ESCMID and ECMM joint clinical guidelines for the diagnosis and management of systemic phaeohyphomycosis: diseases caused by black fungi

Diagnosis of Cladophialophora bantiana cerebral infection by clinical metagenomics

PURPOSE

Cladophialophora bantiana is a rare cause of severe central nervous system phaeohyphomycosis.

RESULTS

A 44-year-old woman from Northeastern Brazil with a history of scotomas, mental confusion, and impaired coordination presented Magnetic Resonance Imaging with vasogenic edema and nodular enhancement in the left occipital lobe. Brain biopsy showed neutrophilic exudate with eosinophils, macrophages, giant multinucleated cells, and septate hyphae with a brown-colored birefringent wall and acute angle branching. Metagenomic analysis of the biopsy's total RNA revealed the presence of RNA sequences highly similari to C. bantiana. Culture confirmed the presence of olivaceous-gray suede-like to floccose colonies, with septate dematiaceous hyphae and long conidia chains from undifferentiated conidiophores, consistent with C. bantiana.

CONCLUSIONS

This case highlights the potential of metagenomic testing as a tool for early diagnosis of infections caused by uncommon fungal pathogens. To our knowledge, this is the first report of C. bantiana central nervous system infection in Brazil.

Phialophora americana infection in a patient with a compound heterozygous CARD9 mutation

Phaeohyphomycosis caused by Phialophora americana is relatively rare in clinical practice. Deficiency in the human caspase recruitment domain-containing protein 9 (CARD9) is associated with infections caused by Phialophora americana. In this case, the patient has had a decade-long history of recurrent tinea corporis and recently presented with an invasive, deep subcutaneous infection in the right axilla caused by Phialophora americana. Metagenomic next-generation sequencing (mNGS) confirmed that the pathogen infecting the patient was Phialophora americana. Whole exome sequencing (WES) revealed that the patient had compound heterozygous CARD9 gene mutations, with a c.952-1G > A mutation in intron 6 and a c.184 + 5G > T mutation in intron 2. The expression of the CARD9 protein and the levels of cytokines, including IL-17 and IFN-γ, were observed to be decreased in the patient. After an ineffective treatment with amphotericin B, voriconazole was administered for antifungal therapy and yielded satisfactory results. Following discharge, the patient continued oral voriconazole for ongoing antifungal treatment. One month after discharge, the patient returned to the hospital for a follow-up examination, during which it was observed that the symptoms had been successfully resolved. The novel compound heterozygous mutations may lead to CARD9 deficiency, which in turn results in susceptibility to Phialophora americana infection.

American Society of Transplantation and Cellular Therapy Series: #8-Management and Prevention of Non-Aspergillus Molds in Hematopoietic Cell Transplantation Recipients

The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to create a guideline focusing on non-Aspergillus invasive molds, which are uncommon yet lethal invasive fungal diseases in the peri-hematopoietic cell transplant (HCT) period. We used a compendium-style approach by dissecting this broad, heterogeneous, and highly complex topic into a series of standalone frequently asked questions (FAQs) and tables. Adult and pediatric infectious diseases and HCT content experts developed, then answered FAQs, and finalized topics with harmonized recommendations. All the evidence for non-Aspergillus invasive mold infection is non-RCT and mostly level III, therefore there are no recommendation grades, and instead key references are provided. Through this format, this "8th" topic in the series focuses on the relevant risk factors, diagnostic considerations, prophylaxis, and treatment approaches relevant to rare mold infections in the pre- and post-transplant periods.

Cerebellar abscess caused by Cladophialophora bantiana involving an elderly Japanese woman

Phaeohyphomycosis is a rare fungal infection that presents significant challenges in diagnosis and treatment. Herein, we document a case of a cerebellar abscess caused by Cladophialophora bantiana. A 77-year-old woman with type 2 diabetes mellitus and a previous history of diffuse large B-cell lymphoma gradually developed ataxia and was transferred to an emergency department. Head imaging investigations indicated a cerebellar mass and the patient underwent an emergent endoscopic drainage. Although bacterial cultures of the drainage specimen yielded no growth, a dematiaceous fungus was isolated and subsequently identified as C. bantiana through ITS sequencing analysis. The patient received antifungal combination therapy, initially with liposomal amphotericin B and voriconazole, and finally posaconazole and 5-fluorocytosine. Brain abscesses caused by C. bantiana are rarely documented, and an optimal treatment strategy has yet to be established. Given the high fatality rate, an early surgical intervention is crucial for both diagnosis and treatment. The present case was successfully treated with minimally invasive surgical intervention alongside the antifungal combination therapy.

Fungal β-Glucans: Biological Properties, Immunomodulatory Effects, Diagnostic and Therapeutic Applications

Research from the past to the present has shown that natural ingredients in the human daily diet play a crucial role in preventing various diseases. One well-known compound is β-glucan, a natural polysaccharide found in the cell walls of many fungi, yeasts, and some microorganisms, as well as in plants such as barley and wheat. β-glucans are widely recognized for their ability to lower cholesterol and blood glucose levels, thereby reducing the risk of cardiovascular disease and diabetes. In addition to their effects on lipid levels and glucose metabolism, these molecules exhibit antioxidant properties by eliminating reactive oxygen species. As a result, they help lower the risk of conditions such as atherosclerosis, cardiovascular disease, neurological disorders, diabetes, and cancer. Furthermore, β-glucans have been reported to possess immune-boosting and antitumor effects. By binding to specific receptors on the surface of immune cells, they stimulate immune activity. Additionally, β-glucans belong to a group of probiotics that promote the growth and activity of beneficial gut microbiota, preventing the proliferation of harmful pathogens. They play a vital role in maintaining gastrointestinal health, reducing inflammation, and lowering the risk of colon cancer. Further research on the health benefits of β-glucans may be key to improving overall well-being and preventing many chronic non-communicable diseases such as diabetes, high cholesterol, obesity, cardiovascular disease, and cancer.

Dematiaceous Molds

Dematiaceous molds are darkly pigmented environmental molds found worldwide, especially prevalent in tropical and subtropical regions. Common genera include Bipolaris, Cladophialophora, Exophiala, and Alternaria. They cause disease in both immunocompetent and immunocompromised individuals, presenting as cutaneous infections, allergic sinusitis, pneumonia, and, rarely, disseminated infections. Contaminated medical products have also led to fungal meningitis outbreaks. Treatment typically involves itraconazole, voriconazole, or posaconazole, along with source control and reduction in immunosuppression, if possible. Newer antifungals may have a role in treatment. Mortality is high in disseminated disease, especially with Lomentospora prolificans in immunocompromised individuals, prompting global efforts to improve diagnostics and treatments.

