Dual Invasive Infection with Phaeoacremonium parasiticum and Paraconiothyrium cyclothyrioides in a Renal Transplant Recipient: Case Report and Comprehensive Review of the Literature of Phaeoacremonium Phaeohyphomycosis

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.

A Cutaneous Phaeohyphomycosis Case Caused by Paraconiothyrium cyclothyrioides in Southern China

Paraconiothyrium cyclothyrioides is a coelomycetous fungus species that was recently identified. We present a case of an elderly farmer with chronic skin lesions of the opisthenar caused by P. cyclothyrioides.

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.

Phaeoacremonium tuscanicum and Phaeoacremonium indicum sp. nov. associated with subcutaneous phaeohyphomycosis

Two cases of phaeohyphomycotic infections were caused by Phaeoacremonium tuscanicum, not previously identified in human infections, and one new species, Phaeoacremonium indicum, respectively. Morphological and cultural investigation as well as phylogenetic analysis was constructed based on maximum likelihood analyses using actin and -tubulin sequences to identify the fungal isolates.

Whole-genome sequencing and functional annotation of pathogenic Paraconiothyrium brasiliense causing human cellulitis

BACKGROUND

A pathogenic filamentous fungus causing eyelid cellulitis was isolated from the secretion from a patient's left eyelid, and a phylogenetic analysis based on the rDNA internal transcribed spacer region (ITS) and single-copy gene families identified the isolated strain as Paraconiothyrium brasiliense. The genus Paraconiothyrium contains the major plant pathogenic fungi, and in our study, P. brasiliense was identified for the first time as causing human infection. To comprehensively analyze the pathogenicity, and proteomics of the isolated strain from a genetic perspective, whole-genome sequencing was performed with the Illumina NovaSeq and Oxford Nanopore Technologies platforms, and a bioinformatics analysis was performed with BLAST against genome sequences in various publicly available databases.

RESULTS

The genome of P. brasiliense GGX 413 is 39.49 Mb in length, with a 51.2% GC content, and encodes 13,057 protein-coding genes and 181 noncoding RNAs. Functional annotation showed that 592 genes encode virulence factors that are involved in human disease, including 61 lethal virulence factors and 30 hypervirulence factors. Fifty-four of these 592 virulence genes are related to carbohydrate-active enzymes, including 46 genes encoding secretory CAZymes, and 119 associated with peptidases, including 70 genes encoding secretory peptidases, and 27 are involved in secondary metabolite synthesis, including four that are associated with terpenoid metabolism.

CONCLUSIONS

This study establishes the genomic resources of P. brasiliense and provides a theoretical basis for future studies of the pathogenic mechanism of its infection of humans, the treatment of the diseases caused, and related research.

Paraconiothyrium cyclothyrioides, a novel cutaneous fungal pathogen in a dog and a cat

A dog and a cat presented with pyogranulomatous mycotic pododermatitis. Panfungal PCR and next-generation sequencing identified Paraconiothyrium cyclothyrioides with 100% identity. Paraconiothyrium cyclothyrioides can rarely cause cutaneous infection and systemic disease in immunocompromised humans. This is the first report of infections in domestic animal species.

Phaeohyphomycosis in Kidney Transplant Recipients: Highlighting the Importance of Early Recognition and Surgical Debridement

Fungal infections are a recognized complication of immunosuppression in solid organ transplant recipients. Phaeohyphomycoses are fungal infections caused by a diverse group of dematiaceous fungi.

Methods

We share the learning points from 2 Australian cases of phaeohyphomycosis secondary to Phaeacreomonium species (spp). A literature review was performed using Medline, Embase, and Google Scholar to identify this condition among kidney transplant recipients.

Results

With the 2 cases reported in this article, a total of 17 cases were identified in the literature. Phaeacremonium spp is ubiquitous in humid and temperate flora, including Australia. Minor trauma is likely the source of inoculation in most cases and diagnosis is often delayed. Presently, no guidelines for management exist given the rarity of this condition. Most known cases have been treated with surgical debulking combined with long-course antifungal therapy.

Conclusion

This paper describes 2 Australian cases of phaeohyphomycosis in kidney transplant recipients. A high index of suspicion, especially in the immunosuppressed, is essential for timely diagnosis in kidney transplant recipients. There are several diagnostic and therapeutic challenges that remain with this condition.

Fungal Osteomyelitis due to Phaeoacremonium venezuelense: A Case Report

CASE

A 56-year-old immunosuppressed man presented with pain and swelling in the medial and anterior right foot with accompanied numbness in the second and third toes 1 month after a puncture wound by a Sylvester palm tree thorn. An intraoperative culture/biopsy returned positive for septic arthritis of the naviculocuneiform joint and fungal osteomyelitis of the navicular, medial, and intermediate cuneiforms due to Phaeoacremonium venezuelense.

