Cutaneous hyalohyphomycosis caused byPurpureocillium lilacinumin an immunocompetent patient: case report and review

Cutaneous Hyalohyphomycosis and Its Atypical Clinical Presentations in Immunosuppressed Patients

There has been a substantial increase in the number of cases of invasive fungal infections worldwide, which is associated with a growing number of immunosuppressed patients and a rise in antifungal resistance. Some fungi that were previously considered harmless to humans have become emerging pathogens. One of them is Purpureocillium lilacinum, a ubiquitous filamentous fungus commonly found in the environment, especially in the air and soil. P. lilacinum belongs to a bigger group of hyaline fungi that cause hyalohyphomycosis, a fungal infection caused by fungi with colorless hyphae. Although this is a heterogeneous group of fungi, there are similarities regarding their ubiquity, ways of transmission, affected patients, and difficulties in diagnostics and treatment. In hyalohyphomycosis, the skin is one of the most affected organs, which is why the involvement of dermatologists is crucial for the initial assessment, since the timely recognition and early diagnosis of this condition can prevent life-threatening infections and death. In this review, we covered cutaneous hyalohyphomycosis caused by P. lilacinum and other fungi in the same group, including Fusarium, Penicilium, Scedosporium, Scopulariopsis, Acremonium, and Trichoderma genera.

Infections by entomopathogenic fungi in common green iguanas (Iguana iguana) in captivity in Brazil

Entomopathogenic fungi, widely available biological agents used to control agricultural pests, are sporadically reported to cause focal or disseminated infection in reptiles and mammals, including humans. This study summarizes the clinical presentation, histopathological and molecular findings by panfungal polymerase chain reaction and sequencing of four cases of hypocrealean fungal infections in captive common green iguanas (Iguana, iguana). One case of granulomatous pneumonia, hepatitis and serositis was related to Metarhizium flavoviride complex infection. Two disseminated fungal infection cases, with scarce inflammatory cell infiltration, were caused by Beauveria bassiana while there was one case of multifocal granulomatous and necrotizing pneumonia by Purpureocillium spp. To the best of our knowledge, this is the first report of fatal mycosis infection due to entomopathogenic fungi in captive common green iguanas.

Chronic subcutaneous infection of Purpureocillium lilacinum in an immunocompromised patient: Case report and review of the literature

Our case reports a 52-year-old woman who presented with Purpureocillium lilacinum skin infection after a renal transplantation. The diagnosis was difficult and this species exhibits many resistances to antifungal agents. The clinical history was marked by a relapse causes by a foreign body. Our case suggests that posaconazole may be an alternative to cure P. lilacinum infection, and that the surgical debridement, the identification and removal of a foreign body may improve the prognosis.

Microbial Diversity Analyses of Fertilized Thitarodes Eggs and Soil Provide New Clues About the Occurrence of Chinese Cordyceps

Chinese cordyceps is a well-known fungus-larva complex with medicinal and economic importance. At present the occurrence of Chinese cordyceps has not been fully illuminated. In this study, the microbial diversities of fertilized Thitarodes eggs from sites A (high occurrence rates of Chinese cordyceps), B (low occurrence rates), and C (no Chinese cordyceps) were analyzed using 16S rRNA and ITS gene-sequencing technique. The previous sequencing data of soil from the same sites were conjointly analyzed. The results showed that bacterial communities among the eggs were significantly different. The bacterial diversity and evenness were much higher on site A. Wolbachia was overwhelmingly predominant in the eggs of sites B and C, while Spiroplasma showed preference on site A. The fungal between-group differences in the eggs were not as significant as that of bacteria. Purpureocillium in Cordyceps-related families showed preference on site A. Wolbachia, Spiroplasma, and Purpureocillium were inferred to be closely related to Chinese cordyceps occurrence. Intra-kingdom and inter-kingdom network analyses suggest that closer correlations of microbial communities (especially closer fungal positive correlations) in fertilized eggs might promote Chinese cordyceps occurrence. Besides, metabolic pathway analysis showed that in fertilized eggs or soil the number of bacterial metabolic pathways with significant differences in every comparison between two sites was greater than that of fungi. Collectively, this study provides novel information about the occurrence of Chinese cordyceps, contributing to the large-scale artificial cultivation of Chinese cordyceps.

