Cutaneous infection by Phaeoacremonium parasiticum

BackgroundPhaeoacremonium parasiticum is considered a rare infectious agent that is part of a heterogeneous group of fungi causing phaeohyphomycosis. This organism is capable of producing subcutaneous infections, eumycetomas, osteomyelitis, arthritis, myositis and also disseminated diseases, such as fungemia and endocarditis.Case reportWe describe a case of cutaneous infection by P. parasiticum in a kidney transplant patient. The identification of this microorganism was performed by microbiological and histopathological studies and confirmed with the sequence of the gene encoding β-tubulin and a real time panfungal PCR targeting 18S ribosomal RNA gene. The microorganism was correctly identified by phenotypic and molecular methods. The patient was treated with oral antifungal therapy and a debulking surgery and evolved without any complication.ConclusionsThe diagnosis of this infection is difficult and usually affects kidney transplant patients, but the reasons of this association are still unknown.     

Renal abscess due to Aspergillus fumigatus as the only sign of disseminated aspergillosis in a patient with AIDS

BackgroundAspergillus fumigatus can cause a wide variety of clinical syndromes, especially in the three largest immunocompromised groups, such as HIV-infected patients. Primary renal aspergillosis is an extremely rare entity.AimsWe report an unusual case of renal abscess due to Aspergillus fumigatus in a patient with AIDS.MethodsWe review clinical and laboratory records, and provide follow up of the patient.ResultsA 38-year-old man, HIV seropositive, was admitted to our hospital with fever, lumbar pain and respiratory symptoms. Abdominal ultrasound and computerised tomography showed a single and large lesion consistent with an abscess located in the left kidney. Aspergillus fumigatus was isolated from clinical sample obtained by ultrasound-guided needle aspiration. Despite a correct treatment based on amphotericin B and drainage of the abscess, surgery was necessary and nephrectomy was carried out. Histopathological examination of the surgical specimen confirmed the diagnosis of renal aspergillosis. Systemic antifungal therapy based on intravenous and oral voriconazole and highly active antiretroviral therapy was started after surgery. The patient had a good response to the established treatment and he remains in a good clinical condition at one year of follow up.ConclusionsCombined medical and surgical treatment is the elective therapy for renal abscesses due to Aspergillus when percutaneous drainage and the administration of systemic antifungal drugs, such as amphotericin B and/or oral voriconazole or itraconazole, fail. This case emphasizes renal fungal infections should be included in the differential diagnosis of kidney abscesses in AIDS patients.     

Lethal destructive sinusopathy due to amphotericin B-resistant Aspergillus flavus: A case report

BackgroundThe prevalence of pulmonary aspergillosis and the importance of its early diagnosis are recognized. However, non-pulmonary involvement, including the sinuses region, is not frequently reported, and an infection in this area can affect all paranasal sinuses (pansinusopathy), being a rare pathology that affects immunocompromised hosts. Recent studies have highlighted the occurrence of Aspergillus flavus resistant to antifungal therapy. Therefore, a nasal sinus infection by resistant Aspergillus strains in immunocompromised patients may be linked to a high risk of lethality.Case reportWe are reporting a resistant A. flavus infection in an allogeneic hematopoietic stem cell transplant recipient with episodes of febrile neutropenia, and prolonged use of various antibacterial drugs and antifungal prophylaxis. The patient underwent brain magnetic resonance, which showed the presence of pansinusopathy, and presented necrosis in the left nasal region. Direct microscopic examination of a sample taken from the nasal mucosa revealed the presence of septate hyphae and conidiophores resembling those of A. flavus, that species being the identification achieved with MALDI-TOF MS. Antifungigram was performed by microdilution in broth (EUCAST-E.DEF. 9.3.2) and E-test, and resistance to amphotericin B was shown in both tests. The patient died after septic shock and hemorrhage.ConclusionsInvasive fungal infections due to amphotericin-B resistant A. flavus may lead to the death of the patient due to an ineffective therapeutic management. Therefore, antifungal susceptibility testing are of utmost importance for administering the proper treatment.     

