Hyalohyphomycoses due to Fusarium spp.--two case reports and review of the literature

Fusarium solani: An Emerging Fungus in Chronic Diabetic Ulcer

Fusarium species, a mold which causes disease mainly in plants has emerged as pathogen in immunocompromised patients. Fusarium is known to cause keratitis, onychomycosis, and endophthalmitis. Fusarium solani, is the most common isolate from clinical specimen. Here is a case, a 65-year-old male with type II diabetes mellitus since 10 years presented with a large ulcer on the left leg since 8 months following trauma. The fungal culture of the escar of the ulcer isolated a mold, Fusarium solani. The patient's leg was amputated and was treated with amphotericin B. The patient was discharged on healing of the stump. This case gives emphasis on fungal culture in chronic diabetic ulcer.

Other fungi causing onychomycosis

Nondermatophyte onychomycosis account for 2% to 12% of all nail fungal infections and can be caused by a wide range of fungi, mainly Scopulariopsis brevicaulis, Aspergillus versicolor, A. flavus, A. niger, A. fumigatus, Fusarium solani, F. oxysporum and Scytalidium spp. Among the predisposing factors are footwear, hyperhidrosis, local trauma, peripheral circulatory disease, and immunosuppression. These nondermatophyte fungi lack the keratinolytic capacity of dermatophytes, but they still can infect alone or in combination with the latter. Because most are considered laboratory contaminants, special criteria have been created for the correct diagnosis of nondermatophyte onychomycosis. The etiologic agent does not determine the clinical pattern of nail invasion, but superficial onychomycosis is frequently observed; leukonychia and melanonychia can also be clinical manifestations.

Cutaneous infections due to opportunistic molds: uncommon presentations

Molds are quite more often suspected as pathogens by the public than by the medical care community. Molds may, however, cause serious medical problems, and mold infections can develop incognito. Among the mycoses caused by opportunistic molds, alternariosis and fusariosis together with aspergillosis are of particular importance. They are more common than other groups with pathological characteristics. The aim of our presentation is to demonstrate the important role of common molds as causative agents in skin and ear infections. The clinical picture, etiology and pathogenesis, diagnosis and treatment, and course and prognosis of cutaneous infections will be given. The spectrum of clinical symptoms ranges from eczemalike lesions to chronic erythematous, verrucous lesions of the skin or multiple acute infiltrations of the dermis, occasionally forming abscesses. The mycologic direct preparation of the specimens, particularly with optical brighteners, and a histological examination of a skin biopsy are strongly recommended. The outbreak of cutaneous infections is triggered by weakened host defense mechanisms. A review of the literature regarding immunosuppressed and immunocompetent patients will be given.

Endophthalmitis caused by Fusarium proliferatum

Fusarium proliferatum caused endophthalmitis after cataract surgery. Diagnosis was established by classical microbiology and molecular biology methods (PCR and DNA typing). The treatment with local amphotericin B, oral ketoconazole, and topical natamycin was successful.

Fusarium peritonitis concomitant to kidney transplantation successfully managed with voriconazole: case report and review of the literature

Fusarium infections in solid organ transplant recipients are often localized, occur later in the post-transplantation period, and have a better outcome than fusarial infections in patients with hematologic malignancies or bone marrow transplants. We report the first case of proven peritonitis caused by Fusarium species in a renal transplant recipient which is also the first successfully managed with voriconazole. We also review previously reported cases of fusarial infection in solid organ transplant recipients.

Onicomicoses por fungos emergentes: análise clínica, diagnóstico laboratorial e revisão

