Cutaneous infection due to Scedosporium apiospermum in an immunosuppressed patient

Recurrent Scedosporium apiospermum Cutaneous Infection in a Patient with Rheumatoid Arthritis: The Potent Role of IL-6 Signaling Pathway Blockade: A Case-Based Review

Rheumatoid arthritis (RA) patients deal with a higher risk of bacterial and fungal infections compared to the general population because of their dysregulated immune system as well as the immunosuppressive therapy they usually receive. Scedosporium spp. is a fungal pathogen responsible for cutaneous, lung, central nervous system, and eye infections, mostly in immunocompromised patients, leading to death in disseminated cases. We report the case of an 81-year-old woman with rheumatoid arthritis treated with steroids and an IL-6 inhibitor who was diagnosed with scedosporiosis of the upper limb. She was treated with voriconazole for one month, which was discontinued due to adverse events, and when scedosporiosis relapsed, she switched to itraconazole. We also reviewed the current literature on RA patients presenting with Scedosporium infections. Early and accurate diagnosis of scedosporiosis has therapeutic and prognostic implications, as traditionally this fungus is resistant to commonly used antifungals. Clinical alertness regarding uncommon infections, including fungal, in patients with autoimmune diseases on immunomodulatory agents is essential for effective treatment.

Superficial mycoses, a matter of concern: Global and Indian scenario-an updated analysis

Superficial mycoses of skin, nails and hair are among the common fungal infections. They are caused by dermatophytes, non-dermatophyte moulds, yeasts and yeast-like fungi. Such fungal infections are widespread all over the world and are predominant in tropical as well as subtropical regions. Environmental factors, such as warm, humid and pitiable hygienic conditions, are conducive for their growth and proliferation. Although it does not cause mortality, it is known to be associated with excessive morbidity which may be psychological or physical. This affects the quality of life of the infected individuals which leads to a negative impact on their occupational, emotional and social status. Such infections are increasing on a global scale and, therefore, are of serious concern worldwide. This review article covers the global and Indian scenario of superficial mycoses taking into account the historical background, aetiological agents, prevalence, cultural and environmental factors, risk factors, pathogenesis and hygienic practices for the prevention of superficial mycoses.

Fungal Community and Biodeterioration Analysis of Hull Wood and Its Storage Environment of the Nanhai No. 1 Shipwreck

The Nanhai No. 1 shipwreck is a Chinese merchant ship in the Southern Song Dynasty, and now it is stored in a huge enclosed glass warehouse in Maritime Silk Road Museum in Guangdong Province. At present, the hull of the Nanhai No. 1 shipwreck is still being excavated, and a small part of the hull wood is soaked in a specific solution to desalt. Through long-term exploration, we found that the above two states of hull wood had undergone biodeterioration, so the purpose of this study is to analyze the fungal community of exposed and soaked wood from the Nanhai No. 1 shipwreck. We sampled 10 exposed hull wood and sea mud samples, two wood storage water samples, and air samples in the glass warehouse. We used scanning electron microscope and optical microscope to find that there were obvious fungal structures in exposed wood and wood storing water samples. High-throughput sequencing of fungi revealed that the most abundant genera in exposed and soaked wood were Fusarium sp., and Scedosporium sp., respectively. In addition, Fusarium solani and Scedosporium apiospermum were successfully isolated from the hull wood surface and wood storing water samples, and the degradation tests of lignin and cellulose, the sensitivity tests of biocides and growth curve assay were carried out. We also found that Penicillium sp. and Cladosporium sp. are the most abundant in the glass warehouse air. Our research results show that F. solani and S. apiospermum should be regarded as a major threat to the preservation of the Nanhai No. 1 shipwreck. These results provide a reference for our protection of shipwrecks and other similar artifacts.

Localized cutaneous infection caused by Scedosporium apiospermum: Report of a case diagnosed on cytology

Scedosporium apiospermum (also known as Pseudallescheria boydii) is a ubiquitous filamentous fungus. This fungus is known as a cause of mycetoma, which may occur in a normal immune host following trauma and nonmycetoma-localized skin infections without grain production which are much rarer. However, in an immunocompromised host, S. apiospermum may cause a life-threatening infection. We describe a case of S. apiospermum infection of the left middle finger in an immunocompetent patient, which was diagnosed on cytology and later confirmed on culture.