Diagnosis from Tissue: Histology and Identification

The diagnosis and initiation of appropriate treatment against invasive fungal infections depend upon accurate identification of pathogens by pathologists and clinical microbiologists. Histopathology is often critical in providing diagnostic insight in patients with suspected fungal infections, and such findings are incorporated into the definitions of proven or probable disease caused by certain pathogens. Such examinations can offer provisional identifications of fungal organisms, which can help guide initial therapy while laboratory results are pending. Common etiologic agents of invasive mycoses may be recognized based on morphologic characteristics observed in tissue and biologic fluids, such as those obtained from bronchoalveolar lavage and bronchial washings. However, care should be taken in the interpretation of these findings, as there may be a false sense of the ability to correctly categorize fungal organisms to the genus or species level by morphologic features alone. Studies have demonstrated discordant results between histopathology and laboratory results due to overlapping morphologic features, morphologic mimics, and sampling errors. Thus, histopathology plays an integral role in providing a differential of potential fungal pathogens but must be combined with results from laboratory studies, including cultures, antigen tests, serology, and molecular assays, in order to improve accuracy in the identification of etiologic agents of fungal infections. Inaccurate identification of the infecting organism can lead to inappropriate antifungal therapy and possibly poor clinical outcomes.

Complicated multiple organ infection of Purpureocillium lilacinum and varicella-zoster virus infection in a patient with Evans’ syndrome

Purpureocillium lilacinum (P lilacinum) is a rare pathogenic fungus, which mainly involves immunocompromised individuals. Here, we report a case of complicated multiple-organ infections involving skin, lungs, and spleen in a 63-year-old female with Evans’ syndrome after 9 months of glucocorticoid treatment. Microbial examinations of skin biopsy and blood samples revealed P lilacinum infections. Posaconazole was effective in this patient. During anti-fungi treatment, she developed varicella-zoster virus infection and was diagnosed through next-generation sequencing examination. In conclusion, P lilacinum may affect different organ systems and is susceptible to posaconazole treatment. The molecular-based methods like microbial cell-free DNA sequencing could provide accurate and timely identification of a wide range of infections.

Purpureocillium lilacinum an emergent pathogen: antifungal susceptibility of environmental and clinical strains

Purpureocillium lilacinum is a filamentous and hyaline fungus cosmopolitan, saprophytic, largely used in the biological control of plant-parasitic nematodes and insects, also considered an emerging and opportunistic human pathogen. The standard treatment for hyalohyphomycosis caused by P. lilacinum is not yet defined, since this fungus is resistant to different antifungals, in vitro and in vivo. The aim of this study was to evaluate and compare in vitro antifungal activity against environmental and clinical P. lilacinum isolates and our results demonstrated that these isolates can be resistant to newer generation triazoles, such as voriconazole, and to caspofungin, a drug of the echinocandin class. In summary, we highlight the importance of knowing the different susceptibility profiles of P. lilacinum isolates, and besides that, the emergence of uncommon human and animal opportunistic fungi, such P. lilacinum, especially during COVID-19, highlight the need for antifungal susceptibility testing of isolates since empirical therapy with different treatment schedules failed in great number of patients.

Entomopathogenic Fungi Biodiversity in the Soil of Three Provinces Located in Southwest China and First Approach to Evaluate Their Biocontrol Potential

Entomopathogenic fungi (EF), who represent active agents to control insect natural populations, usually persist in terrestrial habitats. Southwest area in China has various climate conditions and abundant plant biodiversity (crop, forest, grassy, orchard and arable areas). Nevertheless, the potential of soil-inhabitant EF as insect pest biocontrol agents, is unknown. In this study, first the EF biodiversity from soil of three provinces (Guizhou, Sichuan, and Yunnan) was surveyed. Then, the virulence of 29 isolated strains against Bemesia tabaci and Spodoptera litura was assessed. After analyzing 212 soil samples, 497 isolated fungi were identified. Out of them, 490 isolates were classified in 45 species of 24 genera, whereas the other seven isolates, belonging to Paecilomyces and Purpureocillium genera, were not identified under species level. Furthermore, the EF biodiversity from soil of Sichuan, Yunan, and Guizhou areas, analyzed by Shannon Wiener Index (SWI) was rated at 2.98, 1.89, and 2.14, while SWIs-biodiversity in crop, forest, grassy, orchard and arable areas was rated at 2.88, 2.74, 3.05, 2.39, and 2.47. SWI data suggested that soil from Sichuan area and grassy had higher EF biodiversity compared with other analyzed provinces and areas. Virulence bioassay results indicated that, out of the 29 isolates tested, 24 were pathogenic against B. tabaci and S. litura, resulting in mortality rates >10%. In conclusion, this study reports the EF distribution and biodiversity in soil from three provinces located at Southwest China, whereas their potential use as a tool for the B. tabaci and S. litura biocontrol must be further investigated.

