Entomophthoramycosis by Conidiobolus coronatus. Report of a case successfully treated with the combination of itraconazole and fluconazole

Mycological isolation from animal enclosures and environments in National Wildlife Rescue Centre and National Zoo, Malaysia

It is important to provide a baseline of fungal composition in the captive wildlife environment to better understand their role in overall wildlife health. The objectives were to identify species of fungi existing within wildlife animal enclosures and their environment at the National Wildlife Rescue Centre (NWRC) and the National Zoo, Malaysia and to describe their medical and veterinary importance. Samples of air, wall or floor swab, enrichment swab and soil were taken from the animal enclosures, exercise yard and enrichments at NWRC and National Zoo respectively. All samples including those pre-treated samples were plated onto Sabouraud’s Dextrose Agar (SDA). Numerous fungi were grown on all sampling SDA plates regardless by either single or multiple growth. Samples of air in both NWRC and National Zoo had the highest growth of Penicillium spp. with a prevalence of 31.2% and 83.7% respectively. Samples of swab from the wall, floor and enrichments were predominantly by Candida spp. (42.6%) in NWRC and Penicillium spp. (41.6%) in the National Zoo. Prevalence of multiple fungi isolated from the soil samples in NWRC were 57.9% and yeast species was the most common in National Zoo with a prevalence of 88.9%. Overall, 29 and 8 isolates were found in both samples from the NWRC and National Zoo with a predominant species of potential zoonotic fungi have been identified in both premises. The expected fungus Aspergillus spp. was not isolated in all samples in NWRC. Prevalent fungal species found in this study are known to cause disease in animals and humans as primary pathogen and also as opportunistic pathogens that may also cause infection. Thus, health safety precautions should be considered particularly in dealing with conservation of endangered wildlife species, along with personnel and public involvements.

Conidiobolomycosis: An Unusual Fungal Disease-Our Experience

Conidiobolomycosis is a rare mycotic disease caused by Conidiobolus coronatus. Very few cases have been reported in English literature. Often it is clinically misdiagnosed as soft tissue tumour. A prospective case study was done from 2006 to 2015 in a tertiary care hospital of West Bengal, India. The objectives of our study were to describe the epidemiological and clinical features and treatment of Conidiobolomycosis to prevent disfigurement. Patients clinically suspected to be suffering from Conidiobolomycosis were subjected to biopsy followed by histopathological and mycological examinations. Then they were treated with oral saturated solution of potassium iodide along with other drugs. Total six cases were histopathologically proved to be suffering from Conidiobolomycosis. Fungus was isolated and identified in one case. Complete resolution was seen in five patients. Conidiobolomycosis should be brought into mind as differential diagnosis of subcutaneous swelling in the rhinofacial region.

In vitro assessment of antifungal, antibacterial, and antiprotozoal drugs against clinical isolates of Conidiobolus lamprauges

We have determined the in vitro activity of antifungal, antibacterial, and antiprotozoal drugs alone and in combination against seven Conidiobolus lamprauges clinical isolates. The assays were based on the M38-A2 protocol and the checkerboard microdilution method. The lowest inhibitory concentrations were observed for amphotericin B, miconazole (MCZ), terbinafine, and miltefosine (MTF) (MIC range 0.25-1; 2-8; 0.25-2; 2-16 μg/ml, respectively). The main synergism observed was through the combination of azithromycin (AZI)+MTF and dapsone (DAP)+MTF (100%), AZI+DAP (85.7%), AZI+MCZ (57.1%) as well as MCZ plus CTX and DAP (42.9%). The in vitro activities suggest that the combination of MTF and AZI or DAP are promising candidate therapies for conidiobolomycosis.