Surgical resection of a rare cutaneous manifestation of Scedosporium apiospermum in a patient who underwent renal transplant

A man aged 47 years who was immunosuppressed following renal transplantation for focal segmental glomerulosclerosis was referred to the Plastic Surgery team for management of a painful, chronic, granulomatous lesion of the right forearm. Serial ultrasound scans and MRI scans were not diagnostic, but microbiological specimens tested positive for the fungus Scedosporium apiospermum The renal transplant graft-which was failing-was removed, allowing him to cease immunosuppression. He then underwent a resection of the lesion and reconstruction with a split thickness skin graft. Analysis of the specimen revealed fibrosis, granulomatosis and a collection of S. apiospermum He was started on voriconazole which, in conjunction with his surgical resection, appears to have kept the disease at bay. With increasing numbers of solid organ transplants and improved survival, this case highlights the growing burden of rare, opportunistic infections, the difficulty in diagnosis and the need for specialist intervention.

Autochthonous cases of mycetoma in Europe: report of two cases and review of literature

BACKGROUND

Mycetoma is a chronic granulomatous infection involving cutaneous and subcutaneous tissues. It is endemic in tropical and subtropical areas, but sporadic cases have been reported also in countries of temperate climate. The purpose of this paper is to review the cases of mycetoma in European subjects (and presumably acquired in Europe), to give an insight in the main factors associated with this condition, and to describe two previously unpublished cases observed at our Centre.

METHODS AND FINDINGS

PubMed was systematically searched for case reports and case series of mycetoma in Europeans reported between 1980 and 2014, using specific search strategies. Two further cases diagnosed by the authors are described. Forty-two cases were collected. Eleven cases were caused by Scedosporium apiospermium, mainly in immunosuppressed patients from Bulgaria, Germany, the Netherlands, Portugal, Slovenia, Spain and the United Kingdom. Excluding all patients with immunosuppression, 29 cases remain. Most of them were reported from Bulgaria and in Albanian patients (all diagnosed outside Albania). In the Bulgarian case series many different micro-organisms, both bacteria and fungi, were isolated, while all the 5 cases from Albania were caused by Actinomadura spp. Other countries reporting cases were Greece, Italy and Turkey. In general, Actinomadura spp is the most frequent causative agent isolated, followed by Nocardia spp and Madurella mycetomatis. The foot was the most reported site involved. Most patients were medically treated, but unfortunately a long-term follow up (at least one year) was available only in a few cases.

CONCLUSIONS

Our review and our own cases suggest that Europeans without travel history can be affected by Madura foot. The lack of a surveillance system is likely to cause an underreporting of cases. Moreover, the unfamiliarity of Western doctors with this peculiar infection may cause a mismanagement, including unnecessary amputations.

Diabetic foot ulcer due to scedosporium apiospermum

We report a case of diabetic foot ulcer caused by Scedosporium apiospermum in a seventy year old male patient with uncontrolled diabetes. Scedosporium apiospermum, the asexual phase of Pseudallescheria boydii a fungus isolated from a variety of natural substrates throughout the world including soil, polluted water, sewage and manure of poultry and cattle. P.boydii is now recognized as a medically important opportunistic fungus. This case has been reported for its rarity.

ScedosporiumSpecies Infections and Treatments

Scedosporium species are now increasingly isolated from immunocompromised and immunocompetent patients. Unfortunately, Scedosporium species infections are generally resistant to amphotericin B, and S. prolificans strains are particularly resistant to presently-available antifungal agents. Here we review the microbiology, expanding epidemiology, numerous clinical presentations, and diagnostic tools available for Scedosporium species infections. Finally, we detail the available in vitro, animal model, and clinical data on the treatment of Scedosporium species infections with special emphasis on the role of newer antifungal therapies for these recalcitrant infections.