Polyextremotolerant, opportunistic, and melanin-driven resilient black yeast Exophiala dermatitidis in environmental and clinical contexts

Exophiala dermatitidis, a polyextremotolerant black yeast, thrives in diverse natural and human-made environments. Additionally, it is an opportunistic pathogen, capable of infecting immunocompromised individuals, particularly causing neurotropic infections. This study examined 41  E. dermatitidis strains from diverse environments, investigating their growth under different temperatures, NaCl concentrations, and pH levels. Optimal growth occurred at 28 °C, with large variations among strains at other temperatures, from 4 to 42 °C. Growth was enhanced at 5% NaCl, though strains also grew at 10% and 17% NaCl. Growth varied across different pH levels, from pH 2.5 to 12.5. Most strains showed the highest biofilm formation at 37 °C, α- and γ-hemolysis and resistance to antifungal agents. Better growth was detected on neurotransmitters than on (poly)aromatic compounds. High-throughput metabolic analyses revealed consistent oxidation patterns across 94 carbon sources in five selected strains. Genomic analysis revealed a diverse repertoire of carbohydrate-active enzymes and pathways for degrading polyaromatic hydrocarbons and neurotransmitters. Melanin biosynthesis inhibitor tricyclazole minimally affected E. dermatitidis growth under stress, but induced morphological changes in some cases. This study underscores E. dermatitidis' urban extremophilic nature, with high resilience, metabolic adaptability, and potential for heightened pathogenicity in evolving global conditions.

A case of disseminated autochthonous Cladophialophora bantiana infection in a renal transplant recipient in the UK

Disease associated with Cladophialophora bantiana infection is uncommon but can be characterised by severe and life-threatening CNS involvement. Diagnosis is challenging due to both the infection's rarity and non-specific clinical presentation, which can mimic malignancy and infection caused by more common organisms. Transmission can occur via inhalation or inoculation through compromised skin, followed by haematogenous dissemination to the brain and other organs. We report a case of a 42-year-old renal transplant recipient with no travel history presenting with neurological symptoms and skin and lung lesions due to C bantiana infection. An aggressive treatment approach comprising combination antifungal therapy, surgical debridement, and withdrawal of immunosuppression resulted in disease control, although this treatment was complicated by voriconazole-induced skeletal fluorosis. This organism, more commonly encountered in tropical regions, has traditionally been considered imported into the UK by returning travellers, therefore this case of autochthonous infection could reflect an expanding range alongside global climactic shifts.

Impact of an institutional antifungal stewardship program on antifungal usage and outcomes in patients with invasive fungal infections

Therapeutic and prophylactic use of antifungals is rising continuously. However, inadequate awareness of diagnostic and treatment guidelines and limited laboratory modalities lead to inappropriate use. This study assessed the impact of an institutional antifungal stewardship program on antifungal use practices and patient outcomes. In the pre-intervention phase, data was collected regarding antifungal therapy among patients with invasive fungal infections. Appropriateness of antifungal prescription was assessed. In the intervention phase, simple algorithms for diagnosis and management of fungal infections were prepared from international guidelines and incorporated into a booklet for distribution. Monthly training sessions were conducted. New serological and molecular tests and therapeutic drug monitoring were introduced. In the post-intervention phase, an antifungal stewardship team was constituted for clinical advisory on demand and ongoing training. Data regarding antifungal therapy was collected and compared with pre-intervention data. Untreated patients decreased from 25% to 18.9% post-intervention (P = .28). Appropriate antifungal use increased from 72.6% to 77.9% (P = .4) among patients with a single fungal infection, and from 57.1% to 88.5% (P = .04) for at least one infection among those with dual fungal infections. 49 incidents of inappropriate use in various categories were seen among 75 patients receiving antifungals pre-intervention, decreasing to 42 incidents among 94 patients post-intervention (P = .06), particularly evident among patients with dual infections (P = .002). Mortality increased from 51% to 75.86% post-intervention (P = .0001). Overall, the small improvement noticed in antifungal usage pattern can still be considered significant, given the limited study period.

A fatal case of disseminated Cladophialophora bantiana infection in a renal transplant recipient

Dematiaceous molds often cause noninvasive disease but have the potential to cause disseminated infection, particularly in immunosuppressed hosts. Cladophialophora bantiana is the most neurotropic of dematiaceous molds and is associated with brain abscesses, but disseminated infection is quite rare. Here we present a case of disseminated C. bantiana in a 67-year-old renal transplant recipient with multifocal soft tissue, bone and presumed central nervous system involvement. C. bantiana infections have been associated with significant mortality and our patient had progression of his disease despite intensive dual antifungal therapy with close therapeutic drug monitoring. There was a delay in diagnosis and initiation of antifungal therapy as the multifocal disease was presumed to represent a malignant process. This case review highlights the importance of having a high index of suspicion for disseminated fungal infection in immunocompromised patients and the need for tissue biopsy to aid in the prompt and timely diagnosis and initiation of empiric antifungal therapy, with concomitant surgical management whenever possible to improve patient outcomes.

Nomenclature for human and animal fungal pathogens and diseases: a proposal for standardized terminology

Medically important pathogenic fungi invade vertebrate tissue and are considered primary when part of their nature life cycle is associated with an animal host and are usually able to infect immunocompetent hosts. Opportunistic fungal pathogens complete their life cycle in environmental habitats or occur as commensals within or on the vertebrate body, but under certain conditions can thrive upon infecting humans. The extent of host damage in opportunistic infections largely depends on the portal and modality of entry as well as on the host's immune and metabolic status. Diseases caused by primary pathogens and common opportunists, causing the top approximately 80% of fungal diseases [D. W. Denning, Lancet Infect Dis, 24:e428-e438, 2024, https://doi.org/10.1016/S1473-3099(23)00692-8], tend to follow a predictive pattern, while those by occasional opportunists are more variable. For this reason, it is recommended that diseases caused by primary pathogens and the common opportunists are named after the etiologic agent, for example, histoplasmosis and aspergillosis, while this should not be done for occasional opportunists that should be named as [causative fungus] [clinical syndrome], for example, Alternaria alternata cutaneous infection. The addition of a descriptor that identifies the location or clinical type of infection is required, as the general name alone may cover widely different clinical syndromes, for example, "rhinocerebral mucormycosis." A list of major recommended human and animal disease entities (nomenclature) is provided in alignment with their causative agents. Fungal disease names may encompass several genera of etiologic agents, consequently being less susceptible to taxonomic changes of the causative species, for example, mucormycosis covers numerous mucormycetous molds.

