Successful treatment of Acremonium fungemia with voriconazole

Non-Aspergillus Hyaline Molds: A Host-Based Perspective of Emerging Pathogenic Fungi Causing Sinopulmonary Diseases

The incidence of invasive sino-pulmonary diseases due to non-Aspergillus hyaline molds is increasing due to an enlarging and evolving population of immunosuppressed hosts as well as improvements in the capabilities of molecular-based diagnostics. Herein, we review the following opportunistic pathogens known to cause sinopulmonary disease, the most common manifestation of hyalohyphomycosis: Fusarium spp., Scedosporium spp., Lomentospora prolificans, Scopulariopsis spp., Trichoderma spp., Acremonium spp., Paecilomyces variotii, Purpureocillium lilacinum, Rasamsonia argillacea species complex, Arthrographis kalrae, and Penicillium species. To facilitate an understanding of the epidemiology and clinical features of sino-pulmonary hyalohyphomycoses in the context of host immune impairment, we utilized a host-based approach encompassing the following underlying conditions: neutropenia, hematologic malignancy, hematopoietic and solid organ transplantation, chronic granulomatous disease, acquired immunodeficiency syndrome, cystic fibrosis, and healthy individuals who sustain burns, trauma, or iatrogenic exposures. We further summarize the pre-clinical and clinical data informing antifungal management for each pathogen and consider the role of adjunctive surgery and/or immunomodulatory treatments to optimize patient outcome.

Fatal disseminated infection due to Sarocladium kiliense in a diabetic patient with COVID-19

Sarocladium kiliense is a soil saprophytic mold with worldwide distribution, which can infect humans and other mammals, sporadically. The clinical manifestations include mycetoma, onychomycosis, keratomycosis, pneumonia, and arthritis. Here, we present a disseminated infection due to S. kiliense in a diabetic patient infected to coronavirus disease 2019 (COVID-19) from Isfahan, Iran.

Calcaneal osteomyelitis caused by Acremonium sp in an immunocompetent adult - A case report

Fungal osteomyelitis of calcaneus is rare in immunocompetent adults. A case of fungal osteomyelitis of calcaneus in a 19 year old immunocompetent female without any history of trauma caused by Acremonium sp is presented. The patient was treated with surgical debridement, autogenous iliac crest bone grafting and antifungal chemotherapy for 6 months. At latest follow up after 2 years, patient is asymptomatic and the osteolytic lesion is healed with no signs of recurrence. This case report highlights a rare presentation of chronic painful calcaneal osteomyelitis with an osteolytic lesion.

A Rare Case of Brain Abscesses Caused by Acremonium Species

Acremonium species are saprophytic fungi that are rarely pathogenic in humans. According to several reports, Acremonium species can cause various diseases, ranging from superficial infections after traumatic inoculation in immunocompetent individuals to invasive infections in the immunocompromised. To the best of our knowledge, this is the first case report of brain abscess in an 18-year-old male caused by Acremonium species in Pakistan. A combination of intravenous amphotericin B and oral voriconazole was administered to the patient, which resulted in marked clinical improvement. However, the recurrence of fungiwas observed after three months of completion of the antifungal course. The purpose of this report is to alert clinicians regarding this pathogen and its ability to cause systemic disease.

Sarocladium and Acremonium infections: New faces of an old opportunistic fungus

The genera Acremonium and Sarocladium comprise a high diversity of morphologically and genetically related fungi generally found in the environment, although a few species, mainly Sarocladium kiliense and Acremonium egyptiacum, can also be involved in many human infections. Clinical management of opportunistic infections caused by these fungi is very complex, since their correct identification is unreliable, and they generally show poor antifungal response. More than 300 clinical cases involving a broad range of Acremonium/Sarocladium infections have so far been published, and with this review we aim to compile and provide a detailed overview of the current knowledge on Acremonium/Sarocladium human infections in terms of presentation, diagnosis, treatments and prognoses. We also aim to summarise and discuss the data currently available on their antifungal susceptibility, emphasising the promising results obtained with voriconazole as well as their impact in terms of animal infections.

Chronic fungal osteomyelitis of the tibia due to Acremonium curvulum: a rare case

Fungal osteomyelitis is a rare disease which usually presents in an indolent manner. Opportunistic infections due to other non-aspergillus moulds are an emerging entity. We report a case of fungal osteomyelitis due to Acremonium spp in an immunocompetent adult which showed a chronic, indolent course but responded well to treatment with voriconazole. This case highlights the importance of diagnosing the causative agent in fungal osteomyelitis as species specific susceptibility can aid in the treatment of fungal osteomyelitis.

