Phaeohyphomycosis caused by Medicopsis romeroi in solid organ transplant recipients: Report of two cases and comprehensive review of the literature

Recurrent Subcutaneous Phaeohyphomycosis Due to Medicopsis romeroi: A Case Report in a Dermatomyositis Patient and Review of the Literature

Medicopsis romeroi phaeohyphomycosis is increasingly reported in immunocompromised patients living in or originating from tropical and subtropical areas. We report a case of subcutaneous phaeohyphomycosis caused by M. romeroi in a 56-year-old Malian woman residing in France for 20 years. She developed a small nodule on her dominant hand's ring finger 15 months after starting immunosuppressive medications for paraneoplastic dermatomyositis. A first surgical debridement was followed by a local recurrence. Despite a second surgical excision combined with posaconazole treatment, the infection recurred one year after antifungal therapy discontinuation. A wide excision was performed again, and antifungal therapy was resumed and maintained for six months, resulting in the absence of relapse during the 18 months following the surgery. This case highlighted the high risk of relapse in immunocompromised patients, suggesting the need for long-term follow-up and prolonged antifungal treatment following surgical excision in cases with sustained immunosuppression. The literature review was performed according to PRISMA guidelines and included 51 scientific publications. A noteworthy predominance of the subcutaneous phaeohyphomycosis presentation was found in immunocompromised patients, whereas eumycetoma had been reported in apparently healthy individuals. A combination of complete excision with antifungal treatment seemed to confer the best outcome.

Disseminated Medicopsis Romeroi Infection in a Kidney Transplant Recipient

Medicopsis romeroi is a rare, dematiaceous fungus that is difficult to identify using conventional fungal tests. Although uncommon, immunocompromised patients are particularly susceptible to this opportunistic fungus. Here, we report the case of a renal transplant recipient who presented with painful disseminated subcutaneous and soft tissue lesions. Sequencing of the Internal transcribed spacer (ITS) region of the ribosomal DNA identified the fungus as Medicopsis romeroi. Additionally, tissue samples from a non-healing wound on the left forearm grew Rhizopus spp. on Sabouraud dextrose agar, indicating a Mucormycosis superinfection. The patient's condition improved with surgical intervention and antifungal therapy with Posaconazole and Terbinafine. This case demonstrates the need for a high index of suspicion in order to facilitate early diagnosis and treatment and thus reduce the risk of dissemination.

Dematiaceous fungal infections in solid organ transplantation: systematic review and bayesian meta-analysis

BACKGROUND

Dematiaceous fungi cause a number of infectious syndromes referred to as phaeohyphomycosis among both immunocompetent and immunocompromised hosts. We performed a systematic review to characterize these infections in solid organ transplant recipients (SOTR).

METHODS

We searched PubMed database (last searched 1/6/2022) for English-language reports on dematiaceous fungal infections in SOTR. Included reports needed individualized demographic, treatment, and outcome data; pediatric reports were excluded. A universally applicable bias assessment was performed on reports. Models for infection type and outcome were created using the Bayesian paradigm.

RESULTS

We included 149 reports on 201 cases of dematiaceous fungal infections in SOTR. The mean age was 54 years, 72% were men, and kidney recipients accounted for 61% of cases. Skin and soft tissue infection (SSTI) was the most common infectious syndrome (73%). Death from infection occurred in 7% of cases (14/201), with disseminated (32%) cases having the highest mortality. Our model for infection type predicted the relative probability of central nervous system infection to be highest in liver recipients. Across all transplant types, higher relative probabilities of disseminated and pulmonary infections occur in the early post-transplant period, and the predicted probabilities for these infection types decreased after 100 months post-transplantation.

DISCUSSION

We identified SSTI as the most common dematiaceous fungal infections in SOTR. Disseminated infections carried the worst prognosis. The evidence in this review is limited by the heterogeneity of included cases. No funding source was used, and this review's protocol was not registered. This article is protected by copyright. All rights reserved.

