Cutaneous Hyalohyphomycosis Caused by <Emphasis Type="Italic">Paecilomyces lilacinus</Emphasis> Successfully Treated by Oral Voriconazole and Nystatin Packing

Paecilomyces lilacinus causes multiple diseases in humans, especially in immunocompromised patients. Cutaneous infections are the second most commonly encountered circumstance. We describe a woman with liver cirrhosis with hemorrhagic, bullous, ulcerative leg lesions caused by Paecilomyces lilacinus. The lesions improved after treatment with oral voriconazole and topical nystatin powder. We also reviewed previously reported cases of cutaneous P. lilacinus infection that were treated by oral voriconazole.     

Use of Voriconazole for the Treatment of Paecilomyces lilacinus Cutaneous Infections: Case Presentation and Review of Published Literature

The fungus Paecilomyces lilacinus is a rare but emerging pathogen that causes severe human infections, especially in immunocompromised hosts. It is an important organism to identify due to its poor susceptibility to conventional antifungal drugs, including amphotericin B, itraconazole, and fluconazole. Oculomycosis and cutaneous infections are the two most common manifestations of P. lilacinus infections. Voriconazole has been used successfully to treat P. lilacinus endophthalmitis, but reports of skin and soft tissue infections treated with voriconazole are limited to six prior publications. Our immunocompromised patient had a subcutaneous P. lilacinus infection successfully treated with 3 months of voriconazole therapy.     

Primary Cutaneous Mucormycosis Presenting as a Giant Plaque: Uncommon Presentation of a Rare Mycosis

Mucormycosis is an uncommon opportunistic fungal infection caused by Zygomycetes. It usually affects immunocompromised, diabetic and trauma patients with infected wounds. We report a case of disseminated infection secondary to facial cutaneous mucormycosis caused by Saksenaea vasiformis in a diabetic patient who had a farming accident causing him severe head injury. The patient was treated with a combination of surgical debridement and antifungal therapy with liposomal amphotericin B, but he had a slow and fatal outcome. In cases of tissue necrosis following trauma involving wound contact with soil (i.e., potential fungal contamination), testing for the presence of Zygomycetes fungi such as S. vasiformis in both immunocompetent and immunocompromised patients is crucial. The reason is that this infection usually has a rapid progression and may be fatal if appropriate treatment is not administered.     

Isolated Cutaneous Granuloma Caused by <Emphasis Type="Italic">Candida glabrata</Emphasis>: A Rare Case Report and Literature Review

The incidence of candidiasis due to non-albicans Candida species (especially Candida glabrata) has significantly increased in recent decades. Candida glabrata often invades immunocompromised hosts and causes systemic or mucosal infections, whereas cutaneous infections are rarely reported. We present a rare case of cutaneous infection caused by C. glabrata and review all similar cases available in the PubMed database. A patient was admitted to the hospital with a 2-month history of a plaque on the face. Histopathological examination displayed typical infectious granulomas in the deep dermis, and the pathogen was finally confirmed as C. glabrata using a series of microbial examinations (fungal culture, biochemical test, and PCR-directed sequencing). The patient was completely cured after 4 months of treatment with oral itraconazole combined with topical terbinafine. We reviewed similar reports of cutaneous infection caused by C. glabrata. All the data suggested that an accurate diagnosis of cutaneous candidiasis depends mainly on histological and fungal examinations, especially molecular biological assays. Antifungal agents based on microbial susceptibility tests are the first-line treatment choice for C. glabrata infection, but the prognosis might be more dependent on the basic condition of the host.     