The High Diversity and Variable Susceptibility of Clinically Relevant Acremonium-Like Species in China

Acremonium-like fungi are emerging as important opportunistic pathogens in cutaneous, subcutaneous and serious invasive infections, especially in immunocompromised and debilitated individuals, and Acremonium infections are usually resistant to antifungal therapy. Several molecular studies have demonstrated that many species in the genus Acremonium are polyphyletic, and currently, the genus is restricted to the family Bionectriaceae (Hypocreales). Molecular identification and in vitro antifungal susceptibility tests of Acremonium-like fungi isolated from human clinical specimens in China were performed in this study. Three genetic loci: the large subunit ribosomal RNA gene (LSU), ribosomal internal transcribed spacer and elongation factor 1-α (EF1-α), were used to assess their taxonomic position for correct identification among various species. The multilocus study of twenty-eight strains showed that these strains were distributed in three main lineages: egyptiacum, Cordycipitaceae and Sarocladium; Acremonium egyptiacum and Sarocladium kiliense were the main species of these strains, and three isolates were too phylogenetically distant to be considered undescribed species. Relatively low minimum inhibitory concentrations (MICs) of 0.25-2 and 0.031-0.5 μg/mL were found for voriconazole and terbinafine for most species, respectively. Varied antifungal activities of ciclopirox olamine, amorolfine and posaconazole were found in our study. However, no antifungal effect of sertaconazole, itraconazole or fluconazole was observed against most strains. This is the first study on Acremonium-like species diversity by multilocus sequence analyses and antifungal susceptibility of clinically relevant isolates in China.

Acremonium pneumonia in an AIDS patient

Acremonium is a saprophytic fungus mostly causing superficial skin, nail, or ocular infections after traumatic inoculation. However, it is being recently recognized as one of the opportunistic infections in immunocompromised patients including neutropenia, malignancies, chronic granulomatous disease (CGD) and transplant recipients. To our knowledge there have been no reported cases of Acremonium infection, related to HIV or AIDS. We present a case of Acremonium pneumonia in a patient with no past medical history who was found to have AIDS.

Systemic Acremonium species infection in a dog

A 2-year-old female Magyar Viszla was referred with fever, lethargy, polyuria/polydipsia, and suspected systemic cryptococcosis. At presentation increased rectal temperature and enlarged lymph nodes were detected. Main laboratory abnormalities included lymphocytosis, eosinophilia, and mildly reduced urine specific gravity. Abdominal ultrasound was unremarkable. Lymph node cytology revealed mycotic infection. Acremonium species was isolated from urine as well as from a popliteal lymph node by fungal culture. Therapy with itraconazol (10 mg/kg p. o. q 12 h) was initiated based on susceptibility testing, but dosage had to be reduced by half due to adverse effects. Despite treatment, the dog developed progressive azotemia. Four months after initial presentation, the patient showed anorexia, lethargy, weight loss, diarrhea, vomitus, neurological signs, and severe azotemia and was euthanized. Acremonium species are emerging opportunistic mould fungi that can represent a potential threat for immunocompromised humans. In dogs, only two cases of systemic infection with this fungal species have been reported so far. This case highlights the fact that systemic fungal infections should be considered as a differential in cases of fever and lymphadenopathy.

Cross-Linking Treatment and Corneal Transplant in Refractory Acremonium Keratitis: Case Report

OBJECTIVES

To report a case of Acremonium keratitis treated with voriconazole, corneal collagen cross-linking, and corneal transplant.

MATERIALS AND METHODS

Case report.

RESULTS

A 42-year-old woman who wore contact lenses daily was referred for refractory keratitis. Her main complaints were gritty sensation and pain. At slit lamp biomicroscopy, an infiltrate on the inferior paracentral cornea and an arcuate conjunctival ulceration were evident. The rest of the cornea was clear with no anterior chamber reaction. Scrapings from the corneal ulcer showed Candida parapsilosis and Acremonium species, which were sensitive to voriconazole. Despite the administration of topical, systemic, and intrastromal voriconazole for 1 month, repeat corneal scraping was positive for Acremonium, and clinical appearance and pain did not resolve. Therefore, corneal collagen cross-linking was applied. Although the pain resolved immediately after the procedure, the lesion showed no improvement. After a month of cross-linking, corneal transplant was performed for visual rehabilitation and treatment of the refractory lesion. The excised corneal button was negative for any microorganisms.