The genus Madurella: Molecular identification and epidemiology in Sudan

Eumycetoma (mycotic mycetoma) is the fungal form of mycetoma, a subcutaneous infection occurring in individuals living in endemic areas of the disease. The Sudan is hyperendemic for mycetoma, with the highest incidence being reported from Gezira State, Central Sudan. The present study was conducted at the Gezira Mycetoma Center and aimed to determine the cause of black-grain eumycetoma in the state and describe its epidemiology. Black-grain specimens were collected during the surgical operation and direct detection of the causative agent was performed using M. mycetomatis species-specific PCR and ITS PCR followed by sequencing. Black-grain was reported from 93.3% of all confirmed mycetoma cases (n = 111/119), with a prevalence in young males. Of the 91 samples subjected to direct PCR, 90.1% (n = 82) gave positive results. The predominant species (88.2%) was Madurella mycetomatis. One sample was identified as M. fahalii, one as M. tropicana, and one matched the phytopathogenic species Sphaerulina rhododendricola. The highest endemic zones were Southern Gezira (76.6%) and Northern Sinnar (23.4%). The study confirmed that direct molecular detection on grains provides rapid and specific diagnosis of agents of eumycetoma.

Eumycetoma is a neglected fungal disease endemic in Africa, India, and Latin America. Black-grain eumycetoma is the most common type in Africa and is mainly caused by Madurella spp. The Sudan, and in particular Gezira State, central Sudan is hyperendemic for black-grain eumycetoma. Patients with this type of mycetoma are treated with surgery in combination with antifungal therapy. In this study, we collected surgical biopsies from patients attending Gezira Mycetoma Center to directly identify the etiology of black-grain eumycetoma in this state. We also studied the epidemiology of the disease based on the demography of the patients’ population. Our result showed that the highest endemic regions were Southern Gezira (76.6%) and Northern Sinnar (23.4%). By applying direct PCR and sequencing we confirmed that the most common etiology of the disease is Madurella mycetomatis (88.2%). In addition, we found one case of M. fahalii and the first Sudanese case of M. tropicana and Sphaerulina rhododendricola.

Medicopsis romeroi nodular subcutaneous infection in a kidney transplant recipient

Phaeohyphomycosis is a set of fungal infections caused by various dematiaceous fungi such as coelomycetes. These infections can occur either in immunocompetent or immunocompromised patients like solid organ transplants. Here we describe a nodular lesion of the right hallux that occurred in a kidney transplant patient. Microscopic examination of the biopsy revealed fungal hyphae and culture was positive to a grey to black mould that lacked characteristic elements to be identified. Nucleic acid sequencing targeting the internal transcribed spacer of the ribosomal DNA identified this mould as Medicopsis romeroi. The patient benefited of an antifungal therapy with voriconazole associated with surgical excision of the lesion. No relapse of the lesion was observed during a six-month follow-up. In solid organ transplants, phaeohyphomycosis caused by Medicopsis romeroi are very rare with only 12 cases reported. The clinical history should be well assessed since the lesion can appear several years after a cutaneous trauma that happened in a tropical region. Therapy generally combines antifungals with surgical excision of the lesion in order to avoid any relapse or dissemination of the infection.

Long-Term Carriage of Medicopsis romeroi, an Agent of Black-Grain Mycetoma, Presenting as Phaeohyphomycosis in a Renal Transplant Patient

Medicopsis species are rare fungal pathogens that frequently resist common antifungal therapies and are difficult to identify morphologically as conidia are produced in pycnidia, a key feature of coelomycetes. Immunocompromised patients are at risk of these infections, even after remote exposure, and typically present with phaeohyphomycoses without dissemination. We present the case of a renal transplant recipient 6.5 years post-transplant who developed a slowly progressive soft tissue infection mimicking a synovial cyst. A cultured isolate was identified as Medicopsis romeroi by sequencing of multiple ribosomal loci. The patient responded well to debridement and posaconazole therapy. Solid-organ transplant patients are at risk of opportunistic fungal infection long after transplant, and molecular methods are often required for definitive identification.