Report of the first human case of lobomycosis in the United States

Lobomycosis Epidemiology and Management: The Quest for a Cure for the Most Neglected of Neglected Tropical Diseases

Lobomycosis is a chronic disease caused by Lacazia loboi, which is endemic to the Amazon rainforest, where it affects forest dwellers in Brazil. There is no disease control program and no official therapeutic protocol. This situation contributes to an unknown disease prevalence and unmet needs of people disabled by this disease who seek access to treatment. This review provides an update on the subject with an emphasis on therapeutic advances in humans. All relevant studies that addressed epidemiology, diagnosis, or therapeutics of lobomycosis were considered. Seventy-one articles published between 1931 and 2021 were included for a narrative literature review on the epidemiology and quest for a cure. An effective therapy for lobomycosis has been found following decades of research led by the State Dermatology Program of Acre in the Amazon rainforest, where the largest number of cases occur. This discovery opened new avenues for future studies. The main recommendations here, addressed to the Brazilian Ministry of Health, are for lobomycosis to become a reportable disease to ensure that disease prevalence is measured, and that it be prioritized such that affected individuals may access treatment free-of-charge.

The taxonomy of two uncultivated fungal mammalian pathogens is revealed through phylogeny and population genetic analyses

Ever since the uncultivated South American fungal pathogen Lacazia loboi was first described 90 years ago, its etiology and evolutionary traits have been at the center of endless controversies. This pathogen infects the skin of humans and as long believed, dolphin skin. However, recent DNA analyses of infected dolphins placed its DNA sequences within Paracoccidioides species. This came as a surprise and suggested the human and dolphin pathogens may be different species. In this study, population genetic analyses of DNA from four infected dolphins grouped this pathogen in a monophyletic cluster sister to P. americana and to the other Paracoccidioides species. Based on the results we have emended the taxonomy of the dolphin pathogen as Paracoccidioides cetii and P. loboi the one infecting human. Our data warn that phylogenetic analysis of available taxa without the inclusion of unusual members may provide incomplete information for the accurate classification of anomalous species.

Lobomycosis in Soldiers, Colombia

Lobomycosis is a disease that is endemic to the Amazon rainforest and is caused by the still uncultured fungus Lacazia loboi. This disease occurs in loggers, farmers, miners, fishermen, and persons living near coastal rivers of this region. We report 6 soldiers in Colombia in whom lobomycosis developed after military service in the Amazon area. The patients had nodular and keloid-like lesions on the face, neck, trunk, and limbs. The duration of illness ranged from 2 years to 15 years. The initial diagnosis was leishmaniasis on the basis of clinical manifestations and direct smear results, but biopsies confirmed the final diagnosis of lobomycosis. Treatment with surgical excision, itraconazole and clofazimine was satisfactory. However, the follow-up time was short. Healthcare professionals responsible for the diagnosis and treatment of skin diseases need to be able to recognize the clinical signs of lobomycosis and differentiate them from those of cutaneous leishmaniasis.

Case Report: Molecular Confirmation of Lobomycosis in an Italian Traveler Acquired in the Amazon Region of Venezuela

Lobomycosis is a chronic skin mycosis endemic in Amazon regions characterized by chronic nodular or keloidal lesions caused by Lacazia loboi, an uncultivable fungus. Imported cases in nonendemic countries are rare and diagnosed after years. We describe a case of lobomycosis in a healthy 55-year-old Italian traveler who had acquired the infection during 5-day-honeymoon in the Amazon region of Venezuela in 1999. Several weeks after return, he recalled pruritus and papular skin lesions on the left lower limb, subsequently evolving to a plaque-like lesion. Blastomycosis and cryptococcosis were hypothesized based on microscopic morphology of yeast-like bodies found in three consecutive biopsies, although fungal cultures were always negative. In 2016, exfoliative cytology and a biopsy specimen examination showed round yeast-like organisms (6-12 μm), isolated or in a chain, connected by short tubular projections fulfilling the morphologic diagnostic criteria of Lacazia spp. The microscopic diagnosis was confirmed by molecular identification.

