Cutaneous phaeohyphomycosis due to Alternaria alternata responding to itraconazole

Cutaneous infection with Alternaria triticina in a Bilateral lung transplant recipient

We report the case of a 60-year-old man who was receiving immunosuppressive therapy for a bilateral lung transplant and presented with a crusted, violaceous plaque on the left hand. Based on histopathology and microbiological culture the patient was diagnosed with infection by Alternaria species. Treatment with itraconazole led to complete resolution of the skin lesion. Forty months later he developed four reddish, nodular, skin lesions on the left leg. Analysis of a biopsy from one of these lesions using histopathologic and molecular techniques identified a mold that shared 98% homology with a strain of Alternaria triticina. Alternaria species belong to a group of dematiaceous fungi that cause opportunistic infections in humans. The incidence of these infections is increasing, mainly in transplant centers. To the best of our knowledge, this is the first reported case of a human infection caused by A. triticina.

Subcutaneous alternariosis

A case of subcutaneous alternariosis caused by Alternaria alternata is reported in a 52-year-old male who underwent kidney transplantation 1 year earlier. The infection manifested as a vegetating mass about 7 cm in diameter on the right forearm. Histological examination with Grocott staining and periodic acid-Schiff diastase revealed fungal spores and hyphae with chronic granulomatous inflammation. Biopsy fragments inoculated on Sabouraud-glucose agar with chloramphenicol produced colonies which were identified as Alternaria alternata on the basis of macroscopic and microscopic characters.

Alternariosis after liver transplantation

Alternaria is a saprophytic fungus that is increasingly recognized as a human pathogen, particularly in immunocompromised hosts, including solid-organ transplant recipients. Although combined surgical and medical treatment seem to be useful in the management of this infection, an optimal antifungal therapy remains to be defined. Only four cases of alternariosis after orthotopic liver transplantation have been reported. We describe an additional case and review the literature on infections due to Alternaria in organ transplant recipients, with special emphasis on treatment.

Sporotrichoid phaeohyphomycosis due to Alternaria infectoria

We describe a cardiac transplant patient who had human cutaneous alternariosis with a sporotrichoid distribution of skin lesions. In this patient identification of the causative organism Alternaria infectoria was achieved by sequencing the rDNA internal transcribed spacer domain. Treatment with itraconazole led to clinical resolution within 4 months.

A case of cutaneous ulcerative alternariosis: rare association with diabetes mellitus and unusual failure of itraconazole treatment

Alternaria species are ubiquitous dematiaceous fungi that are increasingly recognized as pathogens in immunocompromised patients or those with significant underlying disease, but they are also pathogens in otherwise healthy hosts. We describe a case of dermal cutaneous ulcerative alternariosis in a frail 83-year-old patient with diet-controlled diabetes mellitus. Histological analysis revealed hyphal morphology in tissue sections that was initially confused with that of a zygomycetous fungus, and multiple positive culture results were necessary to identify the organism. Treatment with oral itraconazole and surgical debridement were ineffective; clinical improvement was achieved by means of treatment with intravenous amphotericin B lipid complex. We review the literature regarding the role of diabetes mellitus in cutaneous alternariosis and regarding the efficacy of treatment with itraconazole, which has been used very successfully. To our knowledge, this is only the second case report noting diabetes mellitus uncomplicated by steroid administration as a possible predisposing factor for cutaneous infection.

Cutaneous alternariosis in a cardiac transplant recipient

A 55-year-old male cardiac transplant recipient presented with cutaneous nodules on the limbs caused by Alternaria alternata. Oral fluconazole 200 mg daily for 3 weeks was ineffective. Itraconazole 100 mg oral daily was ceased when hyperglycaemia developed. Individual lesions were successfully treated with either curettage and cautery or double freeze-thaw cryotherapy. Alternaria spp. are ubiquitous fungal saprophytes which may cause cutaneous infections particularly in immunocompromised patients.

