Molecular and Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry-Based Characterization of Clinically Significant Melanized Fungi in India

Phaeohyphomycosis: A 10-Year Study From a Tertiary Care Centre in South India

Background Phaeohyphomycosis, a fungal infection caused by dematiaceous fungi, presents a significant health challenge affecting both immunocompromised and immunocompetent individuals. Despite its clinical importance, phaeohyphomycosis remains underrepresented in epidemiological studies, leading to gaps in our understanding of its prevalence, clinical manifestations, and associated risk factors. This retrospective study conducted in South India aims to address these gaps by examining the incidence, diverse clinical presentations, and other relevant epidemiological aspects of phaeohyphomycosis in patients referred for pathological examination. Objective To investigate the epidemiological trends, clinicopathological characteristics, and microbiological spectrum of phaeohyphomycosis in patients at a tertiary care center in South India over 10 years. Materials and methods This comprehensive study was conducted at Employees State Insurance Corporation Medical College & Post Graduate Institute of Medical Sciences and Research (ESIC Medical College and PGIMSR), Chennai, embodying a retrospective observational approach. Over a decade, researchers meticulously reviewed cases diagnosed with phaeohyphomycosis. This involved an in-depth analysis of patients' medical records to gather detailed information on presenting symptoms, history of thorn pricks, diabetic status, and other pertinent epidemiological data. Additionally, culture samples were selectively obtained from patients exhibiting abscesses or cystic swellings, followed by a thorough assessment of the culture reports. Results In the ten-year study period, a total of 46 cases were identified. Most lesions were solid or cystic and located on extremities, predominantly affecting the digits. Eight cases (17%) had a history of thorn prick injuries, and six cases (13%) were associated with diabetes mellitus. Microscopic examination revealed necrosis, granulomas, varying degrees of inflammatory infiltrates, giant cells, and pigmented fungal hyphae. In some cases, biopsies revealed pseudoepitheliomatous hyperplasia. Among the 19 cases where culture was performed, Alternaria was the most commonly isolated pathogen (42%). Conclusion The study brings to light the diagnostic challenges inherent in phaeohyphomycosis cases, which often eluded clinical diagnosis and were only conclusively identified via pathological examinations. While this research was primarily focused on outpatients presenting with minor symptoms, it underscores the potential for more severe clinical presentations in immunocompromised patients. Our findings emphasize the need for increased clinical awareness and the pivotal role of histopathological examination in accurately diagnosing phaeohyphomycosis, particularly in cases with extremity lesions. This study contributes significantly to the understanding of phaeohyphomycosis and advocates for ongoing research to better understand its epidemiology and clinical diversity.

Chromoblastomycosis caused by Alternaria infectoria, concurrent with myiasis, in a recipient of a kidney transplant: a compelling case report

Neglected tropical diseases (NTDs) pose a significant threat to the health of millions of people worldwide, particularly in impoverished populations in tropical and subtropical regions. The World Health Organization (WHO) considers certain fungal infections, such as chromoblastomycosis, as NTDs. Chromoblastomycosis is a chronic fungal infection affecting the skin and subcutaneous tissue, primarily found in tropical and subtropical regions of Latin America, Africa, and Asia. This case report presents a 46-year-old female patient with chromoblastomycosis who had a history of renal transplantation and was receiving immunosuppressive therapy. The patient exhibited dark, verrucous, and ulcerative lesions on the legs, and the diagnosis was confirmed through the microscopic examination of skin scrapings by observing medlar bodies. Two sequential fungal tissue cultures and ITS sequencing verified the presence of Alternaria infectoria, not formerly described in chromoblastomycosis. Moreover, observation of fly larvae in the lesions verified the diagnosis of myiasis. Treatment with voriconazole and terbinafine resulted in complete resolution of the lesions after 5 months. This case emphasizes the importance of considering chromoblastomycosis in individuals with occupational exposure in tropical areas, as well as the challenges associated with its diagnosis, coinfections, and treatment.