Cladosporium cladosporioides brain abscess: an enigmatic case

A fifteen-year-old boy was brought to emergency department with complaints of altered sensorium, aphasia and right sided hemiparesis following severe dengue one month back. On physical examination, tone was flaccid and power was diminished in right upper and lower limbs. Reflexes were diminished in all four limbs. Magnetic resonance imaging showed multiple well defined thin walled ring-enhancing lesions in left basal ganglia, bilateral cerebellum, left occipital lobe and bilateral fronto-temporo-parietal lobes. The basal ganglia focus was tapped. Potassium hydroxide-calcofluor white mount of the intra-operative pus sample showed fragmented septate hyphae with folding and with wide variations in breadth. A provisional report of septate and aseptate hyphae suggestive of mixed infection was given. Empirical voriconazole was stopped and the patient was started on liposomal amphotericin B to cover a broader spectrum of molds. Subsequently, fungal culture of the pus sample grew off-white glabrous colonies in multiple culture tubes. On lactophenol cotton blue mount, shield cells were seen suggestive of Cladosporium spp. Amphotericin B was stopped after provisional identification of Cladosporium spp. was given by the laboratory and IV voriconazole was started. The identification was confirmed to be Cladosporium cladosporioides by microculture and sequencing of the internal transcribed spacer region of the 18s ribosomal DNA. The patient improved with drainage of the largest basal ganglia focus and voriconazole. This case exemplifies the potential of saprobic fungi to cause invasive infections in human.

Simultaneous distinct cutaneous fungal infections with chromoblastomycosis due to Exophiala xenobiotica and hyalohyphomycosis due to Scedosporium apiospermum in a patient with severe cellular immunodeficiency

Deep-seated dermatomycosis is a rare disease that is often caused by trauma and/or systemic immunodeficiency. We describe a case of chromoblastomycosis complicated by hyalohyphomycosis that occurred simultaneously at different sites. A 92-year-old Japanese man who had been taking oral prednisolone for an IgG4-related respiratory disease visited our clinic. He developed brownish plaques with grayish-white scales with pseudo-carcinomatous hyperplasia and numerous brownish muriform cells developing in the dermis of his right hand, and multiple painful abscesses with pustules and papules and numerous hyphae within and around the histiocytes in the dermis of his right lower leg. Upon skin tissue culture and DNA sequencing, Exophiala xenobiotica and Scedosporium apiospermum were detected separately. He had severe cellular immunodeficiency indicated by low levels in the phytohemagglutinin (PHA)-stimulated lymphocyte transformation test (LTT) and serum interferon-gamma (IFN-γ), although his humoral immunity was normal. The patient died of bacterial pneumonia, despite antifungal drug treatment for 2 months. IFN-γ producing type 1 T helper (Th1) cells play an important role in the defense against fungal infections, however, corticosteroids specifically suppress Th1 cell responses and promote the induction of fungal infection. Measurement of PHA-stimulated LTT and serum IFN-γ may be useful in determining the severity and prognosis of deep-seated dermatomycosis in patients undergoing corticosteroid treatment.

Neglected Pulmonary Infection Caused by Exophiala dermatitidis Misidentified as Rhodotorula spp

Exophiala dermatitidis is an emerging black fungus that causes pulmonary infections that may be underestimated by conventional culture methods. We encountered one case that initially appeared to be yeast and was misidentified as Rhodotorula spp. using a commercial identification kit. Thus, genetic identification and clinical background investigations were conducted on 46 strains of Rhodotorula spp. The sequences of the internal transcribed spacer and large-subunit RNA genes (D1/D2 regions) of 43 isolates, excluding two environmental isolates and one difficult-to-culture isolate, were determined and genetically identified. Notably, 22 isolates were identified as E. dermatitidis and misidentified as Rhodotorula spp. using the conventional method. Based on the exclusion criteria, the clinical information of 11 patients was retrospectively reviewed. Five cases (definite) had definite exacerbation of pulmonary infections due to E. dermatitidis, and six cases (possible) had undeniable infections. Of the 11 cases of pulmonary infection suggested to be caused by E. dermatitidis, comorbidities included two cases of chronic pulmonary aspergillosis (CPA), three cases of pulmonary non-tuberculous mycobacterial (NTM) infection and one case of pulmonary nocardiosis, suggesting a trend towards simultaneous detection of chronic pulmonary infections. Steroid and immunosuppressive drug use was observed in five cases, and β-D-glucan elevation was observed in three of five definite cases of pulmonary infections due to E. dermatitidis. The possibility of E. dermatitidis infection should be considered when Rhodotorula spp. are isolated from cultures of airway-derived specimens, and, in addition to CPA and NTM, identification of E. dermatitidis may be important in chronic pulmonary infections.

A Rare Case of Cladophialophora bantiana Intracranial Infection: Highlighting the Utility of Next-Generation Sequencing in Diagnosis

Cladophialophora bantiana is a dematiaceous fungi and the most common cause of cerebral phaeohyphomycosis. Here, we report a rare case of cerebral ventriculitis with development of a cerebral abscess due to C. bantiana diagnosed by cell-free DNA next-generation sequencing. Noninvasive diagnostics led to earlier disease identification and initiation of antifungal therapy, which has the potential to reduce mortality in this highly fatal disease.

Invasive phaeohyphomycosis co-infection with Alternaria spp. and Curvularia spp. in a neutropenic host

Phaeohyphomycoses are infections caused by dark-walled dematiaceous fungi. Alternaria and Curvularia are two genera of dematiaceous molds known to cause invasive fungal rhinosinusitis, particularly in immunocompromised patients. Co-infection with two dematiaceous fungi is rarely reported in the literature. This report describes a case of biopsy proven invasive fungal rhinosinusitis with Alternaria spp. and Curvularia spp. co-infection in a neutropenic host. The infection characteristics, microbiologic findings, and treatment are described.