Analysis of Immune Response Markers in Jorge Lobo's Disease Lesions Suggests the Occurrence of Mixed T Helper Responses with the Dominance of Regulatory T Cell Activity

Jorge Lobo's disease (JLD) is a chronic infection that affects the skin and subcutaneous tissues. Its etiologic agent is the fungus Lacazia loboi. Lesions are classified as localized, multifocal, or disseminated, depending on their location. Early diagnosis and the surgical removal of lesions are the best therapeutic options currently available for JLD. The few studies that evaluate the immunological response of JLD patients show a predominance of Th2 response, as well as a high frequency of TGF-β and IL-10 positive cells in the lesions; however, the overall immunological status of the lesions in terms of their T cell phenotype has yet to be determined. Therefore, the objective of this study was to evaluate the pattern of Th1, Th2, Th17 and regulatory T cell (Treg) markers mRNA in JLD patients by means of real-time PCR. Biopsies of JLD lesions (N = 102) were classified according to their clinical and histopathological features and then analyzed using real-time PCR in order to determine the expression levels of TGF-β1, FoxP3, CTLA4, IKZF2, IL-10, T-bet, IFN-γ, GATA3, IL-4, IL-5, IL-13, IL-33, RORC, IL-17A, IL-17F, and IL-22 and to compare these levels to those of healthy control skin (N = 12). The results showed an increased expression of FoxP3, CTLA4, TGF-β1, IL-10, T-bet, IL-17F, and IL-17A in lesions, while GATA3 and IL-4 levels were found to be lower in diseased skin than in the control group. When the clinical forms were compared, TGF-β1 was found to be highly expressed in patients with a single localized lesion while IL-5 and IL-17A levels were higher in patients with multiple/disseminated lesions. These results demonstrate the occurrence of mixed T helper responses and suggest the dominance of regulatory T cell activity, which could inhibit Th-dependent protective responses to intracellular fungi such as L. loboi. Therefore, Tregs may play a key role in JLD pathogenesis.

Jorge Lobo's disease: a case of keloidal blastomycosis (lobomycosis) in a nonendemic area

Lobomycosis or lacaziosis is a chronic subcutaneous fungal infection, caused by the fungus Lacazia loboi, which is phylogenetically related to Coccidioides, Blastomyces, Histoplasma, and Paracoccidioides. The disease was first recognized in 1931 by Jorge Lobo, who found the disease to be a keloidal blastomycosis and named it Jorge Lobo's disease. This case was perplexing initially as this fungal infection is very uncommon in the USA. However, with the ever-increasing frequency of international travel, many more cases of lobomycosis have been diagnosed in areas of nonendemicity, such as the USA, Europe, and South Africa. The clinical histories of such imported fungal infections often illustrate their long latency periods. In lobomycosis, the onset of the disease is usually insidious and often difficult to document. We describe a case of a New York resident who presented with multiple skin nodules over both his arms and forearms, and was subsequently diagnosed with Jorge Lobo's disease. The case, diagnosis, histopathologic findings, complication, and management of this rare clinical disease are discussed.

Lobomycosis: epidemiology, clinical presentation, and management options

Lobomycosis is a subcutaneous mycosis of chronic evolution caused by the Lacazia loboi fungus. Its distribution is almost exclusive in the Americas, and it has a particularly high prevalence in the Amazon basin. Cases of lobomycosis have been reported only in dolphins and humans. Its prevalence is higher among men who are active in the forest, such as rubber tappers, bushmen, miners, and Indian men. It is recognized that the traumatic implantation of the fungus on the skin is the route by which humans acquire this infection. The lesions affect mainly exposed areas such as the auricles and upper and lower limbs and are typically presented as keloid-like lesions. Currently, surgical removal is the therapeutic procedure of choice in initial cases. Despite the existing data and studies to date, the active immune mechanisms in this infection and its involvement in the control or development of lacaziosis have not been fully clarified. In recent years, little progress has been made in the appraisal of the epidemiologic aspects of the disease. So far, we have neither a population-based study nor any evaluation directed to the forest workers.