An updated list of eumycetoma causative agents and their differences in grain formation and treatment response

SUMMARYIn 2023, the World Health Organization designated eumycetoma causative agents as high-priority pathogens on its list of fungal priority pathogens. Despite this recognition, a comprehensive understanding of these causative agents is lacking, and potential variations in clinical manifestations or therapeutic responses remain unclear. In this review, 12,379 eumycetoma cases were reviewed. In total, 69 different fungal species were identified as causative agents. However, some were only identified once, and there was no supporting evidence that they were indeed present in the grain. Madurella mycetomatis was by far the most commonly reported fungal causative agent. In most studies, identification of the fungus at the species level was based on culture or histology, which was prone to misidentifications. The newly used molecular identification tools identified new causative agents. Clinically, no differences were reported in the appearance of the lesion, but variations in mycetoma grain formation and antifungal susceptibility were observed. Although attempts were made to explore the differences in clinical outcomes based on antifungal susceptibility, the lack of large clinical trials and the inclusion of surgery as standard treatment posed challenges in drawing definitive conclusions. Limited case series suggested that eumycetoma cases caused by Fusarium species were less responsive to treatment than those caused by Madurella mycetomatis. However, further research is imperative for a comprehensive understanding.

Practical issues related to non-Aspergillus invasive mold infections

Infection by non-Aspergillus molds has been increasingly reported. The management of such infections is challenging both for diagnosis and treatment, including the need of well-trained mycologists to properly identify rare fungi, difficulties in distinguishing between contamination, colonization and infection, the lack of randomized studies comparing different drugs or regimens, poor activity of available antifungal agents, lack of correlation between in vitro antifungal susceptibility tests and clinical outcome, and poor prognosis. Mucormycosis and fusariosis are the most frequent non-Aspergillus mold infections. Mucormycosis occurs more frequently in four major groups of patients: solid organ transplant recipients, patients with hematologic malignancies receiving chemotherapy or hematopoietic cell transplantation, diabetic patients, and immunocompetent individuals who suffer various types of skin and soft tissue trauma. Invasive fusariosis occurs almost exclusively in patients with hematologic malignancies. In this review we discuss practical issues related to the management of these and other non-Aspergillus mold infections.

Rhino sinusitis caused by Lasiodiplodia theobromae in a diabetic patient

We report an uncommon instance of rhinosinusitis by Lasiodiplodia theobromae in a known diabetic patient. A melanized fungus called Lasiodiplodia theobromae causes a typical plant disease that rots fruits and plants. Infections in humans are currently limited. Mostly from tropical and subtropical regions, there have been few reported occurrences. The fungus has been associated with clinical manifestations such as onychomycosis, corneal ulcers, and phaeohyphomycosis. Identification by phenotype was inconclusive. DNA sequencing was used for final identification. Amphotericin B and surgical debridement were effective treatments for the patient.

Mass spectrometry in research laboratories and clinical diagnostic: a new era in medical mycology

Diagnosis by clinical mycology laboratory plays a critical role in patient care by providing definitive knowledge of the cause of infection and antimicrobial susceptibility data to physicians. Rapid diagnostic methods are likely to improve patient. Aggressive resuscitation bundles, adequate source control, and appropriate antibiotic therapy are cornerstones for success in the treatment of patients. Routine methods for identifying clinical specimen fungal pathogen are based on the cultivation on different media with the subsequent examination of its phenotypic characteristics comprising a combination of microscopic and colony morphologies. As some fungi cannot be readily identified using these methods, molecular diagnostic methods may be required. These methods are fast, but it can cost a lot. Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) is suitable for high-throughput and rapid diagnostics at low costs. It can be considered an alternative for conventional biochemical and molecular identification systems in a microbiological laboratory. The reliability and accuracy of this method have been scrutinized in many surveys and have been compared with several methods including sequencing and molecular methods. According to these findings, the reliability and accuracy of this method are very high and can be trusted. With all the benefits of this technique, the libraries of MALDI-TOF MS need to be strengthened to enhance its performance. This review provides an overview of the most recent research literature that has investigated the applications and usage of MT-MS to the identification of microorganisms, mycotoxins, antifungal susceptibility examination, and mycobiome research.

Matrix-Assisted Laser Desorption Ionization Time-of-Flight for Fungal Identification

Many studies have shown successful performance of matrix-assisted laser desorption ionization time-of-flight mass spectrometry for rapid yeast and mold identification, yet few laboratories have chosen to apply this technology into their routine clinical mycology workflow. This review provides an overview of the current status of matrix-assisted laser desorption ionization time-of-flight mass spectrometry for fungal identification, including key findings in the literature, processing and database considerations, updates in technology, and exciting future prospects. Significant advances toward standardization have taken place recently; thus, accurate species-level identification of yeasts and molds should be highly attainable, achievable, and practical in most clinical laboratories.

