Unusual Case of Cutaneous and Synovial Paecilomyces lilacinus Infection of Hand Successfully Treated with Voriconazole and Review of Published Literature

Paecilomyces lilacinus infection is rare and is found worldwide. The majority of infections occur in immunocompromised people. Among immunocompetent patients, cutaneous infections are the second most common site of infection but are difficult to treat because of antifungal resistance. We report a case of hand cutaneous involvement with synovitis in an immunocompetent patient that improved after treatment with oral voriconazole. To the best of our knowledge, there are only five published cases of cutaneous P.lilacinus infection, all in immunocompromised patient, treated with oral voriconazole. We review all previously reported cases.     

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.     

Long-term maintenance of improvements achieved with (abortive) pharmacological and nonpharmacological treatments for migraine: preliminary findings

This report presents the first prospective comparison of the long-term maintenance of reductions in recurrent migraine headaches achieved with (abortive) pharmacological and nonpharmacological (combined relaxation training and thermal biofeedback training) treatments. Nineteen of 21 (90%) successfully treated patients (50% or greater reduction in headache activity) were contacted for follow-up evaluation 3 years later. Migraine sufferers who had been treated with ergotamine were less likely to still be relying on the treatment they had received and more likely to have additional medical treatment for their headaches and to be using prophylactic or narcotic medication than were migraine sufferers who had been treated with relaxation/biofeedback training. However, daily headache recordings revealed that patients in both treatment groups continued to show lower headache activity at 3-year follow-up than prior to treatment. Although preliminary, these findings raise the possibility that improvements achieved with nonpharmacological treatment are more likely to be maintained without additional treatment than are similar improvements achieved with abortive pharmacological treatment.     

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.     

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.     

Long-term maintenance of improvements achieved with (abortive) pharmacological and nonpharmacological treatments for migraine: Preliminary findings

This report presents the first prospective comparison of the long-term maintenance of reductions in recurrent migraine headaches achieved with (abortive) pharmacological and nonpharmacological (combined relaxation training and thermal biofeedback training) treatments. Nineteen of 21 (90%) successfully treated patients (50% or greater reduction in headache activity) were contacted for follow-up evaluation 3 years later. Migraine sufferers who had been treated with ergotamine were less likely to still be relying on the treatment they had received and more likely to have additional medical treatment for their headaches and to be using prophylactic or narcotic medication than were migraine sufferers who had been treated with relaxation/biofeedback training. However, daily headache recordings revealed that patients in both treatment groups continued to show lower headache activity at 3-year follow-up than prior to treatment. Although preliminary, these findings raise the possibility that improvements achieved with nonpharmacological treatment are more likely to be maintained without additional treatment than are similar improvements achieved with abortive pharmacological treatment.A Baker Award from Ohio University provided support for the original outcome study.Abgelo Theofanous with R. L. Associates (Ann Arbor).     

Disseminated Mucormycosis Due to Saksenaea vasiformis Complex in an Immunocompetent Adult with Sustained Response to Posaconazole Treatment

Mycopathologia - Saksenaea vasiformis complex is an emerging cause of mucormycosis. We report a case of an immunocompetent patient presenting with a non-resolving lung mass who developed multiple...     

Learning from Our Treatment Failures

Barton and Blanchard's report that multicomponent behavioral treatment fails to modify chronic daily headaches is discussed with reference to the effectiveness of behavioral and drug treatments for chronic tension-type headache, the distinction between chronic tension-type headache and chronic migraine, and the psychophysiology of episodic vs. persistent pain (K. A. Barton & E. B. Blanchard, 2001). It is suggested that the treatment of chronic daily headache can be improved through research on the benefits of combined behavioral and drug therapy, the psychophysiology of persistent pain, and methods of preventing episodic headaches from evolving to daily headaches.     

急性淋巴细胞白血病患者侵袭性头状地霉感染1例及文献回顾

目的:通过报道1例急性淋巴细胞白血病患者侵袭性头状地霉感染的临床资料,并结合文献探讨头状地霉感染的临床特点、有效的诊断及治疗方法。方法:报道国内首例急性淋巴细胞白血病患者化疗后骨髓抑制期感染头状地霉病例,并对该病的诊断及治疗等进行系统文献回顾。结果:该白血病患者经血培养证实为头状地霉感染,并累及肺脏、肝脏和皮肤,治疗过程中先后采用卡泊芬净、脂质体两性霉素B和脂质体两性霉素B联合伏立康唑等治疗,虽然脂质体两性霉素B联合伏立康唑治疗患者体温正常,临床症状稍有改善,但是患者在化疗后40天放弃治疗并死于心肺功能衰竭。结论:头状地霉感染的发病率低,临床症状不够典型,诊断困难,预后差。根据患者的临床表现,结合血培养、GM实验、G实验和CT扫描等检查,可有助于诊断。头状地霉感染尚无非常有效的治疗方式,采用脂质体两性霉素B或两性霉素B联合伏立康唑或其他新的抗真菌药物可能获得一定的疗效,早期诊断、早期联合治疗和患者早期脱离粒缺状态是治疗成功的关键。     