Lobomycosis: risk of zoonotic transmission from dolphins to humans

Lobomycosis, a fungal disease of the skin and subcutaneous tissues caused by Lacazia loboi, is sometimes referred to as a zoonotic disease because it affects only specific delphinidae and humans; however, the evidence that it can be transferred directly to humans from dolphins is weak. Dolphins have also been postulated to be responsible for an apparent geographic expansion of the disease in humans. Morphological and molecular differences between the human and dolphin organisms, differences in geographic distribution of the diseases between dolphins and humans, the existence of only a single documented case of presumed zoonotic transmission, and anecdotal evidence of lack of transmission to humans following accidental inoculation of tissue from infected dolphins do not support the hypothesis that dolphins infected with L. loboi represent a zoonotic hazard for humans. In addition, the lack of human cases in communities adjacent to coastal estuaries with a high prevalence of lobomycosis in dolphins, such as the Indian River Lagoon in Florida (IRL), suggests that direct or indirect transmission of L. loboi from dolphins to humans occurs rarely, if at all. Nonetheless, attention to personal hygiene and general principals of infection control are always appropriate when handling tissues from an animal with a presumptive diagnosis of a mycotic or fungal disease.

Lobomycosis: A case from Southeastern Europe and review of the literature

BACKGROUND

Lobomycosis, also known as Jorge Lobo's disease, represents a rare chronic subcutaneous mycosis caused by the fungus Lacazia loboi, an organism that is found within lesions but has not been cultured to date. The natural reservoir of L. loboi is unknown but it is believed to be aquatic, or associated with soil and vegetation. More than 550 human cases have been reported, especially in patients with a history of travel or residence in endemic areas (Central and South America, particularly Brazil) or in communities along rivers.

MAIN OBSERVATIONS

We describe a 64-year-old Greek female farmer living in a coastal region, who presented with an erythematous plaque on her left inner thigh resembling a keloid. The diagnosis was based on the triad: 1) absence of fungal growth in cultures, 2) positive direct microscopic examination of the lesion and 3) histopathology, all consistent with lobomycosis. Particularly, skin biopsy showed deep cutaneous fungal infection with granulomatous reaction. Fungal cells were found inside giant cells. The fungi were thick-walled with some budding, isolated or in short chains. Dermal fibrosis was present. Our patient had a medical history of common variable immunodeficiency but no history of travel to South or Central America. She probably acquired this rare infection by injury during her agricultural works.

CONCLUSION

Our case represents probably the first documented case of human lobomycosis in Southeastern Europe. This case is unusual due to the rarity of lobomycosis in Mediterranean countries, particularly in Southeastern Europe.

Lobomycosis

Lobomycosis is a rare chronic fungal infection of the subcutaneous tissue found in South America, mainly in Brazil. It is caused by Lacazia loboi. Its clinical manifestations are dermal nodules, either lenticular or in plaques, and keloidlike lesions that can resemble nodular leprosy or leishmaniasis, other subcutaneous mycoses (sporotrychosis, chromomycosis, paracoccidioidomycosis), keloids, and malignant tumors. Diagnosis is made by the histopathological findings of the fungus. For treatment, surgical removal of the lesions, followed by itraconazole and clofazimine for disseminated lesions, has been used with variable results.

Genus paracoccidioides: Species recognition and biogeographic aspects

BACKGROUND

Paracoccidioidomycosis is a systemic mycosis caused by Paracoccidioides brasiliensis (species S1, PS2, PS3), and Paracoccidioides lutzii. This work aimed to differentiate species within the genus Paracoccidioides, without applying multilocus sequencing, as well as to obtain knowledge of the possible speciation processes.