CONCLUSIONS

Although corneal collagen cross-linking may be an effective treatment for Acremonium keratitis refractory to medical therapy, corneal transplant was required for visual gain and recovery.

Post-operative endophthalmitis caused by Acremonium falciforme with orbital and extra-orbital involvement following combined cataract and glaucoma surgery: a case report

Introduction

In this report, we describe an unusual case of post-operative Acremonium falciforme endophthalmitis with orbital and extra-orbital involvement following combined cataract and glaucoma surgery.

Case presentation

A 68-year-old Caucasian man with glaucoma presented with endophthalmitis characterized by pain, redness and impaired vision in the left eye fifteen days after combined cataract and filtering surgery. He subsequently underwent a pars plana vitrectomy, with vitreous sampling, silicone oil placement and intra-vitreal injection of antibiotics, but only after a second vitrectomy we identified Acremonium falciforme as the causative agent for the endophthalmitis. An antifungal systemic and topical therapy was started, but meanwhile the infection extended to orbital and peri-orbital tissues. Following these procedures, even if the eye went slowly in phthisis, we were able to limit the further extension and circumscribe the orbital and extra-orbital involvement.

Conclusion

To our knowledge, this report is the first describe Acremonium falciforme endophthalmitis with orbital and extra-orbital involvement, following anterior segment combined surgery. Ophthalmologists and physicians should be aware of the extension risk of a fungal panophthalmitis, but also to potentially serious side effects related to systemic therapy.

ESCMID and ECMM joint guidelines on diagnosis and management of hyalohyphomycosis: Fusarium spp., Scedosporium spp. and others

Mycoses summarized in the hyalohyphomycosis group are heterogeneous, defined by the presence of hyaline (non-dematiaceous) hyphae. The number of organisms implicated in hyalohyphomycosis is increasing and the most clinically important species belong to the genera Fusarium, Scedosporium, Acremonium, Scopulariopsis, Purpureocillium and Paecilomyces. Severely immunocompromised patients are particularly vulnerable to infection, and clinical manifestations range from colonization to chronic localized lesions to acute invasive and/or disseminated diseases. Diagnosis usually requires isolation and identification of the infecting pathogen. A poor prognosis is associated with fusariosis and early therapy of localized disease is important to prevent progression to a more aggressive or disseminated infection. Therapy should include voriconazole and surgical debridement where possible or posaconazole as salvage treatment. Voriconazole represents the first-line treatment of infections due to members of the genus Scedosporium. For Acremonium spp., Scopulariopsis spp., Purpureocillium spp. and Paecilomyces spp. the optimal antifungal treatment has not been established. Management usually consists of surgery and antifungal treatment, depending on the clinical presentation.

Evaluation of the efficacies of Amphotericin B, Posaconazole, Voriconazole, and Anidulafungin in a murine disseminated infection by the emerging opportunistic Fungus Sarocladium (Acremonium) kiliense

We evaluated and compared the efficacies of different antifungal drugs against Sarocladium kiliense (formerly Acremonium kiliense), a clinically relevant opportunistic fungus, in a murine model of systemic infection. Three clinical strains of this fungus were tested, and the therapy administered was as follows: posaconazole at 20 mg/kg of body weight (twice daily), voriconazole at 40 mg/kg, anidulafungin at 10 mg/kg, or amphotericin B at 0.8 mg/kg. The efficacy was evaluated by prolonged animal survival, tissue burden reduction, and (1→3)-β-d-glucan serum levels. In general, the four antifungal drugs showed high MICs and poor in vitro activity. The efficacy of the different treatments was only modest, since survival rates were never higher than 40% and no drug was able to reduce fungal load in all the organs for the three strains tested. Posaconazole, in spite of its high MICs (≥16 μg/ml), showed the highest efficacy. The (1→3)-β-d-glucan serum levels were equally reduced by all drugs evaluated.