Prenatal exposure to fluconazole: an identifiable dysmorphic phenotype

BACKGROUND: Fluconazole is a triazole antifungal used to treat mycotic infections. Fluconazole is reported to act as a teratogen when used continuously at a dosage of 400-800 mg daily. Fluconazole embryopathy was previously reported in 4 cases. The common features that were also seen in the current case include multiple synostosis (including craniosynostosis and digital synostosis), congenital heart defects, skeletal anomalies, and recognizable dysmorphic facial features. CASE: We report the case of a 9-month-old male born to a 30-year-old woman following a 37-week pregnancy. The pregnancy was complicated by maternal human immunodeficiency virus (HIV) infection and multiple drug exposures, including fluconazole (400 mg/day) until the fifth month and then from 6 months to term, efavirenz, nevirapine, methadone, dapsone, pentamidine, and trimethoprim-sulfamethoxazole. At birth the infant had seizures related to neonatal abstinence syndrome and was noted to have multiple congenital anomalies. On examination at age 9 months, he had craniosynostosis secondary to coronal and lambdoidal suture closures, shallow orbital region, hypoplastic supraorbital ridges, hypertelorism, and mild ptosis. He had radioulnar synostosis and metacarpophalangeal-proximal interphalangeal symphalangism of D2-D5 bilaterally. CONCLUSIONS: The findings of cranial synostosis, multiple symphalangism, and long-bone abnormalities in our case are typical of other reported cases of fluconazole embryopathy. Our patient showed no evidence of embryopathy due to efavirenz, and he did not have the features of Antley-Bixler or other craniosynostosis syndromes. We review the literature regarding the teratogenic effects of prenatal exposure to fluconazole and provide additional evidence that prenatal fluconazole exposure has a clearly identifiable phenotype.     

Bilateral proximal cellulitis and onychomycosis in both big toes due to Fusarium solani

We report a case of proximal fold cellulitis in both big toes, associated with a bilateral proximal onychomycosis and an intertrigo of the fourth space due to Fusarium solani. The infection occurred in an immunocompetent man with diabetes mellitus type II. Apparently, the infection was acquired in a tropical country and once the patient was in Spain the infection progressed causing nail detachment (onychomadesis). Seven months later a relapse that affected the left toenail occurred. The patient was treated topically with chemical toenail avulsion contained 40% urea associated with bifonazole followed by ciclopirox-olamine nail lacquer for 12 months. Complete cure without relapse was observed after 10 years of follow-up. In vitro antifungal susceptibility study demonstrated that two of the recovered isolates were both resistant to itraconazole and voriconazole.     

原发性血小板减少性紫癜合并侵袭性真菌感染2例报告附文献复习

目的 报道2例难治性原发性血小板减少性紫癜（ITP）患者用大剂量激素和（或）免疫抑制剂后发生侵袭性真菌感染（IFI）,其治疗经过及相关文献复习。方法 2例难治性ITP患者用大剂量激素和（或）免疫抑制剂后发生IFI,用大扶康、两性霉素B,降颅压,辅助呼吸等治疗。结果 例1发生隐球菌脑膜脑炎、例2出现肺曲酶菌感染,均经抗真菌治疗无效死亡。结论 长期应用激素及免疫抑制剂是难治性ITP患者发生IFI的危险因素,治疗困难,确诊后用药应足量、足疗程。     

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.     

Disseminated cryptococcosis in an AIDS patient with unusual clinical presentation

Disseminated cryptocococcosis is a rare and often fatal disease. Here in we report an unusual fatal case of disseminated cryptococcosis. The patient presented with a past history of postmenopausal bleeding with loss of consciousness, altered mental status, few seizures and a low grade fever. Lumbar puncture revealed elevated pressure, lymphocytic pleocytosis, elevated protein and markedly reduced glucose level. Cryptococcus neoformans was isolated from cerebrospinal fluid and blood. Serological assay revealed the presence of human immunodeficiency virus. The patient was treated with antifungal agents intravenously without any signs of improvement and the patient passed away after two weeks of therapy. This is the first case report of disseminated cryptococcosis in an AIDS patient suffering from cryptoccoccal vaginitis.     