Blooming of Unusual Cytochrome P450s by Tandem Duplication in the Pathogenic Fungus Conidiobolus coronatus

While the Zygomycete fungus Conidiobolus coronatus primarily infects insects, it can be pathogenic to mammals as well, including humans. High variability in the treatment of this fungal infection with currently available drugs, including azole drugs is a very common phenomenon. Azoles bind to the cytochrome P450 monooxygenases (P450s/CYP) including CYP51, a sterol 14-α-demethylase, inhibiting the synthesis of cell membrane ergosterol and thus leading to the elimination of infecting fungi. Despite P450’s role as a drug target, to date, no information on C. coronatus P450s has been reported. Genome-wide data mining has revealed the presence of 142 P450s grouped into 12 families and 21 subfamilies in C. coronatus. Except for CYP51, the remaining 11 P450 families are new (CYP5854-CYP5864). Despite having a large number of P450s among entomopathogenic fungi, C. coronatus has the lowest number of P450 families, which suggests blooming P450s. Further analysis has revealed that 79% of the same family P450s is tandemly positioned, suggesting that P450 tandem duplication led to the blooming of P450s. The results of this study; i.e., unravelling the C. coronatus P450 content, will certainly help in designing experiments to understand P450s’ role in C. coronatus physiology, including a highly variable response to azole drugs with respect to P450s.

A first-line antiretroviral therapy-resistant HIV patient with rhinoentomophthoromycosis

The Conidiobolus coronatus-related rhinoentomophthoromycosis in immunocompetent and immunocompromised (HIV negative) individuals has been treated successfully with antifungal drugs. However, C. coronatus infections in first-line antiretroviral therapy (ART)-resistant (HIV infected) individuals particularly with rhinoentomophthoromycosis have not been reported previously. Here, we describe a case of itraconazole non-responding rhinoentomophthoromycosis in an HIV-infected patient with first-line antiretroviral (ART) drug resistance which was successfully managed through systematic diagnostic and therapeutic approaches in dermatologic setting. A 32-year-old HIV-1-infected man presented with painless swelling, nasal redness and respiratory difficulty. The patient was receiving first-line ART and had a history of traumatic injury before the onset of nasopharyngeal manifestations. The patient's previous history included oral candidiasis and pulmonary tuberculosis.

[A case of rhinofacial entomophthoromycosis in Soudano-Sahelian tropical climate in Burkina Faso]

We describe a rhinofacial entomophthoramycosis case in a sexagenarian (65 years old) housewife. She was immunocompetent and resident of Burkina Faso. She consulted both the service of dermatology and the service of stomatology of the Teaching Hospital of Bobo-Dioulasso in February 2016 for a diffuse facial tumefaction evolving over six months. This tumefaction was associated with headaches and a left nasal obstruction. Histological examination of the lesion showed an important and polymorphic inflammatory reaction. Also, a filamentous fungus with wide non-septated hyphae and right-angled fungal branching, consistent with mucormycosis was isolated. Mycological diagnosis based on fungal culture with Sabouraud medium without any antibiotic and cyclohexemide after incubation at 27°C and at 30°C was negative. Furthermore, it was not possible to amplify the DNA extracted from biopsy. Antifungal therapy based on the administration of fluconazole per os at 800mg/day was started allowing clinical improvement. This is the first case of a rhinofacial entomophtharomycosis documented in Bobo-Dioulasso. Rhinofacial entomophthoromycosis is largely unknown, even in tropical regions such as Burkina Faso. This lack of knowledge results in a delay in the diagnosis, and subsequently a bad prognosis. It is therefore urgent to improve knowledge on this disease to guide diagnostic steps, prognosis of outcome, and antifungal therapy.

Concurrent Infections of Conidiobolus Coronatus with Disseminated Tuberculosis Presenting as Bilateral Orbital Cellulitis

Zygomycetes species contains two orders of organisms that infect humans, namely Mucorales and Entomophthorales. Entomophthorales cause chronic infection in immunocompetent patients, invading subcutaneous tissues but are non-angioinvasive. This includes Basidiobolus ranarum, Conidiobolus incongruus and Conidiobolus coronatus. We report a case of disseminated tuberculosis with Conidiobolus coronatus infection presenting as orbital cellulitis in an adolescent.