METHODOLOGY/PRINCIPAL FINDINGS

Single nucleotide polymorphism analysis on GP43, ARF and PRP8 intein genes successfully distinguished isolates into four different species. Morphological evaluation indicated that elongated conidia were observed exclusively in P. lutzii isolates, while all other species (S1, PS2 and PS3) were indistinguishable. To evaluate the biogeographic events that led to the current geographic distribution of Paracoccidioides species and their sister species, Nested Clade and Likelihood Analysis of Geographic Range Evolution (LAGRANGE) analyses were applied. The radiation of Paracoccidioides started in northwest South America, around 11-32 million years ago, as calculated on the basis of ARF substitution rate, in the BEAST program. Vicariance was responsible for the divergence among S1, PS2 and P. lutzii and a recent dispersal generated the PS3 species, restricted to Colombia. Taking into account the ancestral areas revealed by the LAGRANGE analysis and the major geographic distribution of L. loboi in the Amazon basin, a region strongly affected by the Andes uplift and marine incursions in the Cenozoic era, we also speculate about the effect of these geological events on the vicariance between Paracoccidioides and L. loboi.

CONCLUSIONS/SIGNIFICANCE

The use of at least 3 SNPs, but not morphological criteria, as markers allows us to distinguish among the four cryptic species of the genus Paracoccidioides. The work also presents a biogeographic study speculating on how these species might have diverged in South America, thus contributing to elucidating evolutionary aspects of the genus Paracoccidioides.

Molecular diagnosis of lobomycosis-like disease in a bottlenose dolphin in captivity

We report the diagnosis and molecular characterization of lobomycosis-like lesions in a captive bottlenose dolphin. The clinical picture and the absence of growth in conventional media resembled the features associated with Lacazia loboi. However sequencing of ribosomal DNA and further phylogenetic analyses showed a novel sequence more related to Paracoccidioides brasilensis than to L. loboi. Moreover, the morphology of the yeast cells differed from those L. loboi causing infections humans. These facts suggest that the dolphin lobomycosis-like lesions might have been be caused by different a different fungus clustered inside the order Onygenales. A successful treatment protocol based on topic and systemic terbinafine is also detailed.

Ten years experience with Jorge Lobo's disease in the state of Acre, Amazon region, Brazil

Jorge Lobo's disease is a cutaneous and subcutaneous mycosis that affects patients in the Amazon region. The number of patients is relatively small, but the real situation of the disease as public health problem is not known, because Jorge Lobo's disease is not a notifiable disease. This study aims to report the clinical evolution in patients affected and to determine the prevalence and areas of occurrence of the disease. A retrospective study was carried out based on the analysis of the clinical records, which included a collection of photographs of patients in the Department of Sanitary Dermatology, in Rio Branco, and patients seen in the interior of the state. In a decade, in Rio Branco, 249 cases of the disease were reported, 30 were females and 219 males. Of these patients, 153 had localized lesions, 94 of them were on one ear, 55 had multifocal lesions and 41 had disseminated lesions. The average time between the onset of symptoms and diagnosis was 19 years. The average age at the time of diagnosis was 53 years, and ages ranged from 14 to 96 years.

Lobomycosis. Literature review and future perspectives

Lobomycosis is a cutaneous infection of tropical and subtropical regions caused by the fungus Lacazia loboi, which still has a controversial taxonomical position. The first description of the disease and fungus was made in 1930 by Jorge Lobo. It is a chronic disease with predominance of lesions similar to keloids, in exposed areas, limited to skin and semimucosa. There is no systemic involvement and patients maintain a good general health. Diagnosis is confirmed by direct or histopathologic exam and, until present, the fungus has not been cultivated. Surgery is the treatment of choice for isolated lesions, but there are frequent recurrences. Good therapeutic responses have been reported with clofazimine, with or without itraconazole, and with 5-fluorocytosine. This disease should be recognized by dermatologists worldwide because, although restricted to the Amazon region, it has been observed in other locations. Research development and achievement of new knowledge in molecular biology and genetic engineering of lobomycosis are of utmost importance because they may, in the future, lead to the culture of the fungus in the laboratory and to a better understanding of its pathogenesis, transmission mechanism, and new methods of diagnosis, prevention and treatment.

Lobomycosis in man and lobomycosis-like disease in bottlenose dolphin, Venezuela

We report 1 case of lobomycosis caused by Lacazia loboi in a fisherman and 1 case of lobomycosis-like disease in a bottlenose dolphin (Tursiops truncatus) along the coast of Venezuela. These findings suggest that the marine environment is a likely habitat for L. loboi and a reservoir for infection.