Successful treatment of antifungal- and cryotherapy-resistant subcutaneous hyalohyphomycosis in an immunocompetent case with topical 5% imiquimod cream

Hyalohyphomycosis is an unusual opportunistic mycotic infection where the tissue morphology of the causative organism is mycelial. Etiological agents, which are not responsible for the otherwise-named infections like aspergillosis, are the species of non-dematiaceous hyaline hyphomycetes including Penicillium, Paecilomyces, Acremonium (formerly known Cephalosporium), Beauveria, Fusarium, and Scopulariopsis. Several cases of Acremonium infection have been described in immunocompromised patients; however it can cause invasive disease in an immunocompetent person very rarely. Optimum therapy of Acremonium infection is unclear because of the limited number of reported cases and conflicting results of therapies. Imiquimod, an imidazoquinoline with potent antiviral, antitumor and immunoregulatory properties, is currently approved for the topical treatment of external anogenital warts and actinic keratosis. Imiquimod has also been found to be effective for other virus-associated dermatologic lesions, including common and flat warts, molluscum contagiosum, and herpes simplex virus type-2 as well as for some cases of cutaneous leishmaniasis. We report herein, for the first time, a case of unusually recalcitrant hyalohyphomycosis of the face due to Acremonium strictum successfully treated with topical 5% imiquimod in an immunocompetent patient, who had failed to respond to various antifungals, including itraconazole, and cryotherapy.     

Multiple Bilateral Pulmonary “Fungus Balls” in an Immunocompetent Patient Unsuitable for Surgical Treatment: Efficacy of Azoles Treatment

Data guiding management of pulmonary mycetomas are based on uncontrolled trials and case reports. Surgical resection represents a definitive treatment associated with high mortality and sometimes not feasible due to clinical conditions. We report a case of an immunocompetent patient with multiple pulmonary mycetomas, suggestive for probable chronic aspergillosis, in which surgery was contraindicated. The patient experienced a good response to long-term oral voriconazole therapy with remarkable clinical and radiological improvement at three-month follow-up. In cases of probable chronic aspergillomas, when surgery is contraindicated, long-term antifungal therapy with voriconazole seems to be a valid alternative option.     

Acremonium strictum: Report of a Rare Emerging Agent of Cutaneous Hyalohyphomycosis with Review of Literatures

We present a case of cutaneous hyalohyphomycosis due to Acremonium strictum in an immunocompetent individual along with an overview of fungal infections caused by A. strictum. The diagnosis was confirmed by the presence of hyphae in microscopic examination of cutaneous biopsy and discharge, positive culture for A. strictum and sequencing of the isolate at reference centre. The infection resolved with itraconazole and terbinafine. Cutaneous or subcutaneous infections of A. strictum have rarely been reported. Fungemia or disseminated infection often with fatal outcome in immunocompromised patients was the most common presentation of A. strictum infection found in the literatures. The studies also reveal worldwide variation in the treatment regime and outcome of the treatment.     

Non-Healing Ulcer Due to Trichosporon loubieri in an Immunocompetent Host and Review of Published Reports

We report here a case of non-healing ulcer due to Trichosporon loubieri in an apparently immunocompetent female. The identity of isolate was confirmed by DNA sequencing of D1/D2 region of 26S rDNA. The minimum inhibitory concentrations of the isolate were amphotericin B—0.5 μg/ml; fluconazole—4 μg/ml; posaconazole—0.25 μg/ml; voriconazole—0.06 μg/ml. The patient was managed by extensive debridement and oral fluconazole 150 mg daily for 6 weeks. She responded to therapy. To the best of our knowledge, till date, this is the fourth report of human infection due to T. loubieri and the first of its kind in an immunocompetent host. A review of published literature on infections due to T. loubieri is also included.     