Cutaneous phaeohyphomycosis presenting as multiple ecthyma-like skin lesions caused by Curvularia lunata in a previously healthy man: A case report

Ecthyma grangrenosum is an unusual condition, mostly related to Pseudomonas septicemia. Ecthyma-like skin lesions caused by cutaneous phaeohyphomycosis are extremely rare. Here, we report a case of a 20-year-old Thai man, previously healthy, presenting multiple ecthyma-like skin lesions in both arms and both legs for 2 months. Physical examination revealed ill-defined erythematous plaque with central necrotic crust at both arms and both legs. Tissue biopsy showed a neutrophil collection identified by GMS stain revealing septate hyphae organisms in the vascular lumen. The skin culture was positive for Curvularia lunata, while the final diagnosis was cutaneous phaeohyphomycosis caused by Curvularia lunata. He was empirically treated with amphotericin B and then voriconazole. Itraconazole was administered as a definitive regimen, resulting in complete resolution after 2 months of treatment. Cutaneous phaeohyphomycosis is also an uncommon cause of ecthyma-like lesions and should be considered for investigation when initial results do not demonstrate a bacterial etiology.

In vitro evaluation of antifungal combinations against neurotropic dematiaceous fungi associated with primary cerebral phaeohyphomycosis

Primary cerebral phaeohyphomycosis is a life-threatening disease caused by neurotropic dematiaceous fungi. At present, there are no consensus guidelines regarding optimal antifungal therapy in such cases. Generally, a combination of antifungal agents is recommended for treatment. However, the activities of antifungal combinations against these fungi have not been investigated. In this study, we evaluated the in vitro activities of 13 double and five triple antifungal combinations against clinical isolates of Cladophialophora bantiana (n = 7), Fonsecaea monophora (n = 2), and Cladosporium cladosporioides (n = 1), using a simplified checkerboard procedure. The minimum inhibitory concentrations (MICs) of nine antifungal drugs were determined by the broth microdilution method, and the interaction between antifungal agents in each combination was assessed by the fractional inhibitory concentration index. Excellent activity was observed for posaconazole and itraconazole. Flucytosine had potent activity against C. bantiana but was ineffective against F. monophora, and C. cladosporioides. The echinocandins demonstrated high MICs for all the isolates. Synergistic interactions were observed for all the double combinations, except when itraconazole was combined with either amphotericin B or flucytosine. The combination of amphotericin B with caspofungin showed synergistic interactions against 40% of the isolates. Antagonism was observed with isavuconazole-flucytosine combination against two C. bantiana isolates. The triple combinations of caspofungin and flucytosine with amphotericin B or posaconazole were synergistic against one isolate of F. monophora. For C. cladosporioides, synergy was observed for the triple combination of amphotericin B with caspofungin and flucytosine. Our results indicate that combination of caspofungin with amphotericin B or a triazole, with or without 5-flucytosine has great potential against neurotropic dematiaceous fungi.IMPORTANCEThis research uses a modified version of the checkerboard assay to standardize the in vitro testing of double and triple combinations of antifungal agents against neurotropic dematiaceous fungi. Antifungal combination therapy is associated with improved outcomes in cerebral phaeohyphomycosis. In this study, we demonstrate that posaconazole is the single most active antifungal drug against this group of fungi. The double combination of amphotericin B with caspofungin or a trizole, and the triple combinations of caspofungin and flucytosine with amphotericin B or posaconazole might hold promise in the treatment of cerebral phaeohyphomycosis. Our findings will guide in developing optimal therapeutic strategies for these refractory infections.

Facial cutaneous phaeohyphomycosis in an immunocompetent individual

ABSTRACT

Fungal infection is a rare condition in immunocompetent individuals, and it is associated with high rates of morbidity and mortality. We report on a case of cutaneous phaeohyphomycosis in healthy 25-year-old man. Based on the clinical findings, the case was first thought to be cervico-facial actinomycosis, but Alternaria was identified on the culture after debridement. Simple surgical excision resulted in the complete cure without administration of systemic antifungals.

Disseminated phaeohyphomycosis due to Cladophialophora bantiana in an immunocompetent child

A 3-year-old boy presented with acute headache, vomiting and right focal clonic seizures without history of fever, joint pain or altered sensorium. Neuroimaging showed multifocal contrast enhancing lesions with significant perilesional edema. CECT chest and abdomen showed multiple variable sized nodules in the lungs and hypodense lesion in liver with mesenteric lymphadenopathy. There was persistent eosinophilia with maximum upto 35 %. Liver biopsy and brain biopsy revealed Cladophialophora bantiana. He was treated with IV liposomal amphotericin and voriconazole for 6 weeks with repeat neuroimaging showing more than 50 % resolution of the intracranial lesions. He was transitioned to oral combination of flucytosine and voriconazole. At 14 months follow-up, he remained symptom free with complete radiological resolution of the lesions and no eosinophilia. High suspicion, an aggressive approach in obtaining microbiological diagnosis and timely combination antifungal therapy may give satisfactory outcome without surgery.

Fusarium, Scedosporium and Other Rare Mold Invasive Infections: Over Twenty-Five-Year Experience of a European Tertiary-Care Center

Invasive mold infections (IMD) are an emerging concern due to the growing prevalence of patients at risk, encompassing but not limited to allogeneic hematopoietic stem cell transplant recipients, hematological malignancies patients, solid organ transplant recipients and intensive care unit patients. In contrast with invasive aspergillosis and mucormycosis, other hyalohyphomycoses and phaeohyphomycoses remain poorly known. We conducted a retrospective analysis of the clinical, biological, microbiological and evolutive features of 92 IMD having occurred in patients in our tertiary-care center over more than 25 years. A quarter of these infections were due to multiple molds. Molds involved were Fusarium spp. (36.2% of IMD with a single agent, 43.5% of IMD with multiple agents), followed by Scedosporium spp. (respectively 14.5% and 26.1%) and Alternaria spp. (respectively 13.0% and 8.7%). Mortality at day 84 was higher for Fusarium spp., Scedosporium spp. or multiple pathogens IMD compared with Alternaria or other pathogens (51.7% vs. 17.6%, p < 0.05). Mortality at day 84 was also influenced by host factor: higher among hematology and alloHSCT patients than in other patients (30.6% vs. 20.9% at day 42 and 50.0% vs. 27.9% at day 84, p = 0.041). Better awareness, understanding and treatments are awaited to improve patient prognosis.

Cerebral phaeohyphomycosis due to Cladophialophora bantiana: case report and systematic review of cases

PURPOSE

Cladophialophora bantiana is a wonted melanized fungus causing brain abscess. In past many cases were reported from Asia, particularly from India. Of late, there is a rise in cases in places besides Asia and hence a review of the cases is warranted.

METHODS

We present a case of fatal cerebral phaeohyphomycosis caused by C. bantiana and conduct a systematic review of culture confirmed brain abscess due to C. bantiana reported between 2015 and 2022.