Virulence and antifungal susceptibility of environmental and clinical isolates of Cryptococcus neoformans from Puerto Rico

A case of cerebral cladosporiosis caused by Cladosporium trichoides (bantianum) now known as Xylohypha bantiana is described and illustrated. Predisposing debilitating diseases were not detectable. The Cladosporiosis diagnosis was based on visualisation of hyphal element in direct Gram's stain, direct KOH preparate of pus from brain abscess and on repeated successful cultivation of Cladosporium trichoides from specimen and by histopathology. Following surgery and anti-fungal chemotherapy the patient was cured.     

Experimental central nervous system phaeohyphomycosis following intranasal inoculation of Xylohypha bantiana in cortisone-treated mice

Experimental central nervous system (CNS) phaeohyphomycosis was established in cortisone-treated mice following intranasal exposure to conidia of Xylohypha bantiana (Cladosporium bantianum, C. trichoides). X. bantiana was recovered from the lungs of 78% of intranasally inoculated normal mice sacrificed within the first 3 days of infection and from 15% at day 28. The fungus was not recovered from the brains of normal mice. In contrast, X. bantiana was recovered from only 33% of the lungs of cortisone-treated mice within the first 3 days of infection. However, the fungus was recovered from the brains of 11% of cortisone-treated mice sacrificed or dying over a 28 day period. Histologically and temporally the CNS disease in cortisone-treated, intranasally inoculated mice was consistent with hematogenous dissemination from a primary pulmonary focus.     

Fungal cerebral abscess in a diabetic patient successfully treated with surgery followed by prolonged antifungal therapy

BackgroundIntracranial fungal masses are uncommon diseases, but their incidence is increasing, most often due to the prolonged survival of patients with different immunodeficiencies. The management of patients with intracranial fungal masses included stereotactic biopsy for diagnosis, partial or radical surgery excision and prolonged antifungal therapy.AimsWe report the case of a 51-year-old diabetic man with a history of psoas abscess due to Candida albicans 1 year before the onset of neurological symptoms, including headache and generalized tonoclonic seizures.MethodsMagnetic resonance imaging showed a single lesion located in the right parietal lobe with mass effect, surrounding edema and enhancement after injection of gadolinium. The material was purulent.ResultsDirect microscopic examination showed hyaline, branched and septate hyphae compatible with fungal elements.ConclusionsFungal infections, especially due to Candida species, should be considered in diabetic patients with parenchymal brain abscesses. Radical excision followed by prolonged antifungal therapy based on fluconazole or amphotericin B is necessary to improve the prognosis of this type of patients.     

Refractory disseminated fusariosis by Fusarium verticillioides in a patient with acute myeloid leukaemia relapsed after allogeneic hematopoietic stem cell transplantation: A case report and literature review

BackgroundFusarium species are among the leading fungal pathogens to cause invasive mould infections in patients with hematopoietic malignancy. The Fusarium species most frequently involved in human infections are Fusarium solani, Fusarium oxysporum and Fusarium verticillioides. However, identification is a cumbersome and time-consuming task. Fusarium is resistant in vitro to many of the antifungal agents and the management of fusariosis is not well defined.ObjectivesTo emphasise the difficulty of identifying Fusarium spp. by conventional methods and the need of new rapid molecular tests to achieve earlier diagnosis and appropriate therapy.MethodsA disseminated Fusarium infection due to F. verticillioides was documented in a neutropenic refractory patient with acute myeloid leukaemia, relapsed after allogeneic hematopoietic stem cell transplantation.ResultsThe patient died despite liposomal amphotericin B and voriconazole combination and “in vitro” susceptibility of agents employed. Morphological and molecular identification of F. verticillioides was obtained only after the death of the patient.ConclusionsThis case highlights the poor outcome of an invasive fungal disease caused by Fusarium in aplastic patients. Identification of members of Fusarium genus remains restricted to selected laboratories and should be introduced into routine mycological diagnostics. In immunocompromised patients, diagnosis of fusariosis is directly related to prompt diagnosis and to patient's status. Current diagnosis methods and therapeutic options are discussed.     