FUNDAMENTOS: As dermatomicoses causadas por fungos emergentes são entidades clínicas raras, à exceção das onicomicoses. Como certos fungos e leveduras podem residir na pele, a positividade em culturas de escamas ungueais deve ser interpretada obrigatoriamente em concordância com os respectivos dados clínicos, exames diretos das amostras, quantificação das colônias isoladas em relação aos pontos de inoculação e, principalmente, deve a positividade ser mantida após a repetição dos cultivos. A invasão da unha por fungos não dermatofíticos (nondermatophytic molds, NDM) em diferentes estudos varia de 1,45% a 17,6%. OBJETIVOS: Os objetivos do trabalho são mostrar a ocorrência e realçar a importância dos fungos emergentes como causadores de onicomicose. MÉTODOS: As unhas dos pacientes atendidos nos consultórios dos dermatologistas foram examinadas, e, caso houvesse suspeita clínica de onicomicose, coletavam-se amostras que eram enviadas para exame micológico no laboratório. RESULTADOS: Neste estudo, foram avaliados 2.271 pacientes e diagnosticada onicomicose em 400 deles, sendo 264 com acometimento das unhas do pé, e 136 das unhas da mão. O agente etiológico foi confirmado pelo exame micológico direto e crescimento em cultura. A onicomicose por fungos emergentes representou 4,5% de todas as infecções de unha. Foram detectadas as leveduras do gênero Candida (49%) como agentes etiológicos mais freqüentes de onicomicoses nas unhas das mãos e em mulheres. Em contraste, os dermatófitos foram os mais freqüentes de todas as onicomicoses dos pés, no total de 186 (46,5%). CONCLUSÃO: Ao contrário da rotina diagnóstica hoje utilizada, concluiu-se que o diagnóstico correto do agente etiológico da onicomicose não dermatofítica deve obedecer a determinados critérios, dos quais se destaca o conjunto formado pela positividade no exame direto, na cultura, com comprovação na repetição do exame.

Localized cutaneous hyalohyphomycosis caused by a Fusarium species infection in a renal transplant patient

Fusariosis is a hyalohyphomycosis due to Fusarium species that mainly occurs in immunocompromised hosts. The clinical spectrum of Fusarium infection comprises localized and disseminated forms. A case of localized cutaneous fusariosis caused by Fusarium solani in a renal transplant patient is described, and the skin manifestations of the disease are discussed.

Cutaneous infection by Fusarium species in healthy and immunocompromised hosts: implications for diagnosis and management

Infections by Fusarium species frequently involve the skin, either as the primary or the metastatic site. To better understand the pathophysiology of these infections, 43 new patients with fusariosis were evaluated, and the literature was reviewed. A total of 259 patients (232 immunocompromised and 27 immunocompetent) were identified. Skin involvement was present in 70% of patients, particularly in immunocompromised patients (72% vs. 52%; P=.03). In immunocompetent patients, cutaneous infections were characterized by preceding skin breakdown, localized involvement, slow pace of progression, and good response to therapy. In contrast, skin involvement in immunocompromised patients was only occasionally preceded by skin breakdown and typically was presented as rapidly progressive disseminated lesions at various stages of evolution. Metastatic skin lesions were associated with fungemia, neutropenia, and death. Skin was the single source of diagnosis for the majority of immunocompromised and immunocompetent patients. Recommendations for the prevention of fatal fusariosis originating from skin are presented.

Efficacy of liposomal amphotericin B in treatment of systemic murine fusariosis

We have compared the activities of liposomal amphotericin B (LAMB) at 3, 5, 10, and 20 mg/kg/day and amphotericin B deoxycholate (AMB) at 1.5 and 2.5 mg/kg/day in a murine systemic infection by Fusarium verticillioides. Survival was improved by all treatments except AMB at 1.5 mg/kg/day. The tissue burden in liver was reduced by LAMB at all dosages and by AMB at 2.5 mg/kg/day. The two highest dosages of LAMB showed significant reductions in the spleen.

Mycetoma of the renal pelvis caused by Fusarium species

A preterm infant, with posterior urethral valves had a mycetoma of the renal pelvis caused by Fusarium species. Prolonged treatment with amphotericin B alone or with flucytosine failed. Combined surgical drainage and medical therapy resulted in full resolution.

Case report. Pathohistological findings in a clinical case of disseminated infection with Fusarium oxysporum

Despite appropriate antimicrobial and antifungal therapy (amphotericin B), a disseminated infection with Fusarium oxysporum in a 75-year-old immunocompromised patient (acute myeloid leukaemia, minimal leucocyte count of 0.5 giga l-1) led rapidly to death. A similarly fatal course of an F. oxysporum infection has been reported in several cases. Fusarium oxysporum could be isolated shortly before death from blood cultures and from a swab taken from skin efflorescences. An autopsy revealed histopathologically typical fungal infiltrates in the mucosa of the pharynx, epiglottis, trachea, and oesophagus and in the parenchyma of the spleen, the lung and both kidneys. Because of the high risk of a fatal outcome of this infection, the clinician should aim at maximum diagnostic enforcement. We propose both analysis of blood cultures and immediate skin biopsy--with PAS-staining--of suspicious dermal efflorescences for microscopic examination. The treatment of choice is discussed controversially but a beneficial effect has been reported from granulocyte transfusion, subcutaneous administration of GM-CSF and concomitant treatment with amphotericin B.