Human Cutaneous Protothecosis: A Case Report and Review of Cases from Mainland China,Hong Kong,and Taiwan

We present a case of cutaneous protothecosis caused by Prototheca wickerhamii infection. The patient was a 72-year-old man with hypoalbuminemia. He responded well to fluconazole treatment. We reviewed this case along with 17 other cases of cutaneous protothecosis reported from mainland China, Hong Kong, and Taiwan. Of the 18 cases, 7 each occurred in mainland China and Taiwan, and 4 occurred in Hong Kong. Thirteen cases were caused by P. wickerhamii (72.2%), and three were caused by P. zopfii (16.7%); in two cases, the species was not identified (11.1%). In all, 9 (50%) patients were immunocompromised, and 10 (55.5%) patients denied having a history of trauma. All patients presented with polymorphic skin lesions, and erythematous papules, plaques, or nodules was the most common presentation (15/18, 83.3%). Genotyping was performed in five cases, mostly by means of small subunit ribosomal DNA amplification (four cases). Susceptibility tests (6 patients) showed that P. wickerhamii was sensitive to amphotericin B and voriconazole but resistant to fluconazole or itraconazole. Treatment succeeded in 15 (83.3%) patients and failed in 3 (16.7%). Our data indicate that the number of cutaneous protothecosis cases is underestimated in China, and the skin lesions have some diagnostic value.     

Fusarium Nail and Skin Infection: A Report of Eight Cases from Natal, Brazil

Fusarium spp. are non-dermatophytic hyaline moulds distributed worldwide and recovered from the nature as soil saprophytes and plant pathogens. Human infections are usually precipitated by local or systemic predisposing factors and disseminated infection is associated with impaired immune responses. We report eight cases of cutaneous lesions caused by Fusarium spp. All patients were immunocompetent. Seven cases with presented onychomycosis and one patient with interdigital intertrigo. It is important to alert the medical community about the relevance of the opportunistic fungi, such as Fusarium spp., which have emerged as human infectious agents, emphasizing the importance of correct etiological identification, allowing for appropriate treatment.     

Primary Cutaneous Mucormycosis Caused by <Emphasis Type="Italic">Rhizomucor variabilis</Emphasis> in an Immunocompetent Patient

Primary cutaneous mucormycosis is an uncommon disease and occurs mainly in patients with immunocompromised disorders. We report a case of cutaneous mucormycosis in an immunocompetent man in whom no definite precipitating factors were noted. The isolate was identified as Rhizomucor variabilis according to the fungus morphology and DNA sequencing results. The lesion was successfully treated with oral Itraconazole, although the in vitro drug-susceptibility test showed resistance.     

Rare Invasive Fungal Infections: Epidemiology, Diagnosis and Management

Rare yeast and filamentous fungi belonging to hyalohyphomycetes (e.g., Scedosporium, Fusarium), zygomycetes and dematiaceous (e.g., Alternaria, Bipolaris) are implicated in human infections ranging from colonization and localized infections in immunocompetent individuals to fungemias and disseminated diseases in immunocompromised patients and accounting <10 % of all isolated fungal pathogens. The diagnosis of yeast, Fusarium and Scedosporium infections is based on blood cultures and of filamentous fungal infections on histopathology, direct microscopy and culture of infected tissues. The panfungal marker 1,3-b-D glucan test as well as cross reaction with antigen tests for other fungi can be used; whereas, PCR assays have been developed for direct detection of these fungi in blood and in tissues. Amphotericin B is the drug of choice for most rare yeast infections except for Trichosporon infections where voriconazole is used. The management of the other infections includes surgery combined with antifungal therapy mainly with amphotericin B for zygomycetes, voriconazole or amphotericin B for hyalohyphomycetes, and itraconazole or amphotericin B for dematiaceous fungi.     