RESULTS

Of the 39 cases found, majority (68%) were immunocompromised. The various clinical presentations were headache (53%), hemiparesis (34%), visual disturbance (25%), altered sensorium (18%), aphasia/dysarthria (12%) and seizures (9%). Isolated lesion was observed in 18 (60%) patients. In the sequence of occurrence, the lesions were in frontal (30%), temporal (27%) and parietal (20%) region. There were five cases with coinfections such as concurrent detection of Nocardia pneumonia in two cases, toxoplasma DNA in brain abscess, coexisting pulmonary Cryptococcus neoformans infection and coexisting Candida in a case of brain abscess in one case each. Surgical intervention was performed in 84% cases. Antifungal therapy included voriconazole (80%), liposomal amphotericin B (76%), 5-fluorocytosine (30%), posaconazole (10%), and amphotericin B deoxycholate (6%). The overall mortality was 50% with lower mortality (42%) in regions outside Asia compared to Asia (63.6%) though not statistically significant.

CONCLUSIONS

C. bantiana brain abscess is an emerging infection worldwide. Next generation sequencing is an upcoming promising diagnostic test. Early complete excision of the lesion with effective antifungals may improve the outcome.

Comparison of the antifungal activity of the pyrimidine analogs flucytosine and carmofur against human-pathogenic dematiaceous fungi

Chromoblastomycosis (CBM) and pheohyphomycosis (PHM) are the most common implantation mycoses caused by dematiaceous fungi. In the past, flucytosine (5-FC) has been used to treat CBM, but development of resistance is common. Carmofur belongs to the same class as 5-FC and has in vitro inhibitory activity against the main agents of CBM and PHM. The aim of this study was to compare the action of these two pyrimidine analog drugs against CBM and PHM agents. The minimum inhibitory concentration (MIC) and the selectivity index based on cytotoxicity tests of these two drugs against some agents of these mycoses were determined, with carmofur presenting a higher selectivity index than 5-FC. Carmofur demonstrated here synergistic interactions with itraconazole and amphotericin B against Exophiala heteromorpha, Fonsecaea pedrosoi, Fonsecaea monophora, and Fonsecaea nubica strains. Additionally, carmofur plus itraconazole demonstrated here synergism against a Phialophora verrucosa strain. To evaluate the development of carmofur resistance, passages in culture medium containing subinhibitory concentrations of this pyrimidine analog were carried out, followed by in vitro susceptibility tests. Exophiala dermatitidis quickly developed resistance, whereas F. pedrosoi took seven passages in carmofur-supplemented medium to develop resistance. Moreover, resistance was permanent in E. dermatitidis but transient in F. pedrosoi. Hence, carmofur has exhibited certain advantages, albeit accompanied by limitations such as the development of resistance, which was expected as with 5-FC. This underscores its therapeutic potential in combination with other drugs, emphasizing the need for a meticulous evaluation of its application in the fight against dematiaceous fungi.

Nodular lesions of the buttock for 20 years: the challenge of chromoblastomycosis in non-endemic settings

Chromoblastomycosis is an implantation mycosis of the skin caused by certain species of melanised fungi. A man in his 50s, born in Kerala but living in England for 14 years, presented with a nodular lesion on his left buttock, which had been present for 20 years. Biopsy revealed muriform cells and fungal culture isolated Fonsecaea spp, consistent with a diagnosis of chromoblastomycosis. Treatment with oral terbinafine was initiated and changed to itraconazole based on results of antifungal susceptibility. Drug intolerance and low drug levels of itraconazole necessitated change to voriconazole and topical terbinafine. Despite long-term combined therapy, the lesions worsened, and the patient opted for surgical excision abroad. Recurrence was evident at surgical sites and combined therapy continues. Chromoblastomycosis is an insidious and burdensome neglected tropical disease. Within non-endemic countries, diagnosis remains challenging. A travel history and appropriate fungal investigations are vital.

Concurrent infection of Exophiala dermatitidis and Angiostrongylus cantonensis in central nervous system of a child with inherited CARD9 deficiency: A case report and literature review

Exophiala dermatitidis is a relatively common environmental black yeast with a worldwide distribution that rarely causes fungal infection. Here, we report a case of a 6-year-old girl with central nervous system (CNS) encephalitis caused by E. dermatitidis and Angiostrongylus cantonensis. E. dermatitidis was identified by both cerebrospinal fluid culture and metagenomic next-generation sequencing (mNGS). Angiostrongylus cantonensis infection was confirmed by an enzyme linked immunosorbent assay (ELISA). Whole exome sequencing showed that this previously healthy girl carried a homozygous CARD9 mutation for c.820dupG (p.D274Gfs*61) that underlies invasive fungal and parasite infections. We chose glucocortieoid pulse therapy and anti-infective therapy based on the initial results of laboratory examination and cranial MRI images. With the aggravation of the disease and the evidence of the subsequent etiologic test, the combination of antifungal antiparasitic treatments (voriconazole, fluorocytosine and amphotericin B) were actively used. Unfortunately, the girl finally died due to severe systemic infection. mNGS performs a potential value for diagnosing rare CNS infections, and autosomal recessive CARD9 deficiency should be considered in patient with fatal invasive fungal infections.

Chemotherapy Extravasation Causing Soft-Tissue Necrosis Mimicking Infection: A Longitudinal Case Study

Extravasation injuries are uncommon, underreported, and often misdiagnosed in patients. The signs and symptoms of extravasation injuries vary from simple pain and tenderness to tissue necrosis and potentially fatal secondary infections. Extravasation may progress to more severe conditions such as necrotizing fasciitis (NF) or cellulitis, so special care is needed by physicians to identify and treat these injuries correctly. Here, we explore a case study on extravasation injuries mimicking NF leading to infectious complications and discuss the proper diagnosis and treatment of extravasation injuries as well as other NF-mimicking diseases. We present a case of a 44-year-old Hispanic male with a history of B-cell acute lymphoblastic leukemia who underwent inpatient chemotherapy treatment via a chest port.