CONCLUSION

Fungal osteomyelitis is extremely rare. Only 5 cases by Phaeoacremonium venezuelense have been reported previously in the literature. To the best of our knowledge, this is the first case of osteomyelitis by this strain.

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 Paraconiothyrium: species concepts, biological functions, and secondary metabolites

The genus Paraconiothyrium has worldwide distribution with diverse host habitats and exhibits potential utilisation as biocontrol agent, bioreactor and antibiotic producer. In this review, we firstly comprehensively summarise the current taxonomic status of Paraconiothyrium species, including their category names, morphological features, habitats, and multigene phylogenetic relationships. Some Paraconiothyrium species possess vital biological functions and potential applications in medicine, agriculture, industry, and environmental protection. A total of 147 secondary metabolites have been reported so far from Paraconiothyrium, among which 95 are novel. This paper serves to provide an overview of their diverse structures with chemical classification and biological activities. To date, 27 species of Paraconiothyrium have been documented; however, only seven have been investigated for their secondary metabolites or biological functions. Our review is expected to draw more attention to this genus for providing a taxonomic reference, discovering extensive biological functions, and searching in-depth for new bioactive natural products.

Mycetoma caused by Microascus gracilis: a novel agent of human eumycetoma in Sudan

Species of the genus Microascus are uncommon agents of human diseases despite their ubiquitous presence in the environment. In this communication, the first case of white grain eumycetoma caused by the fungus Microascus gracilis is reported. The patient was initially misdiagnosed as having actinomycetoma based on the grains morphological and cytological features and was treated with antimicrobial therapy with no clinical improvement. She underwent wide local surgical excision to improve the response to medical treatment and further grain cultural, molecular and taxonomy techniques were conducted and the diagnosis of mycetoma due to M. gracilis was established. The antifungal susceptibilities of this isolate to nine drugs were tested in vitro and they showed poor activity. Combination therapy with surgery and itraconazole led to complete recovery. A medical literature search revealed no previous report on M. gracilis as a causative agent of eumycetoma and hence we are reporting this new causative agent of human eumycetoma. Also, the difficulty in the management of this patient emphasizes the need for accurate and appropriate diagnostic tests for the identification of mycetoma-causative organisms and thus proper management.

A rare case of phaeohyphomycosis due to Phaeoacremonium krajdenii from Odisha

A 45-year-old healthy woodcutter presented with a cystic swelling on the sole of the left great toe. Other than barefoot walking, there was no history of trauma or significant illness in the past. Fine needle aspirate showed yeast and hyphae on microscopy and culture grew black mould which was identified as Phaeoacremonium krajdenii species and genus confirmed by internal transcribed spacer sequencing. Aspiration of the lesion resulted in cure. Phaeoacremonium is a genus of fungi which are rare human pathogens, and herein we report a rare case of phaeohyphomycosis due to Phaeoacremonium krajdenii from the state of Odisha, India.

Cutaneous infection caused by paraconiothyrium cyclothyrioides in a renal transplant recipient

Infections because of Coelomycetes are being diagnosed more frequently, ranging from superficial cutaneous to disseminated infections. An increasing incidence of infections because of emerging environmental fungi are being reported in immunocompromised patients because of exposure to soil, plants, and water. We report a case of cutaneous infection because of Paraconiothyrium cyclothyrioides, a Coelomycetous fungi, including literature review on reported cases and discuss suggested treatment options.

The type isolate of a rare Phaeoacremonium species as a cause of human eumycetoma

An isolate of unknown identity that had been identified as causing eumycetoma was retained in an international culture collection, and eventually became the nomenclatural type isolate of the rarely encountered Phaeoacremonium sphinctrophorum. The case featured an indurated, painless, swollen lesion on the dorsum of the foot that had developed in a Canadian resident who had previously been a farmer in Laos. Resection alone was curative.

Chaetomium atrobrunneum causing human eumycetoma: The first report

In this communication, a case of black grain eumycetoma produced by the fungus C. atrobrunneum is reported. The patient was initially misdiagnosed with M. mycetomatis eumycetoma based on the grains’ morphological and cytological features. However, further aerobic culture of the black grains generated a melanised fungus identified as C. atrobrunneum by conventional morphological methods and by internal transcribed spacer 2 (ITS2) ribosomal RNA gene sequencing. This is the first-ever report of C. atrobrunneum as a eumycetoma-causative organism of black grain eumycetoma. It is essential that the causative organism is identified to the species level, as this is important for proper patient management and to predict treatment outcome and prognosis.