Acremonium kiliense: case report and review of published studies

Changes in the spectrum of clinically important fungal infection have been observed in recent years. Acremonium species has been responsible for eumycotic mycetomas but has also been increasingly implicated in systemic fungal diseases. A case of Acremonium kiliense fungemia with proven involvement of the lungs in an allogeneic hematopoietic stem cell patient is reported. A high-resolution computed tomography scan of the lungs showed nodules in both lungs. Multiple cultures of blood demonstrated narrow septate hyphae, cylindrical conidia, and solitary tapering phialides and microconidia that remained grouped in slimy heads. The isolate was identified as A. kiliense based on its morphological characteristics and DNA sequence analysis. Susceptibility testing of the clinical isolate was performed to four antifungal agents. Amphotericin B, fluconazole and itraconazole were found to be inactive in vitro against the isolate; however, it was found to be sensitive to voriconazole. This last drug was indicated, and a high-resolution computed tomography scan of the lungs was normal after 10 days. One year later, the patient was free of symptoms and her blood culture was negative for fungi. Thus, voriconazole was effective in treatment for life-threatening A. kiliense infections. In this work, we performed an overview of worldwide clinical infections caused by A. kiliense.

Phoma and Acremonium invasive fungal rhinosinusitis in congenital acute lymphocytic leukemia and literature review

OBJECTIVE

Invasive rhinocerebral fungal infections are a difficult and often fatal problem in children with hematologic malignancies, with increasing reports of rare pathogens. We describe a case of congenital acute lymphoblastic leukemia (ALL) and invasive fungal rhinosinusitis involving Acremonium and Phoma species, not previously reported in invasive pediatric fungal rhinosinusitis, and review all published cases of human Phoma infections.

METHODS

A literature and institutional review for Phoma spp. was completed including patient demographics, infection site, immune status, treatment and outcome.

RESULTS

A female neonate with acute lymphoblastic leukemia presented with hyperleukocytosis and advanced invasive Phoma and Acremonium spp. rhinosinusitis. Despite aggressive medical and surgical therapy, the disease progressed to a rhinocerebral infection with a fatal outcome. Twenty cases of Phoma spp. were found in a complete literature search, including 6 females and 14 males from 18 months to 77 years old. Infections were superficial in fifteen patients and involved deeper tissue in five patients, with sites including cutaneous, subcutaneous and deep tissue sites (eye, lung, extremity deep tissue compartments).

CONCLUSIONS

This case highlights the risks and grave prognosis of fulminant invasive fungal rhinosinusitis in the context of congenital leukemia, and the potential for rare fungal species in neonates with immunosuppression.

Voriconazole in the management of nosocomial invasive fungal infections

Voriconazole is a new triazole developed for the treatment of life-threatening fungal infections. The drug is available for both oral and intravenous administration; the oral formulation has excellent bioavailability. The side-effect profile of voriconazole presents an acceptable safety and tolerability spectrum: transient visual disturbances, liver enzyme abnormalities, and skin rashes are the most frequently reported side effects but rarely lead to discontinuation. The potential for drug–drug interactions is high, because of its extensive hepatic metabolism. Careful attention to dosage is required, and serum levels and the effects of interacting drugs should be monitored. Review of 25 470 isolates of yeasts and 3216 isolates of filamentous fungi showed voriconazole to have broad-spectrum activity against pathogenic yeasts including intrinsically fluconazole-resistant isolates such as Candida krusei, dimorphic fungi, and opportunistic moulds like Aspergillus spp, amphotericin-B-resistant Aspergillus terreus, Fusarium spp, and Scedosporium apiospermum. It displays excellent clinical efficacy in patients with fluconazole-resistant and -susceptible Candida infections, invasive bone and central nervous system aspergillosis, and various refractory fungal infections. Voriconazole has been approved by the US Food and Drug Administration and by the European Medicines Agency for the treatment of invasive aspergillosis, serious infections caused by Fusarium and S. apiospermum, fluconazole-resistant invasive Candida infections, and candidemia in nonneutropenic patients.

Catheter-Related Acremonium kiliense Fungemia in a Patient with Ulcerative Colitis under Treatment with Infliximab

Acremonium spp. are filamentous, cosmopolitan fungi commonly isolated from plant debris and soil. They are infrequent pathogens in humans. Acremonium fungemia has been reported in neutropenic patients associated with central venous catheters and in nonneutropenic patients receiving long-term total parenteral nutrition. TNF-α blockade is associated with fungal infections, but no Acremonium spp. infection had been reported up to the present. In this paper, we present a patient with ulcerative colitis who developed Acremonium kiliense fungemia associated with infliximab therapy while receiving total parenteral nutrition. The patient was successfully treated with voriconazole. Acremonium sp. infection must be suspected as another cause of fungal infection in patients under treatment with infliximab.