The epidemiology of fusariosis in patients with haematological diseases. Gimema Infection Programme

Fusariosis has been considered an emerging infection in patients with haematological malignancies. In a multicentre retrospective study on filamentous fungi infections in patients with haematological diseases over a period of 10 years in Italy, fusariosis was documented in six patients from two of the 14 centres with a 0.06% incidence in acute leukaemia. A literature search yielded 177 cases of Fusarium infections in haematological diseases and acute leukaemia accounted for 71% of the underlying conditions. An increase from 0.5 to 3.8 cases per year was observed at the M.D. Anderson Cancer Center of Houston in the periods 1975-85 and 1986-95 respectively. Conversely, only 5.1 and 6.3 cases per year have been reported in the periods 1981-90 and 1991-96, respectively, from the other centres in the world. Half of the cases have been observed in the USA. In Europe, most of the cases have been observed in France and Italy. Invasive fusariosis is a rare complication in haematological diseases, as its overall frequency does not seem to be significantly increased within the last 20 years. However, its epidemiological distribution is not homogeneous and the possibility of local clusters of infections by this deadly pathogen should be carefully considered.

Fusarium infections of the skin

Fusarium species are ubiquitous and may be found in the soil, air and on plants. Fusarium species can cause mycotoxicosis in humans following ingestion of food that has been colonized by the fungal organism. In humans, Fusarium species can also cause disease that is localized, focally invasive or disseminated. The pathogen generally affects immunocompromised individuals with infection of immunocompetent persons being rarely reported. Localized infection includes septic arthritis, endophthalmitis, osteomyelitis, cystitis and brain abscess. In these situations relatively good response may be expected following appropriate surgery and oral antifungal therapy. Disseminated infection occurs when two or more noncontiguous sites are involved. Over eighty cases have been reported, many of which had a hematologic malignancy including neutropenia. The species most commonly involved include Fusarium solani, Fusarium oxysporum, and Fusarium moniliforme (also termed F. verticillioides). The diagnosis of Fusarium infection may be made on histopathology, gram stain, mycology, blood culture, or serology. Portals of entry of disseminated infection include the respiratory tract, the gastrointestinal tract, and cutaneous sites.The skin can be an important and an early clue to diagnosis since cutaneous lesions may be observed at an early stage of the disease and in about seventy-five cases of disseminated Fusarium infection. Typical skin lesions may be painful red or violaceous nodules, the center of which often becomes ulcerated and covered by a black eschar. The multiple necrotizing lesions are often observed on the trunk and the extremities. Onychomycosis most commonly due to F. oxysporum or F. solani has been reported. The onychomycosis may be of several types: distal and lateral subungual (DLSO), white superficial (WSO), and proximal subungual (PSO). In proximal subungual onychomycosis there may be associated leukonychia and/or periungual inflammation. Patients with Fusarium onychomycosis have been cured following therapy with itraconazole, terbinafine, ciclopirox olamine lacquer, or topical antifungal agent. In other instances nail avulsion plus antifungal therapy has been successful. In patients with hematologic malignancy or bone marrow transplant, who may experience prolonged or severe neutropenia during the course of therapy, the skin and nails should be carefully examined and consideration given to treating potential infection sites that may serve as portals for systemic dissemination. When disseminated Fusarium infection is present therapy with antifungal agents has generally been disappointing with the chances of a successful resolution being enhanced if the neutropenia can be corrected in a timely manner.

Plantar hyperkeratosis due to Fusarium verticillioides in a patient with malignancy

We report the case of an 82-year-old man with hyperkeratosis of the right sole caused by a Fusarium verticillioides infection mimicking verrucous tuberculosis; the infection was confirmed by direct potassium hydroxide microscopy, biopsy and cultures. The biopsy specimen showed an unusually deep invasion of fungal elements into the epidermis. This is an uncommon presentation in a localized cutaneous infection by Fusarium but in this case, repeated local injuries were the portal of entry initiating the process. Clinical patterns of cutaneous fusarium infections in general are also discussed.

Fusarium fungaemia in severely neutropenic patients

We report two cases of Fusarium infection with evidence of fungaemia in severely neutropenic patients with leukaemia. One patient was a 65-year-old woman with chronic lymphocytic leukaemia infected by Fusarium verticillioides. The other patient was a 45-year-old woman with acute myeloblastic leukaemia infected by Fusarium spp. Fungaemia was the only evident manifestation of these fungal infections.

