Basidiobolomycosis: a case report

Basidiobolomycosis complicated by hydronephrosis and a perinephric abscess presenting as a hypertensive emergency in a 7-year-old boy

A 7-year-old boy presented with a chronic, indurated, tender left thigh swelling in association with a hypertensive emergency. He had a bilateral moderate degree of hydronephrosis and a left perinephric abscess, and MRI features of posterior reversible encephalopathy syndrome. Histopathological examination of the biopsy specimen demonstrated eosinophilic fasciitis with filamentous fungi. Basidiobolus ranarum was isolated from the culture. The fungus was also isolated from a perinephric fluid aspirate. Computerised tomography of the abdomen demonstrated features consistent with fungal invasion of the pelvic floor muscles and urinary bladder, leading to bilateral hydronephrosis. He required multiple antihypertensive drug therapy and was treated with intravenous amphotericin B, oral itraconazole and potassium iodide. Antihypertensive agents were discontinued after 2 weeks of antifungal therapy. At 6-months follow-up, the hydronephrosis had resolved completely. Perinephric abscess associated with basidiobolomycosis has not been reported previously.

Basidiobolomycosis Simulating a Mycobacterium ulcerans Infection in a Togolese Rural Child

Background

Basidiobolomycosis is a deep mycosis which preferentially affects rural young people in tropical countries. We report an atypical case, with multiple ulcers, simulating a Buruli ulcer.

Case Report

A 5-year-old boy, living in a rural area, was seen for ulcers on the buttocks and at the back and right flank that had been in progress for 4 months. On examination, we found an infiltrated plaque with sharp edges, little painful, located on the buttocks, back, and the right flank. On this plaque, there were multiple ulcers with polycyclic contours and fibrinous bottom. There were inguinal inflammatory lymph nodes. The patient had an altered general condition. Examination of other organs was normal. The diagnosis of Buruli ulcer was evoked first; the search for Mycobacterium ulcerans by polymerase chain reaction was negative. Histology test performed revealed hypodermic granulomatous inflammation with predominant macrophage and eosinophils. The mycological culture was not done. The child was treated successfully with ketoconazole (10 mg/kg/day) during eight weeks.

Discussion

Our observation shows great clinical and epidemiological similarities between basidiobolomycosis and Buruli ulcer. It confirms the efficacy of ketoconazole in severe basidiobolomycosis infection with alteration of general condition. Histopathology is very important for differential diagnosis between these two diseases.

Entomophthoromycosis: a challenging emerging disease

Entomophthoromycosis is a rare fungal infection that may affect immunocompetent hosts; predominantly in tropical and subtropical regions. Recently, the importance of this emerging mycosis has increased and the scope of its manifestations has been expanded. These manifestations; however, may masquerade as other clinical entities. Prompt diagnosis of this infection requires a high index of suspicion. Although histopathological examination and cultures are the gold standard diagnostic tools; molecular diagnosis is now available and started to play an important role. The cornerstone treatment is prolonged anti-fungal therapy along with surgical debridement. More awareness of this mycosis is warranted for definitive diagnosis and implementation of early proper therapeutic strategies.

Subcutaneous zygomycosis of the cervicotemporal region: Due to Basidiobolus ranaram

Basidiobolomycosis is a rare chronic subcutaneous infection caused by Basidiobolus ranarum. The disease usually occurs in children, less often in adolescent and rarely in adults. Males are more frequently affected than females. We report a case of subcutaneous zygomycosis of head and neck region caused by B. ranaram, in an immunocompetent adult female presenting with nontender firm swelling over the nape of neck and temporo-parietal region. The diagnosis was confirmed by histopathology, microbiology (culture) and DNA sequencing of molecular technique (sequencing). The patient was successfully treated with amphotericin B and potassium iodide.