Non-dermatophytic onychomycosis. An understimated entity? A study of 51 cases

The aim of our study was to evaluate the incidence, the clinic characteristics, the therapeutic antifungal response and the evaluation of side-effects in 51 non-dermatophytic onychomycosis cases which were observed in a case-study of 1012 patients, affected by different types of onychopathy, attending the Mycology Ambulatory of San Paolo Hospital, Milan, Italy during the period 1994-97.

Cutaneous infection with Alternaria alternata complicating immunosuppression: successful treatment with itraconazole

We report an immunosuppressed patient who presented with unusual leg ulceration caused by Alternaria alternata infection. Alternaria is a common saprophyte that is not usually pathogenic in humans. However, infections have previously been documented. Most cases occur in immunocompromised patients and the skin manifestations may vary considerably. The diagnosis is often missed initially as it is not frequently suspected. The treatment is controversial both in choice of agent used and in duration of therapy.

Ungual phaeohyphomycosis caused by Alternaria alternata

Phaeohyphomycoses are a heterogeneous group of rare mycotic infections caused by dematiaceous fungi. They are classified into four forms: superficial, cutaneous and corneal, subcutaneous, systemic. Alternaria species are ubiquitous fungi that are occasionally aetiological agents of pheohyphomycosis. A case of onychomycosis caused by Alternaria alternata treated with itraconazole is reported.

Phaeohyphomycosis due to Alternaria spp. and Phaeosclera dematioides: a histopathological study

A case of phaeohyphomycosis caused by strains of both Alternaria spp. and Phaeosclera dematioides is presented. The biopsy material was studied using histological, immunohistochemical and transmission electron microscopy techniques. The agent's dematiaceous mycelia are composed of thick-walled hyphae, branched and unbranched, with terminal vesicular formations. All the described structures occur alone or in chains within multinuclear giant foreign body-type cells or invading an abscess. Also present are budding forms. Immunostaining of histiocytic inflammatory cells in either. diffuse or granulomatous infiltrates revealed cytoplasmic positivity for lysozyme and Ki-MIP antibody. The lymphocytic infiltrates of the upper corium show predominantly small T lymphocytes (CD3 and CD45RO positive) and absence of CD20-positive B cells. Plasma cells occurring within the infiltrates of the deeper parts show polyclonal expression of both Ig light chains.

Cutaneous Alternaria alternata infection successfully treated with itraconazole

A case of cutaneous alternariosis due to Alternaria alternata in a 47-year-old man who had the CREST (calcinosis, Raynaud's phenomenon, oesophageal dysfunction, sclerodactyly and telangiectasia) syndrome with pulmonary hypertension is presented. The patient, who lived in a rural area and was receiving prostacycline by continuous infusion, prednisone and azathioprine for his underlying disease, showed cutaneous lesions of the lower extremities spreading from the knees to the ankles. The patient was successfully treated with high doses of oral itraconazole.

Cutaneous phaeohyphomycosis due to Alternaria tenuissima

A 50-year-old gardener with a 3-year history of pemphigus vulgaris and steroid-induced diabetes complained of various papulonodular lesions on the left elbow. The lesions had appeared 11 months previously. Skin biopsy showed chronic granulomatous inflammation of the dermis which contained septate hyphae and large spores mainly free. Fragments of the biopsy specimen, cultured on Sabouraud glucose agar without cycloheximide, for 4 days, produced soft white colonies which later turned blackish brown, especially on the underside. On the basis of the microscopic characters of the conidiophores and conidia, Alternaria tenuissima was identified. This phaeohyphomycete has only been isolated previously in two other cases in Italy.

Cutaneous phaeohyphomycosis caused by Alternaria longipes in an immunosuppressed patient

Alternaria longipes was reported as the agent of a cutaneous infection in a patient with a neoplastic disease. The fungus has not been reported previously as causing disease in humans. It was distinguished by its rather small conidia with smooth or slightly verruculose walls and a pale brown beak which rarely extended into a secondary conidiophore. In vitro inhibitory activities of amphotericin B, ketoconazole, itraconazole, and miconazole were shown.