehydroepiandrosterone sulfate levels. She underwent left adrenalectomy. Pathologic examination of the lesion showed mixed cortical and medullary histologic characteristics, as well as gross and microscopic evidence of malignancy. Including the present case, we identified 17 cases of neoplasms that exhibit features of mixed corticomedullary differentiation.ConclusionsThis report represents the first documented case of mixed corticomedullary carcinoma. Several benign lesions combine clinical, biochemical, and/or histopathologic evidence of both adrenal cortical and medullary differentiation, including mixed corticomedullary adenomas and corticotropin-secreting pheochromocytomas. The differential diagnosis of a lesion with mixed cortical and medullary features should also include a malignant neoplasm. (Endocr Pract. 2012;18:e37-e42)     

Cutaneous B-cell lymphoma in a Perdido Key Beach mouse (Peromyscus poliontus trissyllepsis)

The Perdido Key beach mouse (Peromyscus poliontus trissyllepsis) is an endangered mammal indigenous to the panhandle beaches of Northwest Florida. A captive 3.5-y-old female mouse was evaluated because of severe pruritus, diffuse alopecia, skin reddening, and ulcerations over the dorsum of her body. Initial skin biopsy of the affected area suggested bacterial dermatitis but was inconclusive. Despite empiric antibiotic, anthelmintic, and antihistamine treatments, she continued to decline and developed severe ulcerations over the majority of her body. Postmortem histopathologic evaluation led to a tentative diagnosis of epitheliotropic lymphoma, suggestive of a mycosis fungoides T-cell-type cutaneous lymphoma. However, immunohistochemistry results challenged this diagnosis, indicating that the lesion was actually an epidermotropic B-cell lymphoma. Spontaneous cutaneous B-cell lymphomas are rare in rodents and had not previously been reported to occur in Perdido Key beach mice. This case report provides initial evidence that the Perdido Key beach mouse is susceptible to cutaneous B-cell lymphoma.     

Poroid hidradenoma. Report of a case with cytologic findings on fine needle aspiration.

BACKGROUND: Fine needle aspiration cytology (FNAC) can be used for establishing a diagnosis of cutaneous lesions, especially in cases with cyst formation. Poroid hidradenoma is eccrine neoplasm with both solid and cystic components. CASE: A 77-year-old female presented with a slightly elevated nodule in the skin on her left elbow. The tumor was well demarcated, 2.7 x 2.4 cm and soft, and overlying skin was slightly reddish. FNAC revealed two types of cell: one had abundant cytoplasm in which small to large, occasionally multinucleated nuclei with small but distinct nucleoli were evident. Chromatin was finely granular, and nuclear membrane was thin and almost smooth. Another type of cell had scanty cytoplasm and a round to oval nucleus with small but prominent nucleoli. Histologic diagnosis was poroid hidradenoma. CONCLUSION: FNAC can be useful for diagnosing intradermal cystic lesions before surgical resection.     

Disseminated cutaneous and vascular invasion byFusarium moniliforme in a fatal case of acute lymphocytic leukemia

A 35 year old female patient with acute lymphocytic leukemia developed fusariosis in which dissemination appeared to be limited to cutaneous and vascular invasion. The first evidence of fungemia occurred nearly seven months after initial hospitalization. The fungus was identified asFusarium sp. and was considered a contaminant. Two weeks later blood cultures were again positive forFusarium sp. and the patient was placed on amphotericin B and 5-fluorocytosine therapy. The following day developing lesions were noted on her forearms and face; lesions ultimately spread to her trunk, abdomen, and lower extremities. Skin lesion biopsy sections revealed abundant septate and branching hyphae throughout the dermis and within capillaries. Twenty-six days after the initial isolation the patient died. Post-mortem blood cultures gave rise to the same fungus, which was identified asFusarium monoliforme. Postmortem cultures and stains of spleen, liver, lung, and brain specimens were all negative for fungi. The primary source and portal of entry of the organism remained undetermined.     