Antifungal Susceptibility Testing: A Primer for Clinicians

Clinicians treating patients with fungal infections may turn to susceptibility testing to obtain information regarding the activity of different antifungals against a specific fungus that has been cultured. These results may then be used to make decisions regarding a patient's therapy. However, for many fungal species that are capable of causing invasive infections, clinical breakpoints have not been established. Thus, interpretations of susceptible or resistant cannot be provided by clinical laboratories, and this is especially true for many molds capable of causing severe mycoses. The purpose of this review is to provide an overview of susceptibility testing for clinicians, including the methods used to perform these assays, their limitations, how clinical breakpoints are established, and how the results may be put into context in the absence of interpretive criteria. Examples of when susceptibility testing is not warranted are also provided.

Recurrent cutaneous hyalohyphomycosis secondary to Purpureocillium lilacinum in an immunocompetent individual

Purpureocillium lilacinum, previously classified as Paecilomyces lilacinus, is a ubiquitous hyaline hyphomycete considered to be an emerging opportunistic human pathogen that is resistant to traditional antifungal agents. This case report describes what is to our knowledge the only published case of P. lilacinum recrudescence in an immunocompetent host despite initial best-practice treatment with 10 weeks of voriconazole and surgical excision.

Skin Immune Response of Immunocompetent and Immunosuppressed C57BL/6 Mice After Experimental Subcutaneous Infection Caused by Purpureocillium lilacinum

Hyalohyphomycosis is a fungal infection characterized by the presence of a hyaline mycelium in the host. It is caused by several agents, such as Purpureocillium lilacinum. Our study aimed to evaluate some cell subsets and inflammatory markers involved in the in situ immune response to subcutaneous hyalohyphomycosis by P. lilacinum in C57BL/6 murine models. The fungal isolate was inoculated in mice randomly distributed in immunocompetent/infected (CI) and immunosuppressed/infected (SI) groups. Mice were evaluated on days 1, 3, 5, and 7 after inoculation. Histopathological studies showed several lesions in the site of infection as well as the formation of multifocal and mixed inflammatory infiltrates, which differed between the CI and SI groups. This analysis also revealed conidia and hypha-like structures in subcutaneous tissues of mice of both groups. The immunohistochemical analysis showed lower percentages of macrophages and neutrophils in the SI group compared to those in the CI group. Moreover, the intensity of interleukin (IL)-1β and nitric oxide synthase 2 production by cells of immunosuppressed mice was discreet, compared to immunocompetent mice that ranged from moderate to intense over time. The quantitative interference of dexamethasone in the response to the fungus was also demonstrated. We concluded that our results can be useful not only to broaden the knowledge on P. lilacinum but also, based on this host-parasite relationship, to contribute to the understanding of the mechanisms of infection.

Recent developments in less known and multi-resistant fungal opportunists

Fungal infections have increased in recent years due to host factors, such as oncohaematological and transplant-related disorders, immunosuppressive therapy, and AIDS. Additionally, molecular and proteomic facilities have become available to identify previously unrecognizable opportunists. For these reasons, reports on less-known and recalcitrant mycoses, such as those caused by black fungi, hyaline filamentous fungi, coelomycetes, Mucorales, and non-Candida yeasts have emerged. In this review, novel taxonomy in these groups, which often are multi-resistant to one or several classes of antifungals, is discussed. Clinical presentations, diagnosis and current treatment of some major groups are summarised.

Purpureocillium roseum sp. nov. A new ocular pathogen for humans and mice resistant to antifungals

BACKGROUND

Infectious keratitis is the main cause of preventable blindness worldwide, with about 1.5-2.0 million new cases occurring per year. This inflammatory response may be due to infections caused by bacteria, fungi, viruses or parasites. Fungal keratitis is a poorly studied health problem.

OBJECTIVES

This study aimed to identify a new fungal species by molecular methods and to explore the possible efficacy of the three most common antifungals used in human keratitis in Mexico by performing in vitro analysis. The capacity of this pathogen to cause corneal infection in a murine model was also evaluated.

METHODS

The fungal strain was isolated from a patient with a corneal ulcer. To identify the fungus, taxonomic and phylogenetic analyses (nrDNA ITS and LSU data set) were performed. An antifungal susceptibility assay for amphotericin B, itraconazole and voriconazole was carried out. The fungal isolate was used to develop a keratitis model in BALB/c mice; entire eyes and ocular tissues were preserved and processed for histopathologic examination.

RESULTS AND CONCLUSION

This fungal genus has hitherto not been reported with human keratitis in Mexico. We described a new species Purpurecillium roseum isolated from corneