CUTANEOUS MANIFESTATIONS OF FUNGAL INFECTION

Multiple facial candidal abscesses after self-administered acupuncture in a patient with undiagnosed diabetes mellitus: a case report

Background

Facial abscess caused by Candida albicans infection is a rare condition even in immunocompromised patients, and only a few cases have been reported. To our knowledge, this is the first case of multiple facial candidal abscesses caused by self-administered acupuncture in an undiagnosed diabetes mellitus patient.

Case presentation

A 57-year-old woman who had self-acupuncture treatment 2 weeks previously, presented with a 1-week history of progressive left eyelid swelling, erythema, and pain. Despite the antibiotic treatment, the lesion progressed. Surgical incision and drainage was performed and Candida albicans was isolated from the obtained pus culture. The patient was diagnosed with type 2 diabetes mellitus based on a random serum glucose level of 350 mg/dl and 9.2% HbA1c. The abscess resolved after seven incision and drainage cycles and 4 weeks of intravenous fluconazole treatment with an appropriate control of diabetes mellitus.

Conclusion

Unusual organisms and underlying immunocompromised condition should be suspected in cases of recurrent abscess showing an inadequate response to antibiotic treatment.

Facial candidiasis after maxillofacial trauma: A rare encounter

Facial oedema after maxillofacial trauma is a common occurrence, but those that soon resolve only to appear again do invoke interest! A rare case is presented of a recurring facial swelling occurring after a maxillofacial injury that did not resolve subsequent to medication and repeated aspirations. Cytospin preparations of the aspirate stained with Giemsa revealed candidiasis. The patient's symptoms resolved soon with antifungal medications and he has been asymptomatic since. Such a scenario has never been reported in the literature and can pose a diagnostic dilemma. It gives insight into the unusual clinical presentation of facial candidiasis, the importance of thorough debridement of soft tissue wounds at primary care centres and the need to consider mycoses as a differential diagnosis for nonresolving soft tissue facial swellings after maxillofacial trauma.

Relation between Skin Pharmacokinetics and Efficacy in AmBisome Treatment of Murine Cutaneous Leishmaniasis

AmBisome (LAmB), a liposomal formulation of amphotericin B (AmB), is a second-line treatment for the parasitic skin disease cutaneous leishmaniasis (CL). Little is known about its tissue distribution and pharmacodynamics to inform clinical use in CL. Here, we compared the skin pharmacokinetics of LAmB with those of the deoxycholate form of AmB (DAmB; trade name Fungizone) in murine models of Leishmania major CL. Drug levels at the target site (the localized lesion) 48 h after single intravenous (i.v.) dosing of the individual AmB formulations (1 mg/kg of body weight) were similar but were 3-fold higher for LAmB than for DAmB on day 10 after multiple administrations (1 mg/kg on days 0, 2, 4, 6, and 8). After single and multiple dosing, intralesional concentrations were 5- and 20-fold, respectively, higher than those in the healthy control skin of the same infected mice. We then evaluated how drug levels in the lesion after LAmB treatment relate to therapeutic outcomes. After five administrations of the drug at 0, 6.25, or 12.5 mg/kg (i.v.), there was a clear correlation between dose level, intralesional AmB concentration, and relative reduction in parasite load and lesion size (R² values of >0.9). This study confirms the improved efficacy of the liposomal over the deoxycholate AmB formulation in experimental CL, which is related to higher intralesional drug accumulation.

Facial Candidal Abscess in a Patient with Unknown Type 2 Diabetes Mellitus

INTRODUCTION

Facial candidal abscess is an infection with a fungal cause which was presented in this case such a rarity. We report a rare case of facial abscess due to Candida species in a patient with unknown diabetes.

MATERIALS AND METHODS

The patient presented with a longstanding firm swelling which occurred 2 weeks ago and did not show any improvement of healing process in spite of surgical and medical treatments. MRI examinations were conclusive and compatible with abscess, so she underwent surgical intervention. Facial candidal abscess was the final diagnosis.

CONCLUSIONS

We concluded that, in persistent abscesses, invasive candidiasis should be considered in the differential diagnosis of bacterial infections as it generally affects individuals with diabetes or general defects in the immune system, or those who use widespread antibiotics and steroids.

Concurrent subcutaneous candidal abscesses and pulmonary cryptococcosis in a patient with diabetes mellitus and a history of corticosteroid therapy

A 50-year-old man with a history of long-term corticosteroid treatment following adrenalectomy for Cushing's syndrome and uncontrolled diabetes mellitus was admitted for an examination of an abnormal thoracic shadow. Cryptococcal serum antigens were positive, and the histopathology of a lung biopsy showed encapsulated yeast resembling Cryptococcus neoformans. On admission, the serum β-D-glucan level was approximately twice the cutoff value, several nodules were observed on both legs and magnetic resonance imaging revealed subcutaneous abscesses. Candida albicans was identified from needle aspirates, and the patient was successfully treated with fluconazole and flucytosine. We herein report the first case of concurrent C. albicans skin abscesses and pulmonary cryptococcosis.