Diversity of microbiota in Slovak summer ewes' cheese "Bryndza"

"Bryndza" cheese is an important Slovak traditional regional product. New knowledge on the role of microorganisms involved the "Bryndza" ripening process may provide valuable data on its quality and safety. In our study, the "Bryndza" made from pasteurized ewes milk was studied towards total count of bacteria, coliforms bacteria, enterococci, lactic acid bacteria, and microscopic filamentous fungi. All those groups of microbiota were detected using classical microbiological methods and identified using mass spectrometry. A total of 3,758 isolates were identified with score higher than 2.00. Altogether, 13 families, 24 genus, and 44 species of microbiota were identified in Slovak cheese "Bryndza." The most often isolated species were yeasts Yarrowia lipolitica and Dipodascus geotrichum and the lactic acid bacteria Lactobacillus paracasei subsp. paracasei.

Cerebral phaeohyphomycosis due to Cladophialophora bantiana in an immunocompetent individual: A case report and brief review of literature

Background and Purpose

Fungal infections of the central nervous system (CNS) are life-threatening conditions that are frequently misdiagnosed with bacterial and viral CNS infections. Cerebral phaeohyphomycosis is a cerebral infection caused by dematiaceous fungi, especially Cladophialophora bantiana. Very few cases of fungal CNS infection have been reported across the world. High clinical suspicion should be cast for the patients with brain abscess that do not respond to conventional antibiotic therapy.

Case report

We report a case of a 21-year-old male presenting with headache, seizures and weakness in the limbs. Radiological examination revealed multiple brain abscesses. After surgical excision and laboratory evaluation, it was found to be caused by C. bantiana. The patient's outcome was good with surgical excision and voriconazole therapy.

Conclusion

Brain abscess caused by C. bantiana is on rise, especially in immunocompromised groups. Thus, high clinical suspicion, accurate diagnosis and management are the fundamentals for good prognosis.

Update on Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry Identification of Filamentous Fungi

Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS)-based species identification has found its place in many clinical routine diagnostic laboratories over the past years, allowing significantly reduced turnaround times and high-precision results. With regard to MALDI-TOF MS for filamentous fungi, here, we discuss different approaches for sample processing and growth conditions before analysis. In particular, we review the performances of different commercially available databases as well as the potential of complementary (self-constructed) in-house databases.

Unexpected mould diversity in clinical isolates from French Guiana and associated identification difficulties

New mold species are increasingly reported in invasive fungal infections. However, these fungi are often misdiagnosed or undiagnosed due to the use of inappropriate laboratory diagnostic tools. Tropical countries, such as French Guiana, harbor a vast diversity of environmental fungi representing a potential source of emerging pathogens. To assess the impact of this diversity on the accuracy of mold-infection diagnoses, we identified mold clinical isolates in French Guiana during a five-month follow-up using both microscopy and matrix-assisted laser desorption ionization time-of-flight mass spectrometry. In total, 38.8% of the 98 obtained molds isolates could not be identified and required a DNA-based identification. Fungal diversity was high, including 46 species, 26 genera, and 13 orders. Fungal ecology was unusual, as Aspergillus species accounted for only 27% of all isolates, and the Nigri section was the most abundant out of the six detected Aspergillus sections. Macromycetes (orders Agaricales, Polyporales, and Russulales) and endophytic fungi accounted for respectively 11% and 14% of all isolates. Thus, in tropical areas with high fungal diversity, such as French Guiana, routine mold identification tools are inadequate. Molecular identifications, as well as morphological descriptions, are necessary for the construction of region-specific mass spectrum databases. These advances will improve the diagnosis and clinical management of new fungal infections.

LAY SUMMARY

In French Guiana, environmental fungal diversity may be a source of emerging pathogens. We evaluated microscopy and mass spectrometry to identify mold clinical isolates. With 39% of unidentified isolates, a region-specific mass spectrum database would improve the diagnosis of new fungal infections.