Acremonium kiliense: reappraisal of its clinical significance

A case of Acremonium kiliense peritonitis is described. Diagnosis was established by repeated isolation of the fungus from peritoneal dialysate and by its identification on the basis of morphological characteristics and sequencing of internal transcribed spacer (ITS) regions of ribosomal DNA (rDNA). This report and available literature suggest that A. kiliense may have a greater clinical significance than hitherto recognized.

Recurrent Acremonium infection in a kidney transplant patient treated with voriconazole: a case report

Acremonium infection is rare and associated with immunosuppression. A case of recurrent cutaneous Acremonium infection after short term voriconazole use is described. Surgical resection was the definitive therapy. Oral voriconazole was used in the treatment of Acremonium infection, but recurrence was associated with short therapy. Prolonged antifungal therapy and surgical resection are discussed for the treatment of localized lesions.

Case report of Acremonium intraocular infection after cataract extraction

A 64-year-old woman was referred to our clinic for the treatment of chronic uveitis in her left eye, which had started two weeks after an uncomplicated cataract extraction. She was treated with topical steroids with an initially good response, yet she subsequently developed severe inflammation and plaque-like material around the intraocular lens, despite continuous steroid therapy. She underwent pars plana vitrectomy, smear and culture of the aqueous and vitreous fluids, and intravitreal antibiotic injection under the impression of Propionibacterium acne (P. acne) endophthalmitis. As a result of the smear and culture of the vitreous fluid identified as an Acremonium species, she was treated with intravenous amphotericin B injections for five days, followed by oral voriconazole administration. During the post-operative 18-month follow-up, she was stable without significant relapse of uveitis. In this case, the best correction of visual acuity was an improvement from 20/40 to 20/20.

Acremonium strictum fungaemia in a paediatric immunocompromised patient: diagnosis and treatment difficulties

During the past two decades, an increasing number of unusual moulds has been reported as responsible for septicaemia and systemic or disseminated infections in immunocompromised patients. Investigation of fever in a 10-year-old boy with acute myeloblastic leukaemia, including blood cultures on selective media, allowed the diagnosis of a fungaemia due to the slow-growing fungus Acremonium strictum. The patient recovered with liposomal amphotericin B (AmB) and voriconazole, followed by voriconazole alone due to AmB resistance. Facing a neutropenic patient with fever, clinicians usually suspect bacterial or viral aetiologies. This case, however, illustrates the need for mycological analysis of blood samples in febrile neutropenic patients and for antifungal susceptibility testing.

Lethal double infection with Acremonium strictum and Aspergillus fumigatus during induction chemotherapy in a child with ALL

Fungal infections are a major cause of morbidity and mortality in patients during chemotherapeutic treatments and malignant hematologic disease. We present a case of a double fungal infection with disseminated Acremonium strictum (A. strictum) and pulmonary Aspergillus fumigatus (A. fumigatus) and its rapid clinical course. A 17-year-old boy with prolonged neutropenia developed a disseminated fungal infection during induction chemotherapy of his acute lymphoblastic leukemia. The infection was rapidly lethal despite neutrophil recovery and early antifungal combination therapy with amphotericin B and caspofungin. Since there are only a few reports about invasive Acremonium infections, we present this case with regard to differences in the clinic pathologic features of Aspergillosis and other opportunistic fungal infections due to Fusarium or Acremonium species.

Indicaciones actuales de voriconazol en pacientes onco-hematológicos

Invasive fungal infections (IFI) are the main cause of infectious death in cancer patients, especially in hematological malignancies and hematopoietic transplant recipients. Current epidemiology is characterized by a predominance of IFI caused by molds, mainly aspergillosis, along with a emergence of hard-to-treat fungi such are Zygomicetes, Fusarium and Scedosporium. Voriconazole is a broad spectrum antifungal agent with oral and intravenous formulations, approved by the EMEA for the treatment of invasive aspergillosis, candidemia in non-neutropenic patients, IFI caused by fluconazole-resistant species of Candida as well as Scedosporium and Fusarium infections. However, its use in clinical practice is broader, as empirical antifungal treatment and as secondary prophylaxis. It should be kept in mind the possibility of breakthrough IFI, particularly zygomycosis, in patients treated with voriconazole for long periods.

Acremonium Vertebral Osteomyelitis: Molecular Diagnosis and Response to Voriconazole

We present a case of Acremonium vertebral osteomyelitis that relapsed despite surgical debridement and prolonged treatment with liposomal amphotericin B, but which responded to voriconazole therapy. The report highlights the role of molecular diagnosis of rare fungal osteomyelitis. The patient was successfully treated with voriconazole.