Lobomycosis: diagnosis and management of relapsed and multifocal lesions

We report a case of lobomycosis in the left leg of a patient that had traveled to the endemic Brazilian Amazon region. After surgical resection of the lesion, there was relapse with local dissemination of the disease and the treatment was successfully performed by oral itraconazole and cryosurgery.

Differential and exclusive diagnosis of diseases that resemble keloids and hypertrophic scars

Previous articles suggested the presence of various kinds of malignant tumors that resemble keloid or hypertrophic scar, including dermatofibrosarcoma protuberans, trichilemmal carcinoma, and keloidal basal cell carcinoma. Thus, we studied our cases that were diagnosed with diseases other than keloid or hypertrophic scar. From April 2003 to March 2007, we examined 378 patients self diagnosed with keloid or hypertrophic scar.We detected 4 other diseases (1.06%) in the group of patients. All tumors were benign: apocrine cystadenoma, adult-onset juvenile xanthogranuloma, mixed tumor, and chronic folliculitis. Our study led us to the conclusion that differential or exclusive diagnosis of diseases similar to keloid and hypertrophic scar is important. We found the following considerations important in the examination of keloid or hypertrophic scar: (1) biopsy should be conducted in anomalous cases because malignant disease may be the original or secondary problem, (2) steroid injection should be performed only after careful consideration because malignancy or infections may be present, (3) careful differential diagnosis is particularly challenging in African-Americans because skin and tumor color are often similar, and (4) the presence of bacterial or fungal infection should be investigated.

Accidental Jorge Lobo's disease in a worker dealing with Lacazia loboi infected mice: a case report

INTRODUCTION

Jorge Lobo's disease (Lacaziosis) is a subcutaneous infection of humans living in the Amazon region of Latin America, and in dolphins inhabiting the east coastal areas of the United States. The disease mainly affects people from rural areas living or working in close contact with vegetation and aquatic environments. Most patients refer having developed lesions after accidental trauma with plant thorns or insect bites. Inter-human transmission has never been confirmed suggesting that Lacazia loboi is acquired from environmental propagules.

CASE PRESENTATION

We report the case of a 41-year-old woman from São Paulo, Brazil, a non-endemic area of Jorge Lobo's disease, with L. loboi skin infection most likely accidentally acquired while manipulating experimentally infected mice in the laboratory.

CONCLUSION

Because many patients with Jorge Lobo's disease do not recall accidental skin trauma before their infections, the possibility of accidentally acquired Jorge Lobo's disease through unnoticed broken skin should be considered during the clinical investigation of nodular skin diseases in people who have contact with the fungus or who live in endemic areas. This is the second report of animal to human transmission of this disease.

Cryptic "chromo-fibroma"

Chromoblastomycosis is an uncommon chronic fungal infection capable of presenting in a variety of clinical guises. Herein, we present the histopathological features of an unusual dermal response engendered by this organism, consisting of dermal effacement by a spindle cell proliferation arranged in sweeping fascicles.

Use of sera from humans and dolphins with lacaziosis and sera from experimentally infected mice for Western Blot analyses of Lacazia loboi antigens

Antibodies in the sera of patients with lacaziosis recognized an approximately 193-kDa antigen and other Lacazia loboi antigens. Paracoccidioides brasiliensis gp43 antigen was detected by all evaluated sera, but they failed to detect a protein with the same molecular mass in L. loboi extracts. This study is the first to examine the humoral response to L. loboi antigens by using multiple host sera.