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.     

The First Case of Phaeohyphomycosis Caused by Rhinocladiella basitona in an Immunocompetent Child in China

We present the first case of phaeohyphomycosis caused by Rhinocladiella basitona (R. basitona) in China and describe the mycological characteristics of this pathogen. A 11-year-old girl was presented with plaque on her face for 3 years. Diagnosis was based on histopathology, mycology, and molecular identification. The patient was treated with terbinafine and itraconazole. This case is the second of phaeohyphomycosis caused by R. basitona in the world (previously belonging to Geniculosporium).     

Successful Terbinafine Treatment for Cutaneous Phaeohyphomycosis Caused by Trematosphaeria grisea in a Heart Transplanted Man: Case Report and Literature Review

Phaeohyphomycosis is a chronic infectious disease caused by dematiaceous fungi. It is characterized by the presence of pigmented septate mycelia within tissues. In the case of superficial infection, the lesion(s) chronically evolve(s) toward painless pseudo-tumor(s) of the soft parts. We report herein the original case of a heart transplanted man who exhibited phaeohyphomycosis of the left hand, with no mention of travels in endemic areas. Trematosphaeria grisea was identified as the causative agent, which is quite innovative since this species has been rather described in mycetoma. The antifungal treatment initially based on isavuconazole alone was not sufficient to cure the patient. In contrast, its association with local terbinafine ointment allowed total clinical improvement. This finding is unusual as diagnosis of phaeohyphomycosis caused by T. grisea is uncommon in nontropical countries, and as the outcome appeared successful by the means of add-on therapeutic strategy with terbinafine.

     

Candida parapsilosis meningitis in a patient with AIDS. Report of a case and review of the literature

BackgroundCandida parapsilosis is an important species in the genus Candida that plays a significant role in hospitalized patients with nosocomial infections. In patients with HIV infection or AIDS, central nervous system involvement by Candida species is exceptional.Case reportHere we report a case of an acute meningoencephalitis due to C. parapsilosis in an adult patient with AIDS. We describe the clinical manifestations, the diagnosis methods, antifungal therapy and outcome.ConclusionsC. parapsilosis is uncommonly reported as a cause of meningitis in AIDS patients. A higher index of suspicion and culture is necessary to confirm the diagnosis of candidal meningoencephalitis.     

Fascitis necrotizante por Saksenaea vasiformis en una paciente inmunocompetente tras un accidente de tráfico

BackgroundCutaneous mucormycosis (zygomycosis), with subcutaneous spreading and dissemination, in immunocompetent patients is an uncommon disease caused by species belonging to the fungal genera Apophysomyces, Rhizopus and Saksenaea, among others.Case reportA case of necrotising fasciitis by Saksenaea vasiformis in an immunocompetent woman is described. The infection was acquired through a car accident resulting in multiple injuries affecting mainly her right arm. After the surgical reduction of fractures, skin lesions worsened and led to necrosis. The patient quickly developed a severe necrotising fasciitis with negative cultures at first. Despite the extensive surgical debridement and the aggressive antifungal treatment, the patient died. The histopathological study showed a fungal infection due to a fungus belonging to the Mucorales order, which was confirmed by culturing the clinical sample on Sabouraud agar, and identifying the species by cultures on Czapek-Dox agar, and sequencing of the ITS region of the ribosomal DNA.ConclusionsThis case confirm the presence of this fungus in Spain, the value of histopathology for the mucormycosis diagnosis, as well as the need to perform special cultures to facilitate their isolation and identification to the species level by the combined use of Czapek-Dox agar and sequencing of the ITS region.     