[Probable basidiobolomycosis in a Togolese rural young successfully treated with ketoconazole]

Basidiobolomycosis is a deep mycosis which preferentially affects rural young people in tropical countries. We report a case of basidiobolomycosis successfully treated with ketoconazole. It was a 9-year-old boy of rural origin in whom the diagnosis of basidiobolomycosis was suspected due to a deep skin infiltration involving the chest and neck. Histology revealed hypodermic granulomatous inflammation with predominantly macrophage and eosinophils. The child was treated successfully with ketoconazole in eight weeks. Treatment of basidiobolomycosis is based on azole derivatives which are particularly effective. Histopathology is very important in the diagnosis of this affection, especially in tropical countries where it may simulate Mycobacterium ulcerans infection.

Uso de Cetoconazol® no tratamento da entomoftoromicose cutâneo-mucosa: relato de caso

As entomoftoromicoses constituem entidade clínica pertencente ao grupo das zigomicoses, cujos agentes etiológicos são o Conidiobolus coronatus, Conidiobolos incongruus e o Basidiobolos ranarum. Um caso de entomoftoromicose cutâneo-mucosa é descrito em homem de 51 anos de idade, lavrador, procedente da região amazônica do Estado do Maranhão, Brasil. Teve diagnóstico esclarecido por exame anatomopatológico, um ano após as manifestações clínicas iniciais. Como tratamento utilizou-se um dos derivados imidazólicos (cetoconazol®) 400mg/dia divididos em duas tomadas, por 12 meses), mostrando boa tolerância, com resposta favorável. Na última avaliação, 24 meses após início do tratamento, encontrava-se clinicamente curado.

Disseminated basidiobolomycosis in an immunocompetent woman

Basidiobolomycosis is a chronic subcutaneous infection of the trunk and limbs due to Basidiobolus ranarum. The disease is well known in tropical areas, although recent cases of gastrointestinal basidiobolomycosis have also been reported in Arizona. We describe a young immunocompetent women who had presented with eosinophilia and lung infiltrates. She subsequently died, and diagnosis of disseminated basidiobolomycosis was made on the basis of histological features at autopsy.

Gastrointestinal basidiobolomycosis in Arizona: clinical and epidemiological characteristics and review of the literature

Gastrointestinal basidiobolomycosis (GIB) is an unusual fungal infection that is rarely reported in the medical literature. From April 1994 through May 1999, 7 cases of GIB occurred in Arizona, 4 from December 1998 through May 1999. We reviewed the clinical characteristics of the patients and conducted a case-control study to generate hypotheses about potential risk factors. All patients had histopathologic signs characteristic of basidiobolomycosis. Five patients were male (median age, 52 years; range, 37--59 years) and had a history of diabetes mellitus (in 3 patients), peptic ulcer disease (in 2), or pica (in 1). All patients underwent partial or complete surgical resection of the infected portions of their gastrointestinal tracts, and all received itraconazole postoperatively for a median of 10 months (range, 3--19 months). Potential risk factors included prior ranitidine use and longer residence in Arizona. GIB is a newly emerging infection that causes substantial morbidity and diagnostic confusion. Further studies are needed to better define its risk factors and treatment.