Entomophthoramycosis: a neglected tropical mycosis

The term 'entomophthoramycosis' classically refers to infections caused by members of the order Entomophthorales. A new subphylum, Entomophthoramycota, has been created to include Basidiobolomycetes, Neozygitomycetes and Entomophthoramycetes. Basidiobolomycetes encompass Basidiobolus spp., while the Entomophthoramycetes include Conidiobolus spp. Conidiobolus spp. characteristically cause rhinofacial entomophthoramycosis in apparently immunocompetent hosts. Conidiobolus spp. may also cause disseminated infection in immunocompromised patients. Basidiobolus spp. more typically cause subcutaneous entomophthoramycosis of the limbs, buttocks, back and thorax in immunocompetent patients. While once considered to be rare, there is an increasing number of reported cases of gastrointestinal infection caused by Basidiobolus spp. worldwide in countries such as United States, Thailand, Australia, Iran, Egypt and Saudi Arabia. These cases have clinical presentations similar to those of inflammatory bowel diseases, particularly Crohn's disease. Retroperitoneal, pulmonary, nasal and disseminated basidiobolomycosis have also been reported. Histology of entomophthoramycosis may reveal the Splendore-Hoeppli phenomenon. Culture of infected tissue remains the definitive method of laboratory diagnosis. However, molecular methods with specific DNA probes and panfungal primers, as well as real time PCR, are increasingly used to detect and identify these organisms in tissue. Treatment largely consists of therapy with antifungal triazoles. Surgery plays a selective role in the management of entomophthoramycosis, depending upon location, organism and extent of the infection.

Orofacial infection by Conidiobolus coronatus

Entomophtoramycosis is a type of subcutaneous mycosis which includes both basidiobolomycosis and conidiobolomycosis; the latter is caused by Conidiobolus coronatus, a saprophytic fungus which lives in tropical soils. This mycosis characteristically affects the paranasal sinuses and oropharynx, with the potential to deform the face in patients without apparent immunodeficiency. It has a chronic course of infection with a tendency to form granulomas visible using histology. We present the case of a 28 year-old male agricultural worker, with a clinical profile of 6 months' evolution of rhinofacial tumefaction, nasal obstruction and post-nasal drip who was diagnosed with conidiobolomycosis by means of tissue culture after multiple biopsies of the facial area. The patient received antifungal treatment with amphotericin B and subsequently with itraconazol, resulting in a dramatic improvement without the need for surgical treatment; itraconazol was administered for one year and there was no evidence of relapse at the end of this period. Due to the low frequency of this disease there is no established treatment strategy; however, the use of azoles such as itraconazol with or without adjuvant surgical treatment is increasingly seen in case reports. The present report adds to the clinical experience in Colombia of this rare mycosis and also describes the long-term clinical and therapeutic response.

Chronic rhinofacial basidiobolomycosis caused by Basidiobolus ranarum: Report of a case from Aseer Region, Kingdom of Saudi Arabia

We present a case of fungal sinusitis caused by Basidiobolus ranarum in a 22-year-old male patient with chronic rhinosinusitis in Aseer region, Kingdom of Saudi Arabia. The patient was admitted with nasal obstruction accompanied by itching, sneezing, rhinorrhea, epistaxis and recurrent headache. Axial computed tomography (CT) scan of the paranasal sinuses showed a clear left facial swelling chronic inflammation and granulomata. Basidiobolus ranarum fungus was isolated on Sabouraud dextrose agar from a biopsy specimen. The organism was characterized by flat, yellowish-grey, glabrous, becoming radially folded fungus that under the microscope showed broad vegetative hyaline hyphae that bear zygospores with protuberances. The patient made good recovery and was discharged home with no recurrences after receiving oral itraconazole and removal of the polyps surgically.

A prospective case series evaluating efficacy and safety of combination of itraconazole and potassium iodide in rhinofacial conidiobolomycosis

BACKGROUND

Rhinofacial conidiobolomycosis (RFC) is an uncommon subcutaneous fungal infection producing painless swelling with grotesque deformity of the face. Although there are case reports and small case series; there are very few prospective studies evaluating treatment outcome and long-term follow-up.

OBJECTIVE

To evaluate the safety and efficacy of combination of itraconazole (200 mg twice daily) and saturated solution of potassium iodide (SSKI) in patients with RFC.

METHODS

Ten patients of RFC were studied over a period of 5 years. Diagnosis was confirmed by clinical, histopathological, and microbiological evaluation. Conidiobolus was cultured in four cases and in the rest of the cases, the histopathology was suggestive of RFC. They were treated with itraconazole (200 mg twice daily) and SSKI and followed up for a minimum of 1 year after stopping treatment.