First report of Lasiodiplodia pseudotheobromae keratitis susceptible to voriconazole in an Indian mango grower

The family Botriosphaeriacea comprises cosmopolitan endophytic fungi and many of the genera have frequently been implicated in causing human infections, including subcutaneous infection, sinusitis, invasive mycoses and keratitis. Among them, the genus Lasiodiplodia, which contains >30 species, is grouped as coelomycetous fungi with prototype species Lasiodiplodia theobromae as an important cause of keratitis. Several cryptic species morphologically resembling L. theobromae exist, one of which is Lasiodiplodia pseudotheobromae. We present a rare case of mycotic keratitis in an Indian mango grower following penetrating trauma to the left eye. Direct microscopy revealed retractile hyphal elements, and fungal cultures yielded a dematiaceous mould which was confirmed by sequencing as L. pseudotheobromae. Antifungal susceptibility testing revealed low MICs to amphotericin B and voriconazole and increased MICs to itraconazole and posaconazole. This is the first report of phytopathogenic L. pseudotheobromae keratitis, successfully treated with 2 % voriconazole without keratoplasty.

Phaeohyphomycosis: Cytomorphologic Evaluation in Eleven Cases

OBJECTIVE

Phaeohyphomycosis caused by phaeoid fungi is a type of mycosis emerging worldwide which causes a wide variety of clinical manifestations.

STUDY DESIGN

A retrospective analysis of 11 cases diagnosed with fungal inflammation on cytology over a period of 6 years (2013-2018) was done along with culture/histopathologic confirmation.

RESULTS

Of the total of 11 cases, 9 cases presented with subcutaneous swellings and 1 case each with brain and lung lesions. The age range was 30-83 years (mean: 53.6); 8 patients were male and 3 were female. Cytologic smears showed fungal profiles with septate tortuous hyphae, as well as swollen and narrow, yeast-like swellings with an irregular breadth of the hyphae in all cases. The fungal profiles were visualized on a Masson-Fontana stain. The background showed inflammatory cells, giant cells, and necrosis in variable proportions. Five cases were diagnosed as phaeohyphomycosis on cytology, whereas 3 cases were misdiagnosed as aspergillus and 2 as candida. In 1 case, typing of the fungus was not done. Histopathology was available in 5 cases, and in all these a diagnosis of phaeohyphomycosis was reached. Ten of the 11 cases had confirmation on fungal culture.

CONCLUSIONS

Phaeoid fungi are rarely seen in routine cytologic practice. Careful evaluation of cytologic smears and an awareness of the characteristic morphologic features of phaeohyphomycosis are helpful in arriving at a correct diagnosis. Fine needle aspiration cytology provides a rapid diagnosis, enabling prompt therapy.

Fine needle aspiration of nodular cystic swelling showing a rare melanized fungus Medicopsis romeroi: A case report

A young woman on long term corticosteroid therapy presented with a discrete hyperpigmented nodular cystic swelling on her upper thigh to the buttock region. There was history of discharging sinuses however at presentation the lesion was painless nondischarging. The lesion was subjected to fine-needle aspiration. The cytological smears on routine and special stains showed branching, septate fungal hyphae present extracellularly and intracellularly. The background showed dense mixed inflammation and granulomatous inflammation. The aspirated material was further subjected to culture. A nonsporulating melanized fungus was obtained and a culture isolate was sent for molecular characterization. Medicopsis romeroi, a rare melanized fungus belonging to the order Pleosporales was isolated on Internal transcribed spacer sequencing.

Vitek® MS v3.0 System in the Identification of Filamentous Fungi

Infections caused by filamentous fungi are rising in incidence and became a serious health concern. Their rapid and reliable identification in the clinical laboratory is essential for an early and accurate diagnosis to guide timely therapy. Matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) has been reported as a rapid and reliable method for identification of bacteria and yeasts isolated from clinical samples. However, it has less used for molds identification. The aim of this study was to evaluate Vitek^® MS (a MALDI-TOF MS system) ability to identify molds and differentiate species within a complex. A collection of 90 filamentous fungi, 70 clinical and 20 environmental isolates, was studied by morphological and molecular methods and by Vitek^® MS. Seventy-four isolates (82.2%) were identified using Vitek^® MS v3.0 at Genus/Complex/Species group level; within these, 47/74 (63.5%) were correctly identified at species level and only one was misidentified. In contrast, 16/90 isolates (17.8%) were not identified, of which 13 were not present in the database. Results here expressed favor Vitek^® MS v3.0 as a very useful system for identification of most common clinical isolates of filamentous fungi. Accordingly, it may be an important tool for clinical microbiology laboratories in their task to answer to clinicians, adequately and rapidly, helping in proper patient's management.