Zygomycetes in human disease

The Zygomycetes represent relatively uncommon isolates in the clinical laboratory, reflecting either environmental contaminants or, less commonly, a clinical disease called zygomycosis. There are two orders of Zygomycetes containing organisms that cause human disease, the Mucorales and the Entomophthorales. The majority of human illness is caused by the Mucorales. While disease is most commonly linked to Rhizopus spp., other organisms are also associated with human infection, including Mucor, Rhizomucor, Absidia, Apophysomyces, Saksenaea, Cunninghamella, Cokeromyces, and Syncephalastrum spp. Although Mortierella spp. do cause disease in animals, there is no longer sufficient evidence to suggest that they are true human pathogens. The spores from these molds are transmitted by inhalation, via a variety of percutaneous routes, or by ingestion of spores. Human zygomycosis caused by the Mucorales generally occurs in immunocompromised hosts as opportunistic infections. Host risk factors include diabetes mellitus, neutropenia, sustained immunosuppressive therapy, chronic prednisone use, iron chelation therapy, broad-spectrum antibiotic use, severe malnutrition, and primary breakdown in the integrity of the cutaneous barrier such as trauma, surgical wounds, needle sticks, or burns. Zygomycosis occurs only rarely in immunocompetent hosts. The disease manifestations reflect the mode of transmission, with rhinocerebral and pulmonary diseases being the most common manifestations. Cutaneous, gastrointestinal, and allergic diseases are also seen. The Mucorales are associated with angioinvasive disease, often leading to thrombosis, infarction of involved tissues, and tissue destruction mediated by a number of fungal proteases, lipases, and mycotoxins. If the diagnosis is not made early, dissemination often occurs. Therapy, if it is to be effective, must be started early and requires combinations of antifungal drugs, surgical intervention, and reversal of the underlying risk factors. The Entomophthorales are closely related to the Mucorales on the basis of sexual growth by production of zygospores and by the production of coenocytic hyphae. Despite these similarities, the Entomophthorales and Mucorales have dramatically different gross morphologies, asexual reproductive characteristics, and disease manifestations. In comparison to the floccose aerial mycelium of the Mucorales, the Entomophthorales produce a compact, glabrous mycelium. The asexually produced spores of the Entomophthorales may be passively released or actively expelled into the environment. Human disease with these organisms occurs predominantly in tropical regions, with transmission occurring by implantation of spores via minor trauma such as insect bites or by inhalation of spores into the sinuses. Conidiobolus typically infects mucocutaneous sites to produce sinusitis disease, while Basidiobolus infections occur as subcutaneous mycosis of the trunk and extremities. The Entomophthorales are true pathogens, infecting primarily immunocompetent hosts. They generally do not invade blood vessels and rarely disseminate. Occasional cases of disseminated and angioinvasive disease have recently been described, primarily in immunocompromised patients, suggesting a possible emerging role for this organism as an opportunist.

Zygomycetes in human disease

The Zygomycetes represent relatively uncommon isolates in the clinical laboratory, reflecting either environmental contaminants or, less commonly, a clinical disease called zygomycosis. There are two orders of Zygomycetes containing organisms that cause human disease, the Mucorales and the Entomophthorales. The majority of human illness is caused by the Mucorales. While disease is most commonly linked to Rhizopus spp., other organisms are also associated with human infection, including Mucor, Rhizomucor, Absidia, Apophysomyces, Saksenaea, Cunninghamella, Cokeromyces, and Syncephalastrum spp. Although Mortierella spp. do cause disease in animals, there is no longer sufficient evidence to suggest that they are true human pathogens. The spores from these molds are transmitted by inhalation, via a variety of percutaneous routes, or by ingestion of spores. Human zygomycosis caused by the Mucorales generally occurs in immunocompromised hosts as opportunistic infections. Host risk factors include diabetes mellitus, neutropenia, sustained immunosuppressive therapy, chronic prednisone use, iron chelation therapy, broad-spectrum antibiotic use, severe malnutrition, and primary breakdown in the integrity of the cutaneous barrier such as trauma, surgical wounds, needle sticks, or burns. Zygomycosis occurs only rarely in immunocompetent hosts. The disease manifestations reflect the mode of transmission, with rhinocerebral and pulmonary diseases being the most common manifestations. Cutaneous, gastrointestinal, and allergic diseases are also seen. The Mucorales are associated with angioinvasive disease, often leading to thrombosis, infarction of involved tissues, and tissue destruction mediated by a number of fungal proteases, lipases, and mycotoxins. If the diagnosis is not made early, dissemination often occurs. Therapy, if it is to be effective, must be started early and requires combinations of antifungal drugs, surgical intervention, and reversal of the underlying risk factors. The Entomophthorales are closely related to the Mucorales on the basis of sexual growth by production of zygospores and by the production of coenocytic hyphae. Despite these similarities, the Entomophthorales and Mucorales have dramatically different gross morphologies, asexual reproductive characteristics, and disease manifestations. In comparison to the floccose aerial mycelium of the Mucorales, the Entomophthorales produce a compact, glabrous mycelium. The asexually produced spores of the Entomophthorales may be passively released or actively expelled into the environment. Human disease with these organisms occurs predominantly in tropical regions, with transmission occurring by implantation of spores via minor trauma such as insect bites or by inhalation of spores into the sinuses. Conidiobolus typically infects mucocutaneous sites to produce sinusitis disease, while Basidiobolus infections occur as subcutaneous mycosis of the trunk and extremities. The Entomophthorales are true pathogens, infecting primarily immunocompetent hosts. They generally do not invade blood vessels and rarely disseminate. Occasional cases of disseminated and angioinvasive disease have recently been described, primarily in immunocompromised patients, suggesting a possible emerging role for this organism as an opportunist.