The in situ inflammatory profile of lymphocutaneous and fixed forms of human sporotrichosis

The most common clinical presentations of sporotrichosis are the lymphocutaneous (LC) and fixed cutaneous (F) forms, but little is known about the immunopathologic differences between them. The aim of this study was to evaluate through immunohistochemistry the composition of the in situ inflammatory reaction so as to correlate the results with the clinical presentation of the disease. The following two groups of patients were involved in the studies, i.e., LC (n=19) and F (n=11) patients. Those with the LC form, in contrast to F patients, were found to have a larger number of lesions (P=0.001), of longer duration (P=0.026) and require a more extended course of treatment (P=0.049). LC patients also presented a greater fungal burden (LC:0-6.5; F:0-1.5; P=0.021), a higher percentage of neutrophils (median LC:24.7%; F:6.7%, P=0.002), CD4(+) cells (median LC:40.9%; F:30.0%, P=0.0024), CD22(+) cells (median LC:15.3%; F:2.9%, P=0.048), and higher intensity of NOS2 expression (P=0.009). Thus, our data identified differences in cell profile and inflammatory activity in lesions of LC and F forms of human sporotrichosis.

Candida albicans skin abscess

Subcutaneous candidal abscess is a very rare infection even in immunocompromised patients. Some cases are reported when breakdown in the skin occurs, as bacterial cellulites or abscess, iatrogenic procedures, trauma and parenteral substance abuse. We describe a case of Candida albicans subcutaneous abscess without fungemia, which can be associated with central venous catheter.

Comparative evaluation of the efficacy and safety of two doses of terbinafine (500 and 1000 mg day-1) in the treatment of cutaneous or lymphocutaneous sporotrichosis. Vergleichende Bewertung der Wirksamkeit und Sicherheit zweier Terbinafin-Dosierungen (500 und 1000 mg/Tag) in der Therapie der kutanen und lymphokutanen Sporotrichose

The aim of this study was to evaluate the safety and efficacy of oral terbinafine (500 and 1000 mg day(-1)) in the treatment of cutaneous or lymphocutaneous sporotrichosis. A culture for Sporothrix schenckii was required for inclusion into this multicentre, randomized, double-blind, parallel-group study. Patients received either 250 mg b.i.d. or 500 mg b.i.d. oral terbinafine for up to a maximum of 24 weeks and were assessed up to 24 weeks post-treatment. The main efficacy outcome measure was cure, defined as no lesion and absence of adenopathy at the end of follow-up. Adverse events (AEs), laboratory tests, vital signs and ophthalmological examinations were also assessed. Sixty-three patients (14-85 years of age) were treated with 500 mg day(-1) (n = 28) or 1000 mg day(-1) terbinafine (n = 35). The majority of patients were cured after 12-24 weeks of treatment, and the response was dose-dependent throughout the study and at the end of follow-up. The cure rate was significantly higher in patients treated with 1000 mg day(-1) terbinafine compared with those treated with 500 mg day(-1) terbinafine (87% vs. 52%, respectively; P = 0.004). There were no cases of relapse after 24 weeks of follow-up in the 1000 mg day(-1) terbinafine group, compared with six relapses in the terbinafine 500 mg day(-1) group. Terbinafine was well tolerated and the frequency of drug-related AEs was slightly higher in the 1000 mg treatment group. Both doses of terbinafine were well-tolerated and effective for the treatment of sporotrichosis. The 1000 mg day(-1) terbinafine dose was more efficacious than 500 mg day(-1) in the treatment of cutaneous or lymphocutaneous sporotrichosis.

An overview of fungal infections

The incidence of fungal infections is increasing at an alarming rate, presenting an enormous challenge to healthcare professionals. This increase is directly related to the growing population of immunocompromised individuals, resulting from changes in medical practice such as the use of intensive chemotherapy and immunosuppressive drugs. HIV and other diseases which cause immunosuppression have also contributed to this problem. Superficial and subcutaneous fungal infections affect the skin, keratinous tissues and mucous membranes. Included in this class are some of the most frequently occurring skin diseases, affecting millions of people worldwide. Although rarely life threatening, they can have debilitating effects on a person's quality of life and may in some circumstances spread to other individuals or become invasive. Most superficial and subcutaneous fungal infections are easily diagnosed and readily amenable to treatment. Systemic fungal infections may be caused by either an opportunistic organism that infects an at-risk host, or may be associated with a more invasive organism that is endemic to a specific geographical area. Systemic infections can be life threatening and are associated with high morbidity and mortality. Because diagnosis is difficult and the causative agent is often confirmed only at autopsy, the exact incidence of systemic infections is difficult to determine. The most frequently encountered pathogens are Candida albicans and Aspergillus spp. but other fungi such as non-albicans Candida spp. are increasingly important.

Fungal disease in the immunocompromised host

A variety of superficial and deep mycoses may affect the immunocompromised patient. Among the superficial mycoses, candidal infections are common in all groups, but dermatophyte and pityrosporum infections may also be found. Although not primarily dangerous, they may lead to secondary bacterial infections and morbidity. Of the systemic mycoses, candidiasis, aspergillosis, and mucor-mycosis are frequently lethal and require early diagnosis and aggressive antifungal treatment. Endemic mycoses, such as histoplasmosis and coccidioidomycosis, may result in severe and often fatal infections in those patients with cellular immune alterations. The identification and prophylaxis of high-risk patients and the development of more effective antifungal therapies are beginning to have an impact on the control of fungal disease in this population.