CNS Infections Caused by Brown-Black Fungi

Central nervous system (CNS) infections caused by brown-black or dematiaceous fungi are distinctly rare and represent a small proportion of infections termed phaeohyphomycoses. However, these are becoming more commonly reported. Though many fungi have been implicated in disease, most cases are caused by only a few species, Cladophialophora bantiana being the most common. Most of the fungi described are molds, and often cause infection in immunocompetent individuals, in contrast to infection with other more common molds such as Aspergillus, which is usually seen in highly immunocompromised patients. Diagnosis is challenging, as there are no specific tests for this group of fungi. In addition, these infections are often refractory to standard drug therapies, requiring an aggressive combined surgical and medical approach to improve outcomes, yet mortality remains high. There are no standardized treatments due to a lack of randomized clinical trials, though guidelines have been published based on available data and expert opinion.

A Moldy Application of MALDI: MALDI-ToF Mass Spectrometry for Fungal Identification

As a result of its being inexpensive, easy to perform, fast and accurate, matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-ToF MS) is quickly becoming the standard means of bacterial identification from cultures in clinical microbiology laboratories. Its adoption for routine identification of yeasts and even dimorphic and filamentous fungi in cultures, while slower, is now being realized, with many of the same benefits as have been recognized on the bacterial side. In this review, the use of MALDI-ToF MS for identification of yeasts, and dimorphic and filamentous fungi grown in culture will be reviewed, with strengths and limitations addressed.

MALDI-TOF MS-Based Identification of Melanized Fungi is Faster and Reliable After the Expansion of In-House Database

PURPOSE

Invasive fungal infections caused by melanized fungi are a growing concern. Rapid and reliable identification plays an important role in optimizing therapy. Matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry (MALDI-TOF MS)-based identification has emerged as a faster and more accurate diagnostic technique. However, lack of a protein extraction protocol and limited database restricts the identification of melanized fungi by MALDI-TOF MS. The study is designed to standardize protein extraction protocol, to enrich the existing, and to create an in-house database for the rapid identification of melanized fungi.

EXPERIMENTAL DESIGN

In this study, 59 sequence-confirmed, melanized fungi were used to expand and to create an in-house database using a modified protein extraction protocol. A total of 117 clinical isolates are further used to validate the created database.

RESULT

Using existing Bruker database, only 29(24.8%) out of 117 moulds could be identified. However, all the isolates are identified accurately by supplementing the Bruker database with the created in-house database. MALDI-TOF MS takes significantly lesser time for identification compared to DNA sequencing.

CONCLUSION AND CLINICAL RELEVANCE

An expanded database with modified protein extraction protocol can reduce significant time to identify melanized fungi by MALDI-TOF MS.

Species Identification and Delineation of Pathogenic Mucorales by Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry

This study aimed to validate the effectiveness of matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS)-based identification of filamentous fungi of the order Mucorales. A total of 111 isolates covering six genera preserved at the Research Center for Medical Mycology of Peking University were selected for MALDI-TOF MS analysis. We emphasized the study of 23 strains of Mucor irregularis predominantly isolated from patients in China. We first used the Bruker Filamentous Fungi library (v1.0) to identify all 111 isolates. To increase the identification rate, we created a compensatory in-house database, the Beijing Medical University (BMU) database, using 13 reference strains covering 6 species, including M. irregularis, Mucor hiemalis, Mucor racemosus, Cunninghamella bertholletiae, Cunninghamella phaeospora, and Cunninghamella echinulata All 111 isolates were then identified by MALDI-TOF MS using a combination of the Bruker library and BMU database. MALDI-TOF MS identified 55 (49.5%) and 74 (66.7%) isolates at the species and genus levels, respectively, using the Bruker Filamentous Fungi library v1.0 alone. A combination of the Bruker library and BMU database allowed MALDI-TOF MS to identify 90 (81.1%) and 111 (100%) isolates at the species and genus levels, respectively, with a significantly increased accuracy rate. MALDI-TOF MS poorly identified Mucorales when the Bruker library was used alone due to its lack of some fungal species. In contrast, this technique perfectly identified M. irregularis after main spectrum profiles (MSPs) of relevant reference strains were added to the Bruker library. With an expanded Bruker library, MALDI-TOF MS is an effective tool for the identification of pathogenic Mucorales.