RESULTS

The mean age was 38.7 years and the mean duration of symptoms was 22.4 months. Males were predominantly involved (9 : 1). Seven patients responded to the combination treatment, five had complete resolution and two had good improvement (50-75%); however, in two patients the response was minimal (<25% regression of the swelling) and one patient did not show any improvement after 6 months of treatment.

CONCLUSION

Combination of itraconazole and SSKI is an effective treatment modality for RFC with relatively faster onset of action, low relapse rates, and minimal adverse effects. It can be considered as first-line treatment in patients with RFC.

Eumycetoma by Madurella mycetomatis with 30 years of evolution: therapeutic challenge

We report a case of eumycetoma by Madurella mycetomatis on the buttocks and thighs in an adult immunocompetent patient, diagnosed after 30 years of clinical development. He was treated over four years with fluconazol and itraconazol associated with five times surgical excisions of subcutaneous nodules. At the eighth year of follow-up, one nodule recurred on the right infragluteal region, which was excised surgically and has remained asymptomatic ever since.

In vitro susceptibility of Conidiobolus lamprauges recovered from sheep to antifungal agents

Data regarding the susceptibility of Conidiobolus lamprauges is limited and there is no consensus about the optimal treatment for infections caused by Conidiobolus spp. In this context, the objective of this study was to evaluate the in vitro susceptibility of six C. lamprauges strains isolated from sheep conidiobolomycosis to amphotericin B, ketoconazole, fluconazole, itraconazole, posaconazole, voriconazole, anidulafungin, caspofungin, micafungin, flucytosine, and terbinafine using the CLSI M38-A2 microdilution technique. Terbinafine was the most active (MIC range <0.06-0.5 μg/mL). Resistance or reduced susceptibility was observed for amphotericin B and azole and echinocandin antifungals. Additional studies are necessary to determine the therapeutic potential of terbinafine as monotherapy or in combination therapy with other antifungals.

Rhinofacial conidiobolomycosis (entomophthoramycosis)

Conidiobolomycosis is a tropical rhinofacial subcutaneous mycosis caused by Conidiobolus coronatus. It is characterized histopathologically by the presence of hyphae surrounded by an eosinophilic halo, the so-called Splendore-Hoeppli phenomenon. There is no standard treatment, but itraconazole is an effective option.

Chromoblastomycosis: a clinical and molecular study of 18 cases in Rio de Janeiro, Brazil

BACKGROUND

Chromoblastomycosis (CBM) is a chronic subcutaneous mycosis caused by dematiaceous fungi.

METHODS

We described epidemiological data, clinical presentation, and treatment of 18 cases of CBM diagnosed in Rio de Janeiro, Brazil. Diagnosis was obtained by mycological, histopathological findings demonstrating typical muriform cells with confirmation of isolated by DNA sequencing of the ribosomal internal transcribed spacer.

RESULTS

The majority of patients were male (72.2%) ranging from 39 to 83 years old, farm laborers and construction workers. The duration of disease varied from four months to 32 years. The most common presentations were verrucous form in ten (55.6%) patients, followed by tumoral in three (16.7%) patients, primarily of moderate (55.6%) and severe (38.9%) intensity. Lower (44.4%) and upper limbs (33.3%) were the most affected sites. Fonsecaea pedrosoi isolated from 14 (77.8%), and Cladophialophora carrionii isolated from one case (5.6%). Fifteen patients (83.3%) were treated. Six patients (40%) received oral itraconazole 200-400 mg/day, five patients (33.3%) received oral itraconazole 200-400 mg/day combined with fluconazole 200 mg/day, and four (26.7%) patients were submitted to surgery. The duration of therapy varied from 12 to 48 months. Cure rate was 80% (12/15). No relapse was observed after two years of follow-up.

CONCLUSIONS

Success was due to attending a center with specialized clinical care, laboratory support, and pharmaceutical care.