Deep cutaneous mycoses in kidney transplant recipients: Diagnostic and therapeutic challenges

Deep cutaneous mycoses (DCMs) are rare infections that extend throughout the dermis and subcutis, often occurring after inoculation with pathogenic fungi. Trends toward a growing incidence have been observed that may be partially related to an increasing population of solid organ transplant patients. The aim of this study is to describe the diagnostics and the outcomes of DCM among kidney transplant recipients so as to optimize their management. We performed a retrospective review of cases of DCM occurring among kidney transplant recipients in our institution over 12 years. Twenty cases were included. Lesions were only located on the limbs and presented mainly as single (10/20, 50%) nodular lesions (15/20, 75%), with a mean size of 3 cm. Direct mycological examination was positive for 17 patients (17/20, 85%) and the cultures were consistently positive. Thirteen different fungal species were observed, including phaehyphomycetes (n = 8), hyalohyphomycetes (n = 3), dermatophytes (n = 1), and mucorale (n = 1). The (1-3) beta-D-glucan antigen (BDG) was also consistently detected in the serum (20/20, 100%). Systematic imaging did not reveal any distant infectious lesions, but locoregional extension was present in 11 patients (11/14, 79%). Nineteen patients received antifungal treatment (19/20, 95%) for a median duration of 3 months, with surgery for 10 (10/20, 50%). There is a great diversity of fungal species responsible for DCMs in kidney transplant recipients. The mycological documentation is necessary to adapt the antifungal treatment according to the sensitivity of the species. Serum BDG positivity is a potentially reliable and useful tool for diagnosis and follow-up.

Severe influenza A virus pneumonia complicated with Curvularia lunata infection: Case Report

Human infection with Curvularia lunata (C. lunata) is exceptionally rare. A 23-year-old female patient contracted both bacterial and Curvularia lunata infections during influenza A virus infection. Multiple etiological tests were performed repeatedly during hospitalization due to fluctuations in condition. On the 17th day after hospital admission, mold hyphae were discovered in the pathogen culture of the patient’s bronchoalveolar lavage fluid during one of these examinations. The patient was suspected to have a filamentous fungal infection. Consequently, we further obtained sputum samples for fungal culture, which confirmed the diagnosis of Curvularia infection. The patient, in this case, was in a critical condition, experiencing complications of lung abscess, pneumothorax, sepsis, and multiorgan failure. Despite prompt initiation of antifungal therapy including amphotericin B cholesteryl sulfate complex and isavuconazole upon detection of the fungal infection and concurrent administration of active organ function support treatment, the patient’s condition rapidly deteriorated due to compromised immune function. Ultimately, on the 27th day of treatment, the patient succumbed to septic shock and multiple organ dysfunction syndrome. This is the first case of Curvularia lunata infection in our hospital. In this paper, we aim to raise awareness of Curvularia lunata infection and to emphasize that the possibility of this fungal infection should be considered in patients with severe pneumonia caused by influenza A virus and that empirical antifungal therapy should be given promptly when the patient has invasive lung damage.

Severe influenza A virus pneumonia complicated with Curvularia lunata infection: Case Report

Human infection with Curvularia lunata (C. lunata) is exceptionally rare. A 23-year-old female patient contracted both bacterial and Curvularia lunata infections during influenza A virus infection. Multiple etiological tests were performed repeatedly during hospitalization due to fluctuations in condition. On the 17th day after hospital admission, mold hyphae were discovered in the pathogen culture of the patient's bronchoalveolar lavage fluid during one of these examinations. The patient was suspected to have a filamentous fungal infection. Consequently, we further obtained sputum samples for fungal culture, which confirmed the diagnosis of Curvularia infection. The patient, in this case, was in a critical condition, experiencing complications of lung abscess, pneumothorax, sepsis, and multiorgan failure. Despite prompt initiation of antifungal therapy including amphotericin B cholesteryl sulfate complex and isavuconazole upon detection of the fungal infection and concurrent administration of active organ function support treatment, the patient's condition rapidly deteriorated due to compromised immune function. Ultimately, on the 27th day of treatment, the patient succumbed to septic shock and multiple organ dysfunction syndrome. This is the first case of Curvularia lunata infection in our hospital. In this paper, we aim to raise awareness of Curvularia lunata infection and to emphasize that the possibility of this fungal infection should be considered in patients with severe pneumonia caused by influenza A virus and that empirical antifungal therapy should be given promptly when the patient has invasive lung damage.

Cytology of Rhytidhysteron rufulum: An emerging cause of phaeohyphomycosis

Fine-needle aspiration cytology (FNAC) is often the first-line investigation for detection of any fungal infection. Rhytidhysteron rufulum is an emerging dematiaceous fungus detected as a human pathogen. FNAC combined with molecular techniques helps in the detection of rare fungal species, especially in cases of non-sporulating fungi. We describe the cytomorphologic features of this species in a 62-year immunocompetent male who presented with a localised subcutaneous infection. Molecular studies helped in the final diagnosis.

Combination therapy with itraconazole and terbinafine for phaeohyphomycosis caused by Exophiala spinifera: A case report and literature review

Exophiala spinifera is a rare dematiaceous fungus causing cutaneous, subcutaneous and disseminated phaeohyphomycosis (PHM). Standard antifungal therapy for PHM is still uncertain. Here, we report a case of a Chinese male with PHM caused by E. spinifera, who received significant clinical improvement after the treatment with oral itraconazole and terbinafine. With the aim of evaluating the antifungal therapy for PHM caused by E. spinifera, a detailed review was performed.

Emerging subcutaneous mycoses by opportunistic filamentous fungi: A retrospective study in Northwest Spain

BACKGROUND

Subcutaneous mycoses caused by opportunistic filamentous fungi are emerging infections in developed countries due to the longer survival of immunocompromised patients. The evidence published in relation to subcutaneous mycoses is fundamentally based on case reports and small case series.

METHODS

We performed an observational retrospective study of subcutaneous mycoses caused by opportunistic filamentous fungi diagnosed at our institution between 2017 and 2022. This study aims to estimate the incidence rate of subcutaneous mycoses, identify which fungal species are involved, and analyse which clinical variables predispose to infection and if any are associated with mortality.

RESULTS

Fifteen patients met the inclusion criteria. The median age was 61 years (range 27-84), and 80% of them were males. Alternaria spp. were the most common fungi. Two other organisms were frequently isolated: Scedosporium apiospermum and Fusarium solani. Among patients infected with F. solani, 66.7% died. The most common clinical presentation was suppurative nodules in the lower limbs and the main risk factors for infection were immunosuppressants, corticosteroids, previous trauma and transplantation, but they were not particularly associated with increased mortality. A statistically significant association with mortality was only found in the case of positive blood culture (p = <.001).

CONCLUSIONS

Phaeohyphomycosis has a lower risk of dissemination, especially when compared to subcutaneous mycoses caused by hyalohyphomycetes. It is important to convey the severity of these skin infections to the physicians involved in the treatment and follow-up of susceptible patients to avoid misdiagnosis and delays in the treatment, especially in the case of hyalohyphomycosis.