Dermatic Scedosporium apiospermum infection after autologous bone marrow transplantation

Infection with Scedosporium apiospermum (S. apiospermum) is rare, although it is associated with a high fatality rate, especially in immunosuppressed patients. A 23-year-old man with acute myelogenous leukemia (AML) (M2) who was pretreated with chemotherapy for autologous bone marrow transplantation developed a skin ulcer on the left groin. After a culture study demonstrated the presence of S. apiospermum, voriconazole was administered and the lesion rapidly improved. Since a diagnosis of S. apiospermum continues to depend on the results of a fungal culture and most isolates of S. apiospermum are resistant to amphotericin B, voriconazole should be considered as the first choice when "mold" is thought to be the causative organism.

Infections caused by Scedosporium spp

Scedosporium spp. are increasingly recognized as causes of resistant life-threatening infections in immunocompromised patients. Scedosporium spp. also cause a wide spectrum of conditions, including mycetoma, saprobic involvement and colonization of the airways, sinopulmonary infections, extrapulmonary localized infections, and disseminated infections. Invasive scedosporium infections are also associated with central nervous infection following near-drowning accidents. The most common sites of infection are the lungs, sinuses, bones, joints, eyes, and brain. Scedosporium apiospermum and Scedosporium prolificans are the two principal medically important species of this genus. Pseudallescheria boydii, the teleomorph of S. apiospermum, is recognized by the presence of cleistothecia. Recent advances in molecular taxonomy have advanced the understanding of the genus Scedosporium and have demonstrated a wider range of species than heretofore recognized. Studies of the pathogenesis of and immune response to Scedosporium spp. underscore the importance of innate host defenses in protection against these organisms. Microbiological diagnosis of Scedosporium spp. currently depends upon culture and morphological characterization. Molecular tools for clinical microbiological detection of Scedosporium spp. are currently investigational. Infections caused by S. apiospermum and P. boydii in patients and animals may respond to antifungal triazoles. By comparison, infections caused by S. prolificans seldom respond to medical therapy alone. Surgery and reversal of immunosuppression may be the only effective therapeutic options for infections caused by S. prolificans.

[Case of cutaneous Pseudallescheria boydii infection caused by trauma]

Pseudallescheria boydii is a ubiquitous filamentous fungus. We report a case of cutaneous P. boydii infection of the left knee in a 79-year-old Japanese man who was receiving oral predonisolone (25 mg/day) for radiation pneumonitis after radiation therapy on left breast cancer. He presented with a 2-week-history of a lesion on the left knee. A biopsy specimen from the skin lesion revealed granulomatous inflammation with hyphae. Culture of the pus from the skin specimen confirmed the diagnosis of cutaneous P. boydii infection. rDNA ITS sequence was analyzed to confirm the mycological diagnosis. The patient was treated orally with 200 mg/day of itraconazole. The lesion was gradually cured and left a hypertrophic scar. Cutaneous injury may be responsible for an incidence of localized infection. Such rare fungus infection in immunocompromised patients who have a persistent traumatic skin ulcer needs to be ruled out. An opportunistic infection in immunocompromised patients can be life-threatening and prompt treatment based on accurate diagnosis is important.

Infecção por Scedosporium apiospermum e tratamento com Voriconazol

A infecção pelo Scedosporium apiospermum pode tornar-se grave quando afeta pacientes imunodeprimidos, contexto em que diagnóstico e tratamento são geralmente difíceis. Os autores apresentam caso de paciente diabética usuária de ciclosporina, metotrexato e corticoesteróide sistêmico para o tramento de artrite reumatóide e que apresentou úlceras cutâneas pelo S. apiospermum. Após uso de itraconazol, sem sucesso, ocorreu resolução do quadro com o uso de voriconazol, nova alternativa para determinadas infecções fúngicas.

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.