Schizophillum commune Causing Sinusitis with Nasal Polyposis in the Sub-Himalayan Region: First Case Report and Review

Schizophillum commune is an environmental fungus rarely causing human infections of diverse nature. Sinusitis occurs in immunocompromised persons and seldom in healthy subjects. Though easily isolated, the lack of awareness of its virulence is a bottleneck in the diagnosis of this infection. We report the first case of S. commune sinusitis with nasal polyps in an immunocompetent male from the sub-Himalayan region. The computerized tomography scan findings established the clinical diagnosis, and causative agent was confirmed as S. commune. A white, woolly mold with septate, hyaline hyphae and characteristic spicules but unclamped connections suggested a monokaryotic isolate. Patient was treated successfully with fiberoptic endoscopic sinus surgery, and no antifungal therapy was instituted. There was no recurrence at review after 1 year.     

Change Mechanisms Associated with Combined Relaxation/EMG Biofeedback Training for Chronic Tension Headache

Therapeutic mechanisms hypothesized to underlie improvements in tension headache activity achieved with combined relaxation and eleclromyographic (EMG) biofeedback therapy were examined. These therapeutic mechanisms included (1) changes in EMG activity in frontal and trapezii muscles, (2) changes in central pain modulation as indexed by the duration of the second exteroceptive silent period (ES2), and (3) changes in headache locus of control and self-efficacy. Forty-four young adults with chronic tension-type headaches were assigned either to six sessions of relaxation and EMG biofeedback training (N = 30) or to an assessment only control group (N = 14) that required three assessment sessions. Measures of self-efficacy and locus of control were collected at pre- and posttreatment, and ES2 was evaluated at the beginning and end of the first, third, and lost session. EMG was monitored before, during, and following training trials. Relaxation/EMG biofeedback training effectively reduced headache activity: 51.7% of subjects who received relaxation/biofeedback therapy recorded at least a 50% reduction in headache activity following treatment, while controls failed to improve on any measure. Improvements in headache activity in treated subjects were correlated with increases in self-efficacy induced by biofeedback training but not with changes in EMG activity or in ES2 durations. These results provide additional support for the hypothesis that cognitive changes underlie the effectiveness of relaxation and biofeedback therapies, at least in young adult tension-type headache sufferers.     

Pulmonary pseudallescheriasis in a patient with healed tuberculosis

Pulmonary pseudallescheriasis in an immunocompetent patient without a pre-existing cavity or cyst is a rare phenomenon. We report a case of invasive pulmonary pseudallescheriasis in a lobectomised patient treated for tuberculosis. Filamentous fungi with pyriform conidia were seen in the bronchoalveolar lavage fluid .The fungus was identified as Pseudallescheria boydii on culture.     

Comments on The Failure of Intensive Self-Regulatory Treatment with Chronic Daily Headache

Nonpharmacological therapy of primary headache conditions including chronic daily headache (CDH) is not well-studied. Barton and Blanchard report on their experience with intensive self-regulatory treatment in a cohort of patients with CDH. This negative trial provides preliminary observations that need further investigations in controlled, adequately powered clinical study.     

Cytomegalovirus associated transverse myelitis in an immunocompetent host with DNA detection in cerebrospinal fluid; a case report

ABSTRACT: BACKGROUND: Cytomegalovirus associated transverse myelitis among immunocompetent adults has been rarely reported. We report a patient presenting with clinical myelitis followed by previously unreported finding of cytomegalovirus deoxyribonucleic acid in cerebrospinal fluid. Case report A forty year old immunocompetent male presented with acute onset progressive bilateral lower limb weakness. His spinal magnetic resonance imaging findings, cerebrospinal fluid analysis and clinical picture were compatible with transverse myelitis. Polymerase chain reaction of the cerebrospinal fluid for cytomegalovirus was positive while other infectious agents were not detected by serology or polymerase chain reaction. He was treated with intravenous ganciclovir with partial clinical response. CONCLUSION: Viral genome detection in the cerebrospinal fluid was performed but negative in five out of ten reported cases of cytomegalovirus associated transverse myelitis in the immunocompetent host. In previous cases the inability to isolate the virus in cerebrospinal fluid was considered favouring an immunological mechanism leading to pathogenesis rather than direct viral toxicity but this case is against that theory. This case highlights the fact that Cytomegalovirus should be considered as an aetiological agent in patients with transverse myelitis and that the virus may cause serious infections in immunocompetent host. Therefore this report is of importance to neurologists and physicians in general.     

Aspergillus tubingensis Endocarditis: A Case Report and Review of the Literature

Mycopathologia - Aspergillus endocarditis is a rare infection that may affect immunocompetent patients following heart valve replacement or heart surgery. We report the case of a 39 year...