Lacaziose (doença de Jorge Lobo): revisão e atualização

Lacaziose ou doença de Jorge Lobo é micose crônica, granulomatosa, causada por implantação traumática do fungo Lacazia loboi - patógeno não cultivável até o presente - nos tecidos cutâneo e subcutâneo, manifestando-se clinicamente por lesões nodulares queloidianas predominantes, envolvendo sobretudo pavilhões auriculares, face, membros superiores e inferiores, e não comprometendo as mucosas. A maioria dos casos humanos está registrada em países da América do Sul. Entretanto, a enfermidade apresenta aspectos epidemiológicos destacados, como o aparecimento em tribo Caiabi, no Brasil Central e em mamíferos não humanos, golfinhos de duas espécies (Tursiops truncatus e Sotalia guianensis) capturados na costa da Flórida (EUA), na foz do rio Suriname, na costa de Santa Catarina (Brasil), no golfo de Gasconha (baía de Biscaia-Europa), com manifestações cutâneas e achados histopatológicos muito similares às encontradas no homem. O artigo objetiva abordar características do fungo e sua taxonomia, e aspectos históricos, ecoepidemiológicos, clínicos, imuno-histoquímicos, histopatológicos, ultra-estruturais e terapêuticos.

Lobomycosis in Venezuela

Lobomycosis is a chronic dermal infection that presents a wide spectrum of clinical- dermatological manifestations, mainly characterized by the development of keloid lesions as well as nodular, verrucoid and sometimes ulcerous forms. The etiological agent at an international level, according to the consensus nomenclature, has been called Loboa loboi, even though recently it has been accommodated as Lacazia loboi. The present review extensively covers the clinical-epidemiological aspects as well as the most outstanding historical aspects, including the Venezuelan experience and the presentation of two new cases, which substantiate the Amazon basin as an endemic area for the disease.

Tropical dermatology: fungal tropical diseases

Fungal infections are common in tropical countries and can have an important impact on public health. Lobomycosis is a common fungal infection in the tropical rain forest of South America, and paracoccidioidomycosis (South American blastomycosis) is a widespread and sometimes severe illness. Penicilliosis marneffei is an opportunistic infection of AIDS patients in southeast Asia. Chromoblastomycosis and mycetomas are causes of morbidity around the world. Sporotrichosis is a worldwide subcutaneous mycosis with a high incidence in tropical countries and is an important illness in immunocompromised patients. Rhinosporidiosis was classed as a fungal infection but is now considered a protistan parasite that belongs to the class Mesomycetozoea. It is included in this review because of its historical classification. In the past, most of these mycoses were restricted to specific geographic areas and natural reservoirs. There are, however, situations in which people from other regions come in contact with the pathogen. A common situation involves an accidental contamination of a traveler or worker who has contact with a tropical mycosis. Even minor trauma to the skin surface or inhalation of the fungal conidia can infect the patient. Thus recognition of the clinical symptoms and the dermatologic findings of the diseases, as well as the geographic distribution of the pathogens, can be critical in diagnosis of the tropical mycoses. This review discusses some of the more common tropical subcutaneous and systemic mycoses, as well as their signs, symptoms, methods of diagnosis, and therapies.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be able to recognize the clinical and histologic presentations of tropical fungal diseases with cutaneous manifestations and be familiar with the appropriate therapies.

Lobomycosis in Atlantic bottlenose dolphins from the Indian River Lagoon, Florida

OBJECTIVE

To determine the prevalence of lobomycosis, a mycotic infection of dolphins and humans caused by a yeastlike organism (Lacazia loboi), among dolphins in the Indian River Lagoon in Florida.

DESIGN

Cross-sectional study.

ANIMALS

146 Atlantic bottlenose dolphins.

PROCEDURE

Comprehensive health assessments of bottlenose dolphins in the Indian River Lagoon of Florida (n = 75) and in estuarine waters near Charleston, SC (71), were conducted during 2003 and 2004. Bottlenose dolphins were captured, examined, and released. Skin lesions were photographed and then biopsied. Tissue sections were stained with H&E and Gomori methenamine silver stains for identification of L. loboi.