Cutaneous fusariosis by a species of the Fusarium dimerum species complex in a patient with acute mieloblastic leukemia

BackgroundFusariosis is an emergent opportunistic hyalohyphomycosis produced by fungi belonging to the genus Fusarium. These molds are capable of producing life-threatening diseases in immunocompromised hosts, especially in those suffering from leukemia. It has also been described in immunocompetent patients, where it usually causes non-invasive localized lesions. Fusariosis in immunocompromised individuals has a high morbidity and mortality mainly because of the low sensitivity of these fungi to the antifungal drugs available.Case reportWe describe here the case of a patient with acute mieloblastic leukemia who developed fusariosis by a species of the Fusarium dimerum species complex. The early diagnosis was made on the basis of microscopic observation of samples from cutaneous lesions, and voriconazole treatment was prescribed. A subsequent complete study of the fungal isolate by culture and molecular methods allowed the identification of F. dimerum, a species rarely described as a human pathogen. The sensitivity of the strain was tested using the Sensititre YeastOne^® commercial system, which showed sensitivity to voriconazole and posaconazole, as well as to amphotericin B. The patient died after 7 days at hospital due to an hemodynamic failure.ConclusionsComplete identification of new isolates of Fusarium and their antifungal susceptibility patterns is of high interest to improve our knowledge about the epidemiology of the disease and how to best manage patients.     

Recurrent bacteraemia caused by different Salmonella species in a systemic lupus erythematosus patient

Non-typhoidal Salmonella infections are increasingly being encountered. Recurrent systemic salmonellosis has previously been reported in both immunocompromised and immunocompetent hosts. However, recurrent salmonella bacteraemia by different species of salmonella has rarely been described. We report a patient with systemic lupus erythematosus having Salmonella enteritidis and Salmonella typhimurium infections after ingesting raw eggs and vegetables. Multiple internal organs, including left knee joint, left ovary and bones, were involved. The patient recovered with a prolonged course of antibiotics. This case illustrates that recurrent systemic salmonellosis can be caused by different species of pathogens, especially in immunocompromised hosts. Detailed food history and education on food hygiene is essential in making the diagnosis and preventing recurrence. A prolonged course of antibiotics may be needed to manage these cases.     

A Rare Case Report of Subcutaneous Phaeohyphomycotic Cyst Caused by Exophiala oligosperma in an Immunocompetent Host with Literature Review

We report a rare case of phaeohyphomycotic cyst in an immunocompetent patient caused by Exophiala oligosperma. This fungus is earlier known to cause infections in the immunocompromised. Identification of black fungi at species level is more challenging by conventional methods, and hence final identification of the fungi was based on sequencing of rDNA. The patient was managed with surgical excision. To the best of our knowledge, this is the first case report of E. oligosperma human infection from India.     

The role of IgG avidity determination in diagnosis of Epstein-Barr virus infection in immunocompetent and immunocompromised patients

There is a high degree of variability in the serologic response to Epstein-Barr virus (EBV) infection, especially in viral capsid antigen (VCA)-IgM antibodies. Therefore, additional tests are needed to confirm primary infection. We evaluated the value of IgG avidity determination in diagnosis of EBV infection in immunocompetent and immunocompromised patients. A total of 236 serum samples from immunocompetent patients with symptoms suggestive of EBV infection were tested for the presence of VCA-IgM/IgG antibodies and IgG avidity. Using IgG avidity, acute primary infection was confirmed in 56.7% of the immunocompetent patients with positive and in 1.8% of patients with negative VCA-IgM. Recent primary infection was documented in 8.9% of the IgM positive and 3.5% of the IgM negative patients. In patients with indeterminate serology (equivocal IgM), 6.7% were classified by avidity index (AI) as acute primary infection, 10.0% as post-acute and 83.3% as past infection cases. Concerning the 32 immunocompromised patients, recent primary infection was documented in 3 of the 14 IgM positive patients. High AI was detected in 11 of these patients, indicating an IgM response due to reactivation. Determination of IgG avidity in combination with classical serologic markers seems to be a reliable method to confirm primary infection both in immunocompetent and immunocompromised patients. It may be especially useful to differentiate cases of primary infection in patients with undetectable VCA-IgM antibodies or indeterminate routine EBV serology.     