Two cases of sporotrichosis of the right upper extremity in right-handed patients with diabetes mellitus

BackgroundSporothrix species have proved to show high degrees of endemicity. Sporothrix globosa is the only pathogenic Sporothrix species that has till date been reported from China, where it is endemic in the northeastern provinces.AimsWe report two cases of lymphocutaneous sporotrichosis with diabetes mellitus as underlying disease in patients from the non-endemic area of China.MethodsA 59-year-old farmer and a 60-year-old gardener were admitted in February and June 2014, respectively. Both patients were right-handed men and presented with progressive plaques and nodules, which they had for several years, involving the right upper extremity. Skin biopsy from the granuloma was taken and cultured on Sabouraud medium, and molecular identification based on the calmodulin region was performed. Antifungal susceptibility testing was also performed with the microdilution method.ResultsBiopsy of the lesions showed the presence of infectious granuloma. The fungal cultures were identified as Sporothrix globosa by conventional methods, and confirmed by molecular identification. A subsequent course of oral antifungal therapy with low dosage of itraconazole was well tolerated and resolved the infection.ConclusionsIdentification of fungal species and antifungal susceptibility testing are mandatory for epidemiological and therapeutic reasons. Early diagnosis of sporotrichosis is essential to prevent those sequelae when the disease progresses and provides highly effective methods for treating this emerging disease. Avoiding the exposure to plant material potentially contaminated with fungal spores should be recommended, especially in immunocompromised patients.     

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.     

Multiple opportunistic fungal infections in an individual with severe HIV disease: A case report

BackgroundFungal infections have been commonly diagnosed in individuals with advanced HIV disease. Cryptococcosis, pneumocystosis, and histoplasmosis are the most frequent systemic mycoses in people suffering from HIV/AIDS.Case reportWe report a case of multiple fungal infections in an advanced AIDS-patient. A 33-year-old HIV-positive man from Brazil was hospitalized due to diarrhea, dyspnea, emaciation, hypoxemia, extensive oral thrush, and a CD4+ T lymphocyte count of 20 cells/mm³. Honeycombed-structures consistent with Pneumocystis jirovecii were observed by direct immunofluorescence in induced sputum. Cryptococcus neoformans was recovered from respiratory secretion and cerebrospinal fluid cultures. Histopathology of the bone marrow also revealed the presence of Histoplasma capsulatum. Molecular assays were performed in a sputum sample. Nested-PCR confirmed the presence of P. jirovecii and H. capsulatum; qPCR multiplex was positive for C. neoformans and H. capsulatum. With the treatment of antifungal drugs the patient progressed satisfactorily.ConclusionsThe diagnosis of several systemic mycoses demonstrates the vulnerability of advanced AIDS-patients. Thus, the detection of AIDS cases in the early stages of infection is necessary for a prompt and adequate introduction of HAART therapy, and the use of prophylaxis to control opportunistic infections.     

Endophthalmitis of probable endogenous origin caused by Scedosporium boydii: A case report

BackgroundMycotic ocular infections caused by the Scedosporium apiospermum species complex are challenging to treat because of the delayed diagnoses and poor responses to antifungal drugs and surgical treatment.Case reportA case of a 69-year-old male patient with a history of diabetes mellitus type 2 and prior surgery on the right femur is described. In the 10 days prior to the ophthalmic consultation he started with ocular pain, adding to a previous and progressive loss of visual acuity in his right eye. The diagnosis of endophthalmitis of probable endogenous origin was established. Despite medical treatment, the patient's condition worsened and, due to the imminent risks, an enucleation was performed. Smears of the enucleation tissue revealed fungal cells, and the cultures yielded a fungus belonging to the S. apiospermum species complex, which was identified as Scedosporium boydii by morphological characteristics and sequencing of a PCR amplicon.ConclusionsA diagnosis of endophthalmitis of probable endogenous origin in the right eye was based on a previous right femur surgery. Potential risk to the patient led to enucleation.     