FungiScope™ -Global Emerging Fungal Infection Registry

Rare invasive fungal diseases (IFD) are challenging for the treating physicians because of their unspecific clinical presentation, as well as the lack of standardised diagnostic and effective treatment strategies. Late onset of treatment and inappropriate medication is associated with high mortality, thus, urging the need for a better understanding of these diseases. The purpose of FungiScope^™ is to continuously collect clinical information and specimens to improve the knowledge on epidemiology and eventually improve patient management of these orphan diseases. FungiScope^™ was founded in 2003, and today, collaborators from 66 countries support the registry. So far, clinical data of 794 cases have been entered using a web-based approach. Within the growing network of experts, new collaborations developed, leading to several publications of comprehensive analyses of patient subgroups identified from the registry. Data extracted from FungiScope^™ have also been used as the sole control group for the approval of a new antifungal drug. Due to the rarity of these diseases, a global registry is an appropriate method of pooling the scarce and scattered information. Joining efforts across medical specialities and geographical borders is key for researching rare IFD. Here, we describe the structure and management of the FungiScope^™ registry.

Multicenter Evaluation of the Vitek MS v3.0 System for the Identification of Filamentous Fungi

Invasive fungal infections are an important cause of morbidity and mortality affecting primarily immunocompromised patients. While fungal identification to the species level is critical to providing appropriate therapy, it can be slow and laborious and often relies on subjective morphological criteria. The use of matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry has the potential to speed up and improve the accuracy of identification. In this multicenter study, we evaluated the accuracy of the Vitek MS v3.0 system in identifying 1,601 clinical mold isolates compared to identification by DNA sequence analysis and supported by morphological and phenotypic testing. Among the 1,519 isolates representing organisms in the v3.0 database, 91% (n = 1,387) were correctly identified to the species level. An additional 27 isolates (2%) were correctly identified to the genus level. Fifteen isolates were incorrectly identified, due to either a single incorrect identification (n = 13) or multiple identifications from different genera (n = 2). In those cases, when a single identification was provided that was not correct, the misidentification was within the same genus. The Vitek MS v3.0 was unable to identify 91 (6%) isolates, despite repeat testing. These isolates were distributed among all the genera. When considering all isolates tested, even those that were not represented in the database, the Vitek MS v3.0 provided a single correct identification 98% of the time. These findings demonstrate that the Vitek MS v3.0 system is highly accurate for the identification of common molds encountered in the clinical mycology laboratory.

In Vitro Activities of Luliconazole, Lanoconazole, and Efinaconazole Compared with Those of Five Antifungal Drugs against Melanized Fungi and Relatives

The in vitro activities of novel azoles compared to those of five antifungal drugs against clinical (n = 28) and environmental (n = 102) isolates of black mold and melanized yeast were determined. Luliconazole and lanoconazole had the lowest geometric mean MICs, followed by efinaconazole, against tested isolates compared to the other drugs. Therefore, it appears that these new imidazole and triazole drugs are promising candidates for the treatment of infections due to melanized fungi and their relatives.

A Mycoses Study Group International Prospective Study of Phaeohyphomycosis: An Analysis of 99 Proven/Probable Cases

Background

Phaeohyphomycosis is infection caused by dematiaceous, or darkly pigmented, fungi. The spectrum of disease is broad, and optimal therapy remains poorly defined. The Mycoses Study Group established an international case registry of patients with proven/probable phaeohyphomycosis with the goal of improving the recognition and management of these infections.

Methods

Patients from 18 sites in 3 countries were enrolled from 2009-2015. Cases were categorized as local superficial, local deep (pulmonary, sinus, osteoarticular infections), and disseminated infections. End points were clinical response (partial and complete) and all-cause mortality at 30 days and end of follow-up.

Results

Of 99 patients, 32 had local superficial infection, 41 had local deep infection, and 26 had disseminated infection. The most common risk factors were corticosteroids, solid organ transplantation, malignancy, and diabetes. Cultures were positive in 98% of cases. All-cause mortality was 16% at 30 days and 33% at end of follow-up, and 18 of 26 (69%) with dissemination died. Itraconazole was most commonly used for local infections, and voriconazole was used for more severe infections, often in combination with terbinafine or amphotericin B.

Conclusions

Phaeohyphomycosis is an increasingly recognized infection. Culture remains the most frequently used diagnostic method. Triazoles are currently the drugs of choice, often combined with other agents. Further studies are needed to develop optimal therapies for disseminated infections.