Purpureocillium, a new genus for the medically important Paecilomyces lilacinus

Paecilomyces lilacinus was described more than a century ago and is a commonly occurring fungus in soil. However, in the last decade this fungus has been increasingly found as the causal agent of infections in man and other vertebrates. Most cases of disease are described from patients with compromised immune systems or intraocular lens implants. In this study, we compared clinical isolates with strains isolated from soil, insects and nematodes using 18S rRNA gene, internal transcribed spacer (ITS) and partial translation elongation factor 1-α (TEF) sequences. Our data show that P. lilacinus is not related to Paecilomyces, represented by the well-known thermophilic and often pathogenic Paecilomyces variotii. The new genus name Purpureocillium is proposed for P. lilacinus and the new combination Purpureocillium lilacinum is made here. Furthermore, the examined Purpureocillium lilacinum isolated grouped in two clades based on ITS and partial TEF sequences. The ITS and TEF sequences of the Purpureocillium lilacinum isolates used for biocontrol of nematode pests are identical to those causing infections in (immunocompromised) humans. The use of high concentrations of Purpureocillium lilacinum spores for biocontrol poses a health risk in immunocompromised humans and more research is needed to determine the pathogenicity factors of Purpureocillium lilacinum.     

Successful Antifungal Combination Therapy and Surgical Approach for A<Emphasis Type="Italic">spergillus fumigatus</Emphasis> Suppurative Thyroiditis Associated with Thyrotoxicosis and Review of Published Reports

In immunocompromised patients, Aspergillus infections are important causes of morbidity and mortality. We describe a patient with cryoglobulinemic vasculitis who developed disseminated invasive aspergillosis with thyrotoxicosis caused by Aspergillus fumigatus. The diagnosis was based upon radiological, microbiological and pathological findings. The patient was treated successfully with voriconazole and caspofungin treatment followed by total thyroidectomy. We provide an overview of published reports on Aspergillus thyroiditis with an emphasis on therapeutic approaches.     

Clinical and Treatment Aspects of Brown–Black Fungi

Brown–black (or dematiaceous) fungi are responsible for a wide variety of infectious syndromes in both immunocompetent and immunocompromised patients, including local infections, allergic disease, pneumonia, brain abscess, and disseminated infection. They are distinct from the more common hyaline molds, Aspergillus and Fusarium, that cause human disease. They are often found in soil and generally distributed worldwide. In recent years, these fungi have been increasingly recognized as important pathogens. Dematiaceous fungi may have unique pathogenic mechanisms owing to the presence of melanin in their cell walls, which imparts the characteristic dark color to their spores and hyphae. Diagnosis rests on careful microscopic and pathologic examination, as there are no specific laboratory tests to reliably identify these fungi. Therapy depends upon the clinical syndrome, although disseminated infection often has high mortality. Triazoles such as voriconazole, posaconazole, and itraconazole are the most active antifungal agents available. Further studies are needed to better understand the pathogenesis and optimal treatment of these uncommon infections.     

Acute Disseminated <Emphasis Type="Italic">Talaromyces marneffei</Emphasis> in An Immunocompetent Patient

Talaromyces marneffei (also called Penicilliosis Marneffei or T. marneffei) is a rare fungal disease that is prevalent mainly in Southeast Asia and commonly seen in immunocompromised hosts. It was rarely observed in immunocompetent hosts. We report a case of acute disseminated T. marneffei in an immunocompetent patient in the non-prevalent region. This patient had never visited the endemic area. The patient experienced a persistent fever. Brain CT and magnetic resonance imaging (MRI) showed a mass in the right frontal with osteolytic damage. Excessive white blood cell (WBC) count and C-reactive protein content were observed. Antibiotics including meropenem and linezolid could not play an effect, and another two hard masses appeared in his right neck and front chest wall. The aspirates from the right frontal mass and bone marrow were cultured. The final diagnose of this infection was disseminated T. marneffei. After voriconazole treatment, all symptoms improved gradually. We present this case and aim to promote more clinicians and microbiologists in the non-endemic region to recognize this rare disease.