A visceral mycosis in farmed rainbow trout (Oncorhynchus mykiss) caused by Neopyrenochaeta submersa

A mycotic infection manifesting as abdominal distension with free serous fluid accumulation in the coelomic cavity is documented in farmed rainbow trout. Histological examination using PAS and silver staining revealed the presence of numerous fungal hyphae in the spleen and gastrointestinal wall. The isolated fungus was sterile and identified by using phylogenetic analysis based on four loci as Neopyrenochaeta submersa. This is the first time this fungus has been reported as pathogen.

First case of Rhinocladiella mackenziei brain abscess in Turkey: Case report and review of the literature

Rhinocladiella mackenziei is a highly neurotropic fungus, mainly reported from the Middle East. However, in recent years, there have been some cases from outside this region. We described an additional fatal case of R. mackenziei cerebral infection for the first time from Turkey and made a literature review of all previously reported cases. During 34 years (1988-2022), there have been 42 R. mackenziei brain abscess cases. Most patients have been reported from Saudi Arabia (n = 14, 33.3%). It is noteworthy that 40.5% of patients, including our case, were immunocompetent at initial diagnosis and mostly presented with a single lesion (n = 10, 23.8%). The most frequent comorbidities were solid organ transplant (n = 9, 21.4%), diabetes mellitus (n = 6, 14.3%), malignancy (n = 6, 14.3%) and prior surgery (n = 3, 7.1%). The most commonly used initial antifungal regimen were amphotericin B together with itraconazole (n = 9, 21.4%), combinations of lipid preparations of amphotericin B, voriconazole and/or posaconazole (n = 9, 21.4%) and amphotericin B alone (n = 8, 19%). Although both surgical procedures and antifungal medication in the majority of patients were performed, mortality rates remained high (90.4%). The area at risk of R. mackenziei cerebral abscess cases extends to other countries. Clinicians should be aware of this emerging disease and take a detailed travel history in patients with atypical and undocumented brain abscesses. Our case confirms the hypothesis that this fungus might spread more widely than previously predicted regions.

The Role of Excision for Treatment of Chromoblastomycosis: A Cutaneous Fungal Infection Frequently Mistaken for Squamous Cell Carcinoma

BACKGROUND

Chromoblastomycosis is an uncommon fungal infection of the skin caused by a variety of dematiaceous fungal species that is typically contracted through direct inoculation into the skin.

OBJECTIVE

To collect and examine data pertaining to the clinical presentation and management of patients with chromoblastomycosis.

METHODS

Through a retrospective study, a pathology medical record search was performed from January 2004 to December 2020 at a single institution.

RESULTS

A total of 9 patients were identified. Seven of 9 cases occurred in solid organ transplant recipients. All cases were located on the extremities. Six of 9 cases were clinically suspected to be squamous cell carcinoma. Seven of 9 cases were treated with surgical excision. Six of 9 patients were treated with oral antifungal medication. Four of 9 patients had received combination therapy. Eight of 9 patients had no recurrence of the disease after treatment.

CONCLUSION

Chromoblastomycosis presents as verrucous papules or nodules and may clinically and histopathologically mimic squamous cell carcinoma. Immunosuppression is likely a risk factor for the development of chromoblastomycosis. This study highlights the importance of clinical awareness of this disease's clinical presentation and prevalence in immunosuppressed patient populations.

Topical 1% Voriconazole for Mixed Scedosporium and Exophiala Subcutaneous Infection in a Kidney Transplant Recipient

Abstract is missing (Short communication)

Challenges towards management of CARD9-deficient patients with phaeohyphomycosis: A case report and case series study

BACKGROUND

A number of recalcitrant phaeohyphomycosis cases with a life-threatening prognosis have been observed in CARD9-deficient patients, but little is known about the long-term management strategies that are effective for such intractable individuals.

OBJECTIVES

To study the genetic and immunological mechanisms underlying recalcitrant phaeohyphomycosis and to share our clinical experiences regarding its treatment.

PATIENTS/METHODS

Ten CARD9-deficient patients with recalcitrant phaeohyphomycosis admitted to our centre in the past two decades were followed-up, and their clinical presentations, laboratory findings, treatment and prognoses were analysed; one of them was a novel case of recalcitrant phaeohyphomycosis harbouring CARD9 mutations. Innate and adaptive immunological responses of patient-derived peripheral blood mononuclear cells were evaluated using ELISA and flow cytometry.

RESULTS

We identified a total of seven CARD9 mutations in the ten analysed patients. Moreover, patient-derived cells exhibited a significant impairment of innate and adaptive immune responses upon fungus-specific stimulation. All the patients experienced recurrence and exacerbation; four of them died, two exhibited continued disease progress with unsatisfactory therapeutic efficacy, three showed obvious improvement under maintenance therapy, and only one achieved a clinical cure.

CONCLUSIONS

Our study highlighted that otherwise healthy patients diagnosed with early-onset, unexplained and recalcitrant phaeohyphomycosis should be analysed for CARD9 mutations and immune deficiency. Thereafter, the length and choice of management remain challengeable and must be adjusted based on the clinical presentations and responses of patients over their lifetimes. Although continued posaconazole treatment may be the promising first-line therapy at present, novel strategies are worth exploring.

First report of human infection caused by Curvularia warraberensis, manifesting as invasive sinusitis with intracranial involvement

Curvularia species are saprophytic dematiaceous fungi commonly isolated from environmental sources. Most often, they are responsible for allergic fungal rhinosinusitis, an intense, allergic inflammatory sinus disease in immunocompetent individuals. Though invasive infections are rare and more commonly observed in immunocompromised patients, recent reports indicate an increasing trend of invasive sinusitis caused by Curvularia species in immunocompetent hosts. Over the past few years, new species of the genus Curvularia are increasingly being recognized as human pathogens. Here, we report the first human infection caused by Curvularia warraberensis, a cryptic species of Curvularia primarily described as an endophyte in Australian grasses. The 33-year-old female presented with chronic invasive sinusitis of the sphenoid and ethmoid sinuses that progressed to involve the pituitary gland, mid-brain, the facial-vestibulocochlear nerve complex, and basilar artery. The patient underwent endoscopic sinus surgery. Histopathology, microscopic examination and culture of biopsy tissues revealed a dematiaceous fungus that was identified as C. warraberensis, based on sequencing the internal transcribed spacer (ITS) and large subunit (LSU) regions of ribosomal DNA. Antifungal susceptibility testing (AFST) showed low minimum inhibitory concentrations (MICs) for amphotericin B (1 µg/mL), itraconazole (0.25 µg/mL) and posaconazole (0.125 µg/mL). Accurate identification and AFST are crucial for making treatment decisions as some Curvularia species demonstrate variable susceptibility to antifungal agents. The patient died despite combined surgical and medical intervention owing to late presentation and delay in initiating antifungal therapy. A high index of suspicion together with an early diagnosis and aggressive treatment may improve the outcome in such cases.