Further observations on clinical, histopathological, and immunological features of borderline disseminated cutaneous leishmaniasis caused by Leishmania (Leishmania) amazonensis

Leishmania (Leishmania) amazonensis has for some time been considered as the causative agent of two distinct forms of American cutaneous leishmaniasis (ACL): localized cutaneous leishmaniasis (LCL), and anergic diffuse cutaneous leishmaniasis (ADCL). Recently, a new intermediate form of disease, borderline disseminated cutaneous leishmaniasis (BDCL), was introduced into the clinical spectrum of ACL caused by this parasite, and in this paper we record the clinical, histopathological, and immunological features of eight more BDCL patients from Brazilian Amazonia, who acquired the disease in the Pará state, North Brazil. Seven of them had infections of one to two years' evolution and presented with primary skin lesions and the occurrence of metastases at periods varying from six to 12 months following appearance of the first lesion. Primary skin lesions ranged from 1-3 in number, and all had the aspect of an erythematous, infiltrated plaque, variously located on the head, arms or legs. There was lymphatic dissemination of infection, with lymph node enlargement in seven of the cases, and the delayed hypersensitivity skin-test (DTH) was negative in all eight patients prior to their treatment. After that, there was a conversion of DTH to positive in five cases re-examined. The major histopathological feature was a dermal mononuclear infiltration, with a predominance of heavily parasitized and vacuolated macrophages, together with lymphocytes and plasma cells. In one case, with similar histopathology, the patient had acquired his infection seven years previously and he presented with the largest number of disseminated cutaneous lesions. BDCL shows clinical and histopathological features which are different from those of both LCL and ADCL, and there is a good prognosis of cure which is generally not so in the case of frank ADCL.     

Cytology of primary cutaneous Langerhans cell histiocytosis with a malignant phenotype. A case report

BACKGROUND: Langerhans cell histiocytosis (LCH) is a proliferative disorder of Langerhans cells, but the nature of LCH, whether reactive, benign, or malignant and neoplastic, is controversial. We encountered a case of LCH showing a malignant phenotype initially localized in the skin of an elderly woman. Since there is no other report on the cytologic appearance of primary cutaneous LCH or on LCH with a malignant phenotype, we compared the cytologic features of this case with those of benign cases at other sites reported in the literature. CASE: A 74-year-old woman presented with a gradually enlarging and partially ulcerated skin lesion expanding both sides of her right hand. On histologic and ultrastructural analyses of surgically resected tissue, we diagnosed the lesion as Langerhans cell histiocytosis originating in the skin. Although the patient had no recurrence or metastases for six months after surgical resection of the primary skin lesion and radiation therapy, the tumor extended multisystemically, and the patient died of multiple organ failure 14 months after the initial diagnosis. CONCLUSION: Imprint and scrape cytology of multiple skin lesions six months after surgery was useful in immediately diagnosing the recurrent LCH. The tumor cells had indented, twisted or grooved nuclei, and some had intranuclear inclusions. Immunocytochemically the cells were positive for CD1a and S-100 protein. Numerous eosinophils were seen in the background.     

Cutaneous herpesvirus infection in a mallard duck (Anas platyrhynchos)

Investigations of mortalities involving wild mallard ducks (Anas platyrhynchos) revealed the presence of a herpesvirus associated with skin lesions on the plantar surface of the foot web of one duck. Ultrastructurally, the paracrystalline arrays of viral core particles and unencapsidated nucleoids in the nucleus, and the enveloped viruses in cytoplasmic vacuoles are compatible with a herpesvirus. This appears to be the first report of cutaneous lesions in a mallard duck attributable to a herpesvirus. Whether this lesion is due to duck virus enteritis (DVE), suggesting that cutaneous shedding is possible, or due to another uncharacterized herpesvirus of ducks is unclear.     

Recalcitrant Primary Subcutaneous Phaeohyphomycosis Due to Phialophora verrucosa

Phialophora verrucosa has rarely been reported for causing phaeohyphomycosis, which tends to occur in immunocompromised individuals. The case of primary subcutaneous phaeohyphomycosis due to P. verrucosa in an otherwise healthy Chinese female is presented. The girl presented with asymptomatic skin lesions when she was only 16 year old. Histological examinations revealed multiple dematiceous hyphael elements in the dermis and subcutaneous tissues. Fungal cultures were identified as P. verrucosa repeatedly based on the morphological features and confirmed by the internal transcribed spacer region nucleotide sequencing. The infection was so extremely recalcitrant that prolonged systemic antifungal regimens for 12 years revealed limited effect. The skin lesions slowly progressed and caused marked disfigurement despite the encouraging results of in vitro susceptibility. However, no relevant side effects have been reported in the course, and the patient gave birth to a healthy baby while under the maintenance treatment of itraconazole and terbinafine. This case is special in terms of the early onset, the rare clinical aspect of the pathogen, the discrepancy between in vitro and in vivo antifungal activities and especially the prolonged and recalcitrant course in such an otherwise healthy host.