Cutaneous infection by Phaeoacremonium parasiticum

BACKGROUND

Phaeoacremonium parasiticum is considered a rare infectious agent that is part of a heterogeneous group of fungi causing phaeohyphomycosis. This organism is capable of producing subcutaneous infections, eumycetomas, osteomyelitis, arthritis, myositis and also disseminated diseases, such as fungemia and endocarditis.

CASE REPORT

We describe a case of cutaneous infection by P. parasiticum in a kidney transplant patient. The identification of this microorganism was performed by microbiological and histopathological studies and confirmed with the sequence of the gene encoding β-tubulin and a real time panfungal PCR targeting 18S ribosomal RNA gene. The microorganism was correctly identified by phenotypic and molecular methods. The patient was treated with oral antifungal therapy and a debulking surgery and evolved without any complication.

CONCLUSIONS

The diagnosis of this infection is difficult and usually affects kidney transplant patients, but the reasons of this association are still unknown.

Isavuconazole for treatment of invasive fungal diseases caused by more than one fungal species

The optimal approach to treat invasive fungal disease (IFD) caused by more than one fungal species is unknown. We documented the efficacy and safety of isavuconazole for treatment of IFDs caused by more than one fungal species. VITAL was a single-arm, international, open-label study evaluating the efficacy and safety of isavuconazole (200 mg orally or intravenously every 8 hours for 48 hours, then once daily) for treatment of rare IFDs. The primary outcome was the overall response at Day 42; key secondary outcomes were overall responses at Day 84 and end of treatment (EOT), mortality at Days 42 and 84, and safety. This analysis includes patients with IFD caused by multiple fungal species. Fifteen patients were included in this analysis (including Aspergillus spp., n = 11; without Aspergillus spp., n = 4); median treatment duration was 97 days [range, 6-544] days). Overall treatment success was observed in 2/15 patients (13.3%) at Days 42 and 84, and 2/14 (14.3%) at EOT. All-cause mortality was 2/15 (13.3%) at Day 42 and 4/15 (26.7%) at Day 84. All patients had ≥1 treatment-emergent adverse event (TEAE); 12 patients (80.0%) had serious TEAEs; TEAEs led to discontinuation of isavuconazole in two patients (13.3%). Isavuconazole may be useful to treat some IFDs caused by multiple fungal species.

Transplant tourism and invasive fungal infection

BACKGROUND

Deceased and live-related renal transplants (RTXs) are approved procedures that are performed widely throughout the world. In certain regions, commercial RTX has become popular, driven by financial greed.

METHODS

This retrospective, descriptive study was performed at the Royal Hospital from 2013 to 2015. Data were collected from the national kidney transplant registry of Oman. All transplant cases retrieved were divided into two groups: live-related RTX performed in Oman and commercial-unrelated RTX performed abroad. These groups were then divided again into those with and without evidence of fungal infection, either in the wound or renal graft.

RESULTS

A total of 198 RTX patients were identified, of whom 162 (81.8%) had undergone a commercial RTX that was done abroad. Invasive fungal infections (IFIs) were diagnosed in 8% of patients who had undergone a commercial RTX; of these patients, 76.9% underwent a nephrectomy and 23.1% continued with a functioning graft. None of the patients with RTXs performed at the Royal Hospital contracted an IFI. The most common fungal isolates were Aspergillus species (including Aspergillus flavus, Aspergillus fumigatus, Aspergillus nidulans, and Aspergillus nigricans), followed by Zygomycetes. However, there was no evidence of fungal infection including Aspergillus outside the graft site. Computed tomography (CT) findings showed infarction of the graft, renal artery thrombosis, aneurysmal dilatation of the external iliac artery, fungal ball, or just the presence of a perigraft collection. Of the total patients with IFIs, 23.1% died due to septic shock and 53.8% were alive and on hemodialysis. The remaining 23.1% who did not undergo nephrectomy demonstrated acceptable graft function.

CONCLUSIONS

This is the largest single-center study on commercial RTX reporting the highest number of patients with IFI acquired over a relatively short period of time. Aspergillus spp were the main culprit fungi, with no Candida spp being isolated. A high index of suspicion might be the most reasonable means to reduce the possible very poor outcomes. Improving legal transplant programs and strengthening the associated laws could prevent commercial transplant tourism.

Phaeoacremonium Tenosynovitis of the Wrist

A 79-year-old man presented with a painless, soft, subcutaneous mass lesion of the right volar wrist that had been slowly growing for 3 years. A cloudy, yellow serous effusion was aspirated from the punctured mass, from which Phaeoacremonium spp., an extremely rare cause of tenosynovitis, was isolated in culture. Total synovectomy was performed without the use of antifungal agents. No recurrence or complications occurred as of 6 months after surgery. Fungal infection is rare but should be considered in the differentiation of chronic tenosynovitis.