In-vitro antifungal susceptibilities of Basidiobolus and Conidiobolus spp. strains

The in-vitro antifungal susceptibilities of nine isolates belonging to Basidiobolus spp. and seven to Conidiobolus spp. against six antifungals (amphotericin B, ketoconazole, miconazole, itraconazole, fluconazole and flucytosine) were tested. A broth microdilution method, generally following the NCCLS guidelines, was used. Inoculum concentrations of the order of 100 cfu/mL were obtained by culturing fungi in a broth medium (Czapeck broth supplemented with 2% Tween 80 and 0.07% agar). MICs and MFCs were highly variable and isolate-dependent, with the exception of those of flucytosine which were constantly very high. In general, however, Basidiobolus spp. displayed low MICs of fluconazole, itraconazole, ketoconazole and miconazole, and Conidiobolus spp. were resistant to all antifungals tested.

Deep fungal and higher bacterial skin infections in Thailand: clinical manifestations and treatment regimens

BACKGROUND

Deep fungal and higher bacterial skin infections occur fairly frequently in Thailand.

METHODS

Cases with a provisional diagnosis of deep fungal and higher bacterial infections were prospectively collected from 1994 to 1997 in the Granuloma Clinic, Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand. Demographic data, clinical manifestations, causative organisms, histologic features, treatment, and outcome were investigated.

RESULTS

The total cases in a 4-year period numbered 27. The male to female ratio was approximately 1:1. Mycetoma was most common, followed by chromoblastomycosis. Actinomycetoma was similar in incidence to eumycetoma. The only causative organism that could be identified among the mycetoma cases was Cladosporium carrionii, which caused mycetoma of the buttock of an aplastic anemia patient at the site of bone marrow aspiration. Surgical treatment was recommended for eumycetoma. Chromoblastomycosis was caused by C. carrionii and F. compactum and responded well with itraconazole orally. Mycotic abscesses were found in four cases, basidiobolomycosis in two cases, and cutaneous nocardiosis in one case. Cotrimoxazole was recommended in the treatment of actinomycetoma, cutaneous nocardiosis, and basidiobolomycosis.

CONCLUSIONS

Localized, chronic, slow, progressive, and usually asymptomatic were the main cutaneous manifestations of deep fungal and higher bacterial skin infections. A skin biopsy for histologic study and culture identification should be performed in every suspected case. The causative organisms were found in the histologic sections of every case, but only about one-third were found by culture.

[Intestinal entomothoramycosis: report of a case]

A case of intestinal entomophthoramycosis caused by Entomophthorales in a man with 19 years-old, farmer and without associated disease. The patient was submitted to a intestinal resection and diagnosis was carried through after analysis of the surgical specimen. After a review of the literature, the clinical evolution, clinico-pathologic features, difficulties in diagnosis and treatment are discussed.