Emerging fungal pathogens in pulmonary disease

PURPOSE OF REVIEW

Invasive fungal infections of the lung have been increasing due to the increase of the population most at risk. This review aims to describe some of the emerging fungal pathogens and their complex management.

RECENT FINDINGS

With the increase in immunosuppressed populations, physicians are increasingly encountering uncommon fungal pathogens that historically have been difficult to identify and treat. Many of these fungal infections present with similar clinical features and often show similar histopathological changes. Treatment options are more complex because of an increasing number of antifungals that have become available for clinical use. The correct usage of these antifungals in addressing emerging fungal infections is unclear, however. Drawing from in-vitro and in-vivo susceptibility testing and case reports, some deductions may be made for the best empirical treatment of these deadly diseases. In general, the newer triazoles (voriconazole and posiconazole) and the use of combination therapy have shown promise.

SUMMARY

Invasive fungal infections are on the increase and contribute significantly to overall mortality, particularly among transplant recipients. With the lack of well designed controlled clinical studies, physicians will need to draw from previously described cases and in-vitro susceptibility testing to optimize therapy.

Voriconazole: a broad spectrum triazole for the treatment of serious and invasive fungal infections

For many years, serious systemic fungal infections have been treated with amphotericin B or narrow-spectrum azole antifungals. These treatments have been effective in many patients, but are associated with tolerability or pharmacokinetic concerns, or suboptimal antifungal activity in some patient groups. Voriconazole is a second-generation triazole with an extended spectrum of activity offering the potential to treat life-threatening fungal infections. The drug is available for intravenous or oral administration and has been shown to be effective in invasive aspergillosis, fluconazole-susceptible and -resistant candidiasis, and infections caused by various other fungal pathogens, including some formerly refractory organisms. Voriconazole is generally well tolerated with transient visual disturbances, liver enzyme abnormalities and skin rashes being the most common adverse events reported, but these rarely lead to treatment discontinuation.

Emerging Fungi

The hyalohyphomycetes (especially Fusarium spp) have emerged as significant pathogens in severely immunocompromised patients. Human infections by Fusarium spp can be superficial or limited to single organs in otherwise healthy patients. Such infections are rare and tend to respond well to therapy. By contrast, disseminated fusarial hyalohyphomycosis affects the immunocompromised host and frequently is fatal. Successful outcome is determined by the degree of immunosuppression and the extent of the infection. These infections may be suspected clinically on the basis of a constellation of clinical and laboratory findings, which should lead to prompt therapy.

Treatment of invasive infections due to rare or emerging yeasts and moulds

Emerging fungal infections represent a serious problem in an immunocompromised host. Rapid developments in in vitro antifungal susceptibility testing and the availability of several new antifungal agents have provided excellent opportunities to treat infections that are caused by various Candida spp. and to some extend by Aspergillus spp. However, recently the epidemiology of fungal infections has significantly changed and several new pathogens have emerged. This article attempts to summarise the available data on the management of emerging infections with fungal infections that have recently gained importance. Updated recommendations on antifungal treatment are also discussed.

Tratamiento de las infecciones fúngicas invasoras

Invasive fungal infections have increased progressively in the last decades, producing elevated morbidity and mortality. In recent years, there have been numerous advances in the treatment of these diseases, with the introduction of new drugs in clinical practice and the information derived from several types of studies. This has improved the prognosis of some invasive fungal infections and increased the therapeutic options in various clinical situations. This new knowledge must be assessed to determine its application in clinical practice, taking into account available scientific evidence and clinical experience. With this aim, the Andalusian Society of Infectious Diseases has developed this consensus document containing recommendations for the treatment of the invasive fungal infections.

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.

Acremonium pyomyositis in a pediatric patient with acute leukemia

Invasive Acremonium infection in humans is rare. We report a patient with leukemia who developed pyomyositis due to Acremonium species. Painful cutaneous nodules and severe myalgia were the first clinical manifestations during the neutropenic stage after chemotherapy. Magnetic resonance image (MRI) revealed multiple nodular lesions scattered along the intramuscular regions of the lower legs. Culture of an aspiration grew Acremonium species. Surgical drainage was performed. Although all antifungal agents tested showed no in vitro inhibitory activity, we successfully treated this patient with amphotericin B, granulocyte colony-stimulating factor (G-CSF), and surgical drainage.