RESULTS

9 of 30 (30%) dolphins captured in the southern portion of the Indian River Lagoon had lobomycosis, whereas none of the 45 dolphins captured in the northern portion of the lagoon or of the 71 dolphins captured near Charleston, SC, did. Affected dolphins had low serum alkaline phosphatase activities and high acute-phase protein concentrations.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that lobomycosis may be occurring in epidemic proportions among dolphins in the Indian River Lagoon. Localization of the disease to the southern portion of the lagoon, an area characterized by freshwater intrusion and lower salinity, suggests that exposure to environmental stressors may be contributing to the high prevalence of the disease, but specific factors are unknown. Because only dolphins and humans are naturally susceptible to infection, dolphins may represent a sentinel species for an emerging infectious disease.

Molecular model for studying the uncultivated fungal pathogen Lacazia loboi

Lacazia loboi is an uncultivated fungal pathogen of humans and dolphins that causes cutaneous and subcutaneous infections only in the tropical areas of the Americas. It was recently found by phylogenetic analysis that this unusual pathogen is closely related to Paracoccidioides brasiliensis and to the other fungal dimorphic members of the order Onygenales. That original phylogenetic study used universal primers to amplify well-known genes. However, this approach cannot be applied to the study of other proteins. We have developed a strategy for studying the gene encoding the gp43 homologous protein of P. brasiliensis in L. loboi. The gp43 protein was selected because it has been found that this P. brasiliensis antigen strongly reacts when it is used to test sera from patients with lacaziosis. The principle behind this idea was to obtain the gp43 amino acid sequence of P. brasiliensis and other homologous fungal sequences from GenBank and design primers from their aligned conserved regions. These sets of primers were used to amplify the selected regions with genomic DNA extracted from the yeast-like cells of L. loboi from experimentally infected mice. Using this approach, we amplified 483 bp of the L. loboi gp43-like gene. These sequences had 85% identity at the nucleotide level and 75% identity with the deduced amino acid sequences of the P. brasiliensis gp43 protein. The identity of the 483-bp DNA fragment was confirmed by phylogenetic analysis. This analysis revealed that the L. loboi gp43-like deduced amino acid sequence formed a strongly supported (100%) sister group with several P. brasiliensis gp43 sequences and that this taxon in turn was linked to the other fungal sequences used in this analysis. This study shows that the use of a molecular model for investigation of the genes encoding important proteins in L. loboi is feasible.

Human case of lobomycosis

We describe a 42-year-old woman with histologically confirmed lobomycosis, a cutaneous fungal infection rarely reported outside of Latin America. Our case represents the first published report of imported human lobomycosis in Canada and the fifth in an industrialized country.

Fungal infections among returning travelers

Endemic mycoses, such as histoplasmosis, coccidioidomycosis, and penicilliosis, have emerged as important health threats among travelers to regions of the world where these infections are endemic. Travelers have developed fungal infections as a result of a wide range of recreational and work activities, many of which have involved well-recognized risk factors for these diseases. In some instances, infections have been acquired during short trips, whereas, in other instances, infection has been acquired during a longer period of residence in an area where the infection is endemic. Travelers need to be made aware of the risks of acquiring mycotic diseases when visiting such regions. Health care providers need to consider these infections in their differential diagnosis among returning travelers with respiratory illness and should be familiar with the treatment and prevention of these diseases.

Phylogenetic analysis of Lacazia loboi places this previously uncharacterized pathogen within the dimorphic Onygenales

Lacazia loboi is the last of the classical fungal pathogens to remain a taxonomic enigma, primarily because it has resisted cultivation and only causes cutaneous and subcutaneous infections in humans and dolphins in the New World tropics. To place it in the evolutionary tree of life, as has been done for the other enigmatic human pathogens Pneumocystis carinii and Rhinosporidium seeberi, we amplified its 18S small-subunit ribosomal DNA (SSU rDNA) and 600 bp of its chitin synthase-2 gene. Our phylogenetic analysis indicated that L. loboi is the sister taxon of the human dimorphic fungal pathogen Paracoccidioides brasiliensis and that both species belong with the other dimorphic fungal pathogens in the order Onygenales. The low nucleotide variation among three P. brasiliensis 18S SSU rDNA sequences contrasts with the surprising amount of nucleotide differences between the two sequences of L. loboi used in this study, suggesting that the nucleic acid epidemiology of this hydrophilic pathogen will be rewarding.