Unusual presentation of entomophthoromycosis

Rhinoentomophthoromycosis caused by Conidiobolus sp commonly presents as a chronic granulomatous lesion that affects the rhinofacial subcutaneous tissue. We present an 18-year-old girl who presented with progressive bilateral proptosis and loss of vision since 2 weeks. Biopsy and fungal cultures confirmed diagnosis of Conidiobolus sp infection of the paranasal sinuses bilaterally with orbital extension and blindness. The clinical picture was complicated by the presence of sputum-positive cavitatory pulmonary tuberculosis, which was diagnosed at the same time. To our knowledge, this is the first such case to be reported from India. We also discuss the management of entomophthoromycosis. Despite many reports of success, there remains no consensus on the treatment of Conidiobolus infections of the nose and the paranasal sinuses with antifungal agents.

Topically applied myco-acaricides for the control of cattle ticks: overcoming the challenges

In the absence of commercially viable and environmentally friendly options, the management of cattle ticks is heavily dependent on the use of chemical acaricides. Due to recent advances in production, formulation and application technology, commercial fungus-based biological pesticides (myco-insecticides, myco-acaricides) are becoming increasingly popular for the control of plant pests; however, they have not been used against animal ectoparasites. The literature clearly demonstrates that entomopathogenic fungi are pathogenic to ticks under laboratory conditions. Pasture applications have also shown promise while experiments on topical application have had variable results. These results suggest that major research hurdles still exist especially for the latter. Although literature on ticks and their interactions with entomopathogenic fungi exists, there is not a clear understanding on how this can be influenced by the microenvironment of the cattle skin surface. This paper critically reviews pathogen, tick target and host skin microenvironmental factors that potentially affect pathogenicity of the applied entomopathogen. Factors influencing the route of infection for topically applied myco-acaricides are also reviewed. Major researchable constraints and recommendations are identified and prioritized. In particular, there is the need for basic studies to understand the interaction of entomopathogenic fungi with the components of the skin microenvironment, to identify suitable strains, and to develop improved formulations to overcome the various challenges.

Outbreaks of rhinofacial and rhinopharyngeal zygomycosis in sheep in Paraíba, northeastern Brazil

Two outbreaks of zigomycosis with rhinofacial and two other with rhinopharyngeal lesions involving fungi with filamentous coaenocytic hyphae characteristic of entomoph-thoramycetous fungi are reported in the state of Paraíba, northeastern Brazil. One outbreak of rhinofacial zygomycosis occurred during the rainy season affecting 5 sheep. Another outbreak of the clinical form affected one out of 40 sheep during the dry season. Common clinical signs of the rhinofacial infection were bilateral serosanguineous nasal discharge with swelling of nostrils, upper lip, and the skin of the face. At necropsy the nasal mucosa showed dark brownish ulcerated areas which extended from the mucocutaneous region to 10cm inside the nasal vestibule. The mucosa of the hard palate was also ulcerated. The cutting surface of nostrils and palate showed a brownish or red spongeous tissue of friable consistency. One outbreak of rhinopharyngitis took place on an irrigated coconut farm; 7 out of 60 adult sheep were affected. Another outbreak affected a sheep in a flock of 80 during the dry season. Clinical signs as noisy respiration and dyspnoea due to mechanical blockage of the nasal cavities, swelling of the nostrils, and serosanguineous nasal discharge were observed. Six out of 8 sheep in this group showed exophthalmia, keratitis and unilateral corneal ulceration of the eye. The sheep either died of their infection or were euthanized after a clinical course of 7-30 days. At necropsy there was a dense yellow exudate in the nasopharyngeal area affecting the ethmoidal region, turbinate bones, paranasal sinuses, hard and soft palates, orbital cavity, pharynges, regional muscles and lymph nodes. Histopathologically both forms of the disease showed multifocal granulomas with an eosinophilic necrotic reaction (Splendore-Hoeppli phenomenon) containing ribbon-type coenocytic hyphae with 7-30mum in diameter similar to hyphae of zygomycetous fungi, possibly Conidiobolus spp. Outbreaks of both forms of mycotic rhinitis are common in northeastern Brazil and in other regions of the country.

[Entomophthoramycosis (zygomycosis) caused by Conidiobolus coronatus in Mato Grosso (Brazil): case report]

Zygomycosis is a subcutaneous mycosis caused by soil fungi, such as Conidiobolus coronatus. In general, the main clinical manifestation is a chronic rhinofacial tumor. We report the first case of zygomycosis (entomophthoramycosis) caused by Conidiobolus coronatus, occurring in Mato Grosso, West Brazil.

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

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