Tropical dermatology: fungal tropical diseases

Fungal infections are common in tropical countries and can have an important impact on public health. Lobomycosis is a common fungal infection in the tropical rain forest of South America, and paracoccidioidomycosis (South American blastomycosis) is a widespread and sometimes severe illness. Penicilliosis marneffei is an opportunistic infection of AIDS patients in southeast Asia. Chromoblastomycosis and mycetomas are causes of morbidity around the world. Sporotrichosis is a worldwide subcutaneous mycosis with a high incidence in tropical countries and is an important illness in immunocompromised patients. Rhinosporidiosis was classed as a fungal infection but is now considered a protistan parasite that belongs to the class Mesomycetozoea. It is included in this review because of its historical classification. In the past, most of these mycoses were restricted to specific geographic areas and natural reservoirs. There are, however, situations in which people from other regions come in contact with the pathogen. A common situation involves an accidental contamination of a traveler or worker who has contact with a tropical mycosis. Even minor trauma to the skin surface or inhalation of the fungal conidia can infect the patient. Thus recognition of the clinical symptoms and the dermatologic findings of the diseases, as well as the geographic distribution of the pathogens, can be critical in diagnosis of the tropical mycoses. This review discusses some of the more common tropical subcutaneous and systemic mycoses, as well as their signs, symptoms, methods of diagnosis, and therapies.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be able to recognize the clinical and histologic presentations of tropical fungal diseases with cutaneous manifestations and be familiar with the appropriate therapies.

Subcutaneous infection with Pseudallescheria boydii in an immunocompromised patient

With the broad employment of immunosuppressive therapy, the incidence of Pseudallescheria boydii infections is rising. We report a first case of the localized subcutaneous P. boydii infection in a patient with microscopic polyangiitis. Favorable outcome related to the treatment with voriconazole adds to the growing body of evidence supporting the use of this particular agent in P. boydii infections.

Disseminated subcutaneous nodules caused by Pseudallescheria boydii in an atopic patient

We present a 40-year-old woman with atopic dermatitis and multiple purulent subcutaneous nodules of 20 years' evolution. The biopsy material was cultured and revealed Pseudallescheria boydii. The patient was treated with oral itraconazole for 4 months and incision and drainage of the lesions. Afterwards the patient remained asymptomatic and no new lesions were detected.

Prurigo nodularis: A review

Prurigo nodularis is a chronic condition characterized by a papulonodular pruriginous eruption of unknown aetiology. This condition is a difficult disease to treat and causes frustration to both the patient and the treating doctor. A variety of systemic conditions have been reported to be associated with prurigo nodularis. The mechanism by which these disorders may trigger prurigo nodularis is unknown. Nerve growth factor has been implicated in the pathogenesis of prurigo nodularis. Calcitonin gene-related peptide and substance P immunoreactive nerves are markedly increased in prurigo nodularis when compared with normal skin. These neuropeptides may mediate the cutaneous neurogenic inflammation and pruritus in prurigo nodularis. Topical or intralesional glucocorticoids are the treatment of choice. Other topical treatments such as topical vitamin D3, and topical capsaicin have also been reported to be effective. Oral treatments such as cyclosporin and thalidomide have been shown to improve both appearance of the skin and pruritus. We review the clinical features, associations, pathology, pathogenesis and treatment of prurigo nodularis.

Scedosporium apiospermum soft tissue infection successfully treated with voriconazole: potential pitfalls in the transition from intravenous to oral therapy

An immunocompromised patient with an invasive soft tissue infection due to Scedosporium apiospermum was successfully treated with voriconazole and surgical debridement. After transition from intravenous to oral therapy, successive adjustments of the oral dose were required to achieve complete resolution. For soft tissue infections due to molds characterized by thin, septate hyphae branching at acute angles, voriconazole should be considered a first-line antifungal agent. The potential usefulness of plasma voriconazole levels for guiding optimal therapy should be investigated.

Cutaneous Scedosporium apiospermum Infection in an Immunocompromised Patient and a Review of the Literature

Scedosporium apiospermum (also known as Pseudallescheria boydii) is a ubiquitous filamentous fungus. This fungus is known as a cause of mycetoma, which may occur in a normally immune host following trauma. However, in an immunocompromised host, S. apiospermum may cause a life-threatening infection. We describe a case of S. apiospermum infection of the right hand in a patient who was receiving long-term immunosuppressants for adult Still's disease. We also review the cases of S. apiospermum infection with cutaneous manifestations reported between 1998 and 2003.

Topical antifungal drugs for the treatment of onychomycosis: an overview of current strategies for monotherapy and combination therapy

BACKGROUND

Onychomycosis is a relatively common disease accounting for up to 50% of all nail disorders and its prevalence rises with age. As onychomycosis is an important medical disorder affecting both patient's health and quality of life, it requires prompt and effective treatment.