Cutaneous phaeohyphomycosis

BACKGROUND

Phaeohyphomycosis is an infrequent infection in human beings. However, in recent years, its prevalence has augmented in immunosuppressed patients (mostly in solid organ transplanted patients). Infection can be mucocutaneous or disseminated. In the former, the fungus inoculation occurs mainly through traumatism. Lesions may be polymorphic and asymptomatic, isolated or multiple, and are usually localized in exposed areas of the limbs and head. Treatment is not standardized. When possible, surgical resection of the lesion is combined with systemic antifungals.

METHODS

We communicate three phaeohyphomycosis cases with cutaneous compromise.

RESULTS

The cases we present show diverse clinical characteristics and varied severity and evolution.

CONCLUSION

It is important for dermatologists to recognize this cutaneous fungus infection because the diagnosis using microscopic examination and mycological culture depends on the clinical suspicion.

Coelomycetous Fungi in the Clinical Setting: Morphological Convergence and Cryptic Diversity

Human infections by coelomycetous fungi are becoming more frequent and range from superficial to systemic dissemination. Traumatic implantation of contaminated plant material is the most common cause. The typical morphological feature of these fungi is the production of asexual spores (conidia) within fruiting bodies called conidiomata. This study aimed to determine the distribution of the coelomycetes in clinical samples by a phenotypic and molecular study of a large set of isolates received from a U.S. reference mycological institution and by obtaining the in vitro antifungal susceptibility pattern of nine antifungals against a selected group of isolates. A total of 230 isolates were identified by sequencing the D1 and D2 domains of the large subunit (LSU) nuclear ribosomal RNA (nrRNA) gene and by morphological characterization. Eleven orders of the phylum Ascomycota were identified: Pleosporales (the largest group; 66.1%), Botryosphaeriales (19.57%), Glomerellales (4.35%), Diaporthales (3.48%), Xylariales (2.17%), Hysteriales and Valsariales (0.87%), and Capnodiales, Helotiales, Hypocreales and Magnaporthales (0.43% each). The most prevalent species were Neoscytalidium dimidiatum, Paraconiothyrium spp., Phoma herbarum, Didymella heteroderae, and Epicoccum sorghinum The most common anatomical site of isolation was superficial tissue (66.5%), followed by the respiratory tract (17.4%). Most of the isolates tested were susceptible to the majority of antifungals, and only flucytosine showed poor antifungal activity.

Ten-Year Experience of Cutaneous and/or Subcutaneous Infections Due to Coelomycetes in France

Background.  Coelomycetes are rarely but increasingly reported in association with human infections involving mostly skin and subcutaneous tissues, both in immunocompetent and immunocompromised patients. Coelomycetes constitute a heterogeneous group of filamentous fungi with distinct morphological characteristics in culture, namely an ability to produce asexual spores within fruit bodies. Methods.  We included all cases of proven primary cutaneous and/or subcutaneous infections due to coelomycetes received for identification at the French National Reference Center for Invasive Mycoses and Antifungals between 2005 and 2014. Eumycetoma, chromoblastomycosis, and disseminated infections were excluded. Results.  Eighteen cases were analyzed. The median age was 60.5 years. In all cases, patients originated from tropical or subtropical areas. An underlying immunodepression was present in 89% of cases. Cutaneous and/or subcutaneous lesions, mainly nodules, abscesses, or infiltrated plaques, were observed in distal body areas. Isolates of different genera of coelomycetes were identified: Medicopsis (6), Paraconiothyrium (3), Gloniopsis (3), Diaporthe (3), Peyronellaea (2), Lasiodiplodia (1). Lesion treatment consisted of complete (10) or partial (2) surgical excision and/or the use of systemic antifungal therapy, namely voriconazole (5) and posaconazole (4). Literature review yielded 48 additional cases of cutaneous and/or subcutaneous infections due to coelomycetes. Conclusions.  Infectious diseases physicians should suspect coelomycetes when observing cutaneous and/or subcutaneous infections in immunocompromised hosts from tropical areas; a sequence-based approach is crucial for strains identification but must be supported by consistent phenotypic features; surgical treatment should be favored for solitary, well limited lesions; new triazoles may be used in case of extensive lesions, especially in immunocompromised patients.

In Vitro Susceptibility Profiles of Eight Antifungal Drugs against Clinical and Environmental Strains of Phaeoacremonium

In vitro susceptibilities of a worldwide collection of molecularly identified Phaeoacremonium strains (n = 43) belonging to seven species and originating from human and environmental sources were determined for eight antifungal drugs. Voriconazole had the lowest geometric mean MIC (0.35 μg/ml), followed by posaconazole (0.37 μg/ml), amphotericin B (0.4 μg/ml), and isavuconazole (1.16 μg/ml). Caspofungin, anidulafungin, fluconazole, and itraconazole had no activity.