First case of neonatal fungemia caused by Aureobasidium melanogenum

Aureobasidium melanogenum is a saprophytic, dematiaceous, yeast-like fungus rarely implicated in human infections. Here, we report the first case of A. melanogenum fungemia in a 30-week-old preterm, very low birth weight neonate born to a primigravida with history of gestational diabetes, pregnancy induced hypertension and oligohydramnios. The baby developed respiratory distress, hypotension, bradycardia, coagulopathy and septic shock shortly after birth, and eventually succumbed to multiple organ dysfunction syndrome on day 9 of life. Paired blood culture showed growth of a dematiaceous yeast-like fungus which was identified as A. melanogenum by rDNA internal transcribed spacer (ITS) sequencing. Antifungal susceptibility testing of the isolate showed high minimum inhibitory concentration of fluconazole (32 µg/mL), indicating resistance. Diagnosis of A. melanogenum fungemia is difficult as it is easily confused with Candida species in Gram stained smears and similar colony morphology during the initial stages of growth. Also, the conventional diagnostic methods, such as VITEK 2 and MALDI-TOF MS are unreliable for identification of this pathogen. Accurate identification using molecular techniques is crucial for making treatment decisions as A. melanogenum shows substantial antifungal resistance. Clinicians should be aware that yeast-like cells in blood culture are not only indicative of Candida species, but also rare pathogens like A. melanogenum and should exercise caution while starting fluconazole therapy. At present, there are no established susceptibility breakpoints for Aureobasidium spp. Further studies are needed to determine the optimal treatment for such infections.

Molecular epidemiology of clinical filamentous fungi in Qatar beyond Aspergillus and Fusarium with notes on the rare species

Due to an increasing number of patients at risk (i.e., those with a highly compromised immune system and/or receiving aggressive chemotherapy treatment), invasive fungal infections (IFI) are increasingly being reported and associated with high mortality rates. Aspergillus spp., particularly A. fumigatus, is the major cause of IFI caused by filamentous fungi around the world followed by Fusarium spp., however, other fungi are emerging as human pathogens. The aim of this study was to explore the epidemiology and prevalence of the non-Aspergillus and non-Fusarium filamentous fungi in human clinical samples over an 11-year period in Qatar using molecular techniques. We recovered 53 filamentous fungal isolates from patients with various clinical conditions. Most patients were males (75.5%), 9.4% were immunocompromised, 20.7% had IFI, and 11.3% died within 30 days of diagnosis. The fungal isolates were recovered from a variety of clinical samples, including the nasal cavity, wounds, respiratory samples, body fluids, eye, ear, tissue, abscess, and blood specimens. Among the fungi isolated, 49% were dematiaceous fungi, followed by Mucorales (30%), with the latter group Mucorales being the major cause of IFI (5/11, 45.5%). The current study highlights the epidemiology and spectrum of filamentous fungal genera, other than Aspergillus and Fusarium, recovered from human clinical samples in Qatar, excluding superficial infections, which can aid in the surveillance of uncommon and emerging mycoses.

Flucytosine and its clinical usage

Flucytosine is an antifungal agent first licensed in the 1970's. However, its clinical value has long been overlooked and its availability across the globe is limited. This review highlights the important clinical and pharmacological aspects of flucytosine. This a narrative review of the clinical and in vitro susceptibility literature, with a focus on clinical uses for flucytosine. Detailed literature review including early literature related to primary and acquired resistance to flucytosine. Flucytosine has good antifungal activity against Cryptococcus species, Candida species, and dematiaceous fungi. Its water solubility enables good penetration into the eye, urinary tract, central nervous system (CNS), cardiac vegetations and fungal biofilms. In combination with amphotericin B, it shows early fungicidal activity against Cryptococcus species, and this translates to ~20% improved survival in cryptococcal meningitis. Combination therapy also reduces the mortality of Candida meningitis, and should be used in neonatal candidiasis because of the high frequency of CNS infection. Monotherapy for urinary candidiasis is under-studied, but is usually effective. It is probably valuable in the treatment of Candida endocarditis and endophthalmitis: there are few data. It is not effective for aspergillosis or mucormycosis. Flucytosine monotherapy of urinary candidiasis resulted in 22% developing resistance on therapy and failing therapy, and in 29% of 21 patients with cryptococcosis. Certain regions of the world still do not have access to flucytosine compromising the management of certain severe fungal infections. Flucytosine has an important role in combination therapy for yeast and dematiaceous infections and probably as monotherapy for urinary candidiasis, with a modest risk of resistance emergence. Facilitating access to flucytosine in those regions (especially low-income countries) might alleviate the mortality of invasive fungal diseases.

First case of subcutaneous cystic phaeohyphomycosis due to Phialophora chinensis in a kidney transplant recipient in Martinique

We report a case of subcutaneous mycosis in the form of a subcutaneous cyst of the index finger, successfully treated by surgery and posaconazole in an 84-year-old female kidney transplant patient. Intra-operative mycological analysis enabled the diagnosis of Phialophora chinensis phaeohyphomycosis. Phialophora chinensis is an environmental mold recently described in human pathology in cases of chromoblastomycosis. This is the first case of subcutaneous phaeohyphomycosis due to Phialophora chinensis in an immunocompromised patient.

Surgery plus photodynamic therapy for a diabetic patient with cutaneous infectious granuloma caused by Curvularia lunata

Curvularia lunata (C. lunata) can be easily found in environment and plants and rarely causes human infections. Antifungal agents have been the primary approach to treat such infections; however, adverse hepatotoxic reactions may require discontinuation of the long-term use of antifungal agents in patients with pre-existing liver diseases. New therapeutic approaches are thus needed to cope with these circumstances. Here, we report a 66-year-old diabetic female patient, suffering from a rapidly growing lesion on the nose for 2 months. The patient was diagnosed with cutaneous fungal infection caused by C. lunata, which was based on mycological study and ITS sequencing. The lesion was completely disappeared after a combination of surgery and 3 times of photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA) at 9- day intervals. The patient did not receive any antifungal agents during the treatment. There was no recurrence at 6-month fellow-up. In the following in vitro study, C. Lunata growth was significantly inhibited by ALA-PDT treatment. Therapeutic success in this patent suggests that the ALA-PDT method could be a promising treatment for cutaneous fungal infection caused by C. Lunata and others.