Skin and nail infections due to Fusarium oxysporum in Tuscany, Italy

Nine cases of skin and nail infection due to Fusarium oxysporum, diagnosed in Tuscany in the period 1985-97, are described. Two manifested as interdigital intertrigo of the feet and seven as onychomycosis. All were diagnosed on the basis of repeated mycological examination, direct microscope observation and culture, as well as histological examination of biopsy specimens in two cases of intertrigo. Fragments of the fungal colonies were examined by scanning electron microscopy (SEM) for more detailed observation of fungal morphology. All patients had normal immune status and a history of the infection extending several years. Four of the patients with onychomycosis were treated with oral itraconazole, and clinical and mycological recovery was achieved in three cases. Two others were treated with cyclopyrox nail lacquer, successfully in one case. One patient with intertrigo was treated with oral itraconazole and one with oral terbinafine; both were also treated and with topical drugs, however clinical recovery was not confirmed by the mycological results.

Systemic Fusarium oxysporum infection in an immunocompetent patient with an adult respiratory distress syndrome (ARDS) and extracorporal membrane oxygenation (ECMO)

We report a case of disseminated fusariosis in a 42-year-old patient with adult respiratory distress syndrome (ARDS) and extracorporal membrane oxygenation (ECMO), but without definite immunosuppression. Fusarium oxysporum was isolated from a bronchial lavage taken 6 days ante mortem. Despite antifungal treatment with amphotericin B and flucytosine the patient died in septic multiorgan failure. A post-mortem examination was performed. The patient's liver was found to contain fungus cells and F. oxysporum could be cultured from ascites.

Fusarium, a Significant Emerging Pathogen in Patients With Hematologic Malignancy: Ten Years' Experience at a Cancer Center and Implications for Management

Despite increasing reports of life-threatening Fusarium infections, little is known about its pathogenesis and management. To evaluate the epidemiology, clinicopathologic features, and outcome of invasive fusariosis in patients with hematologic cancer, we conducted a retrospective study of invasive fusarial infections in patients with hematologic malignancy treated at a referral cancer center over a 10-year period (1986 to 1995), as well as a literature review. Forty patients with disseminated and three patients with invasive lung infection were included in the analysis. All patients were immunocompromised. The infection occurred in three patients postengraftment following bone marrow transplantation. All patients were diagnosed antemortem. Thirteen patients responded to therapy, but the infection relapsed in two of them. Response was associated with granulocyte transfusions, amphotericin B lipid formulations (four patients each), and an investigational triazole (two patients). Resolution of infection was only seen in patients who ultimately recovered from myelosuppression. Portal of entry was the skin (33%), the sinopulmonary tree (30%), and unknown (37%). Fusarium causes serious morbidity and mortality, and may mimic aspergillosis. The infection seems to respond to newer therapeutic approaches, but only in patients with ultimate recovery from myelosuppression, and it may relapse if neutropenia recurs.

Fusarium, a Significant Emerging Pathogen in Patients With Hematologic Malignancy: Ten Years' Experience at a Cancer Center and Implications for Management

Despite increasing reports of life-threatening Fusarium infections, little is known about its pathogenesis and management. To evaluate the epidemiology, clinicopathologic features, and outcome of invasive fusariosis in patients with hematologic cancer, we conducted a retrospective study of invasive fusarial infections in patients with hematologic malignancy treated at a referral cancer center over a 10-year period (1986 to 1995), as well as a literature review. Forty patients with disseminated and three patients with invasive lung infection were included in the analysis. All patients were immunocompromised. The infection occurred in three patients postengraftment following bone marrow transplantation. All patients were diagnosed antemortem. Thirteen patients responded to therapy, but the infection relapsed in two of them. Response was associated with granulocyte transfusions, amphotericin B lipid formulations (four patients each), and an investigational triazole (two patients). Resolution of infection was only seen in patients who ultimately recovered from myelosuppression. Portal of entry was the skin (33%), the sinopulmonary tree (30%), and unknown (37%). Fusarium causes serious morbidity and mortality, and may mimic aspergillosis. The infection seems to respond to newer therapeutic approaches, but only in patients with ultimate recovery from myelosuppression, and it may relapse if neutropenia recurs.