Pulmonary nodules: An unusual onset of HIV infection belatedly diagnosed

BackgroundCryptococcosis is a generally systemic and potentially lethal fungal infection. Although HIV infection is a predisposing condition, especially if the CD₄₊ lymphocyte count is less than 100 cells/mm³, other forms of immunosuppression may be associated with this opportunistic fungal condition, such as prolonged steroid therapy or solid organ transplantation. Pulmonary presentation must be included in the differential diagnosis of pneumonia or pulmonary neoplasia in the immunosuppressed patient.Case reportWe report a case of pulmonary cryptococcosis in a non-diagnosed HIV patient. In a 44 year-old male suffering from dyspnea and chest pain the image of a pulmonary nodule was observed in a radiological finding. In the histopathological study, intracellular structures suggestive of fungal conidia, and morphologically compatible with Cryptococcus, were observed. HIV serology and cryptococcal antigen detection in serum were requested, given the possibility of cryptococcosis. Cryptococcus neoformans var. grubii was isolated from the culture of the pulmonary biopsy. The patient was finally diagnosed with pulmonary cryptococcosis and HIV-1 infection. With a proper antifungal treatment the patient evolved satisfactorily.ConclusionsThe best strategy to avoid opportunistic infections such as cryptococcosis in HIV-infected patients consists of an early diagnosis and a highly active antiretroviral treatment. In our case, the diagnosis of a pulmonary infection by C. neoformans var. grubii allowed a late diagnosis of HIV-1 infection.     

Phenotypic and molecular identification of Coccidioides posadasii in a patient evaluated for bilateral lung transplantation

BackgroundCoccidioidomycosis is an endemic fungal infection caused by Coccidioides immitis and Coccidioides posadasii. It can be particularly severe in transplant recipients that have a current or a previous coccidioidal infection. Fatal case of coccidioidomycosis has been described in this group of patients.AimsWe report a severe case of pneumonia caused by C. posadassi in a 29 year-old white woman that had been admitted to hospital as part of the evaluation for bilateral lung transplantation. The patient was a native and resident of Catamarca, Argentina. Molecular methodologies contributed to the species identification.MethodsClinical, laboratory records and microbiological tests were carried out to diagnose the infection and to identify C. posadasii.ResultsA fungus was isolated from BAL culture. Phenotypic characterization, specific PCR and experimental animal inoculation demonstrated the presence of C. posadasii. The patient responded well to amphotericin B deoxycholate. Lung transplantation was postponed.ConclusionsSpecific PCR can be an important alternative for the correct identification of C. immitis or C. posadasii in laboratories with implemented molecular biology tools. This case emphasizes the need for a systematic assessment in organ transplant units of patients inhabiting endemic areas of coccidioidomycosis.     

Aspergilosis pulmonar en un paciente crítico no inmunodeprimido

BackgroundIn non-immunocompromised patients admitted to intensive care departments or units (ICU), it is difficult to establish a definitive diagnosis of pulmonary aspergillosis because the signs and symptoms of this infectious disease are non-specific, and serological techniques are not very specific as well. For this reason, a diagnosis of possible pulmonary aspergillosis is initially established, and the starting of the treatment is controversial.Case reportAn immunocompetent subject had a work-related accident after a fall, which resulted in multiple injuries (head, thorax, lower extremities). The patient required mechanical ventilation since admission. On the second week of ICU admission, he showed a clinical presentation of respiratory infection with fever, purulent secretions, bilateral pulmonary infiltrates and repeated isolation of Mucor and Aspergillus fumigatus in bronchial secretions and pharyngeal swabs. The patient was treated with amphotericin B lipid complex and voriconazole with an excellent clinical and radiological outcome.ConclusionsCombined treatment of antifungal agents, in this case amphotericin B lipid complex and voriconazole, is a therapeutic possibility to be considered in patients who failed to respond to initial antifungal monotherapy.