OBJECTIVE

Topical antifungal nail lacquers have been formulated to provide efficient delivery to the nail unit. As both amorolfine and ciclopirox have proved useful as monotherapy for onychomycosis that does not involve the nail matrix area, the purpose of this article is to check if, when combined with oral agents, the effectiveness and scope of treatment can be improved further.

METHODS

Combining data for mycological cure with clinical success (nail morphology) provides a more exacting efficacy measure.

RESULTS

Clinical investigations have shown that the combination of oral therapies with antifungal nail lacquer can confer considerable advantage over monotherapy with either drug type.

CONCLUSION

The improved effectiveness and economic advantages of combined topical/oral therapies benefit both patients and health providers; these treatment regimens therefore have an important role to play in the modern management of onychomycosis.

Infections Due to Scedosporium apiospermum and Scedosporium prolificans in Transplant Recipients: Clinical Characteristics and Impact of Antifungal Agent Therapy on Outcome

BACKGROUND

Unique characteristics, impact of therapy with antifungal agents, and outcome of infections with Scedosporium species were assessed in transplant recipients.

METHODS

The patients comprised a total of 80 transplant recipients with Scedosporium infections, including 13 patients from our institutions (University of Pittsburgh Medical Center [Pittsburgh, PA], University of Maryland [Baltimore], Duke University Medical Center [Durham, NC], Emory University [Atlanta, GA], and Hospital Gregorio Maranon [Madrid, Spain]) and 67 reported in the literature. The transplant recipients were compared with 190 non-transplant recipients with scedosporiosis who were described in the literature.

RESULTS

Overall, 69% of the infections in hematopoietic stem cell transplant (HSCT) recipients and 53% of the infections in organ transplant recipients were disseminated. HSCT recipients, compared with organ transplant recipients, were more likely to have infections caused by Scedosporium prolificans (P=.045), to have an earlier onset of infection (P=.007), to be neutropenic (P<.0001), and to have fungemia (P=.04). Time elapsed from transplantation to Scedosporium infection in transplant recipients has increased in recent years (P=.002). The mortality rate among transplant recipients with scedosporiosis was 58%. In a logistic regression model using amphotericin B as comparison treatment, voriconazole was associated with a trend towards better survival (odds ratio [OR], 10.40; P=.08). Presence of disseminated infection (OR, 0.20; P=.03) predicted lower survival, and receipt of adjunctive surgery as treatment (OR, 5.52; P=.02) independently predicted a better survival in this model.

CONCLUSIONS

Scedosporium infections in transplant recipients were associated with a high rate of dissemination and a poor outcome overall. The use of newer triazole agents warrants consideration as a therapeutic modality for these infections.

Fungal biocatalysts in the biofiltration of VOC-polluted air

Gas-phase biofilters used for the treatment of waste gases were originally packed with compost or other natural filter beds containing indigenous microorganisms. Over the past decade much effort has been made to develop new carrier materials, more performant biocatalysts and new types of bioreactors. Elimination capacities reached nowadays are 5 to 10 times higher than those originally reported with conventional compost biofilters. With the recently developed inert filter beds, inoculation is a prerequisite for successful start-up and operation. Either non-defined mixed cultures or pure bacterial cultures have originally been used. The search for efficient fungal biocatalysts started only a few years ago, mainly for the biofiltration of waste gases containing hydrophobic compounds, such as styrene, alpha-pinene, benzene, or alkylbenzenes. In this review, recently isolated new fungal strains able to degrade alkylbenzenes and other related volatile organic pollutants are described, as well as their major characteristics and their use as biocatalysts in gas-phase biofilters for air pollution control. In biofiltration, the most extensively studied organism belongs to the genus Exophiala, although strains of Scedosporium, Paecilomyces, Cladosporium, Cladophialophora, and white-rot fungi are all potential candidates for use in biofilters. Encouraging results were obtained in most of the cases in which some of those organisms were present in gas-phase biofilters. They allow reaching high elimination capacities and are resistant to low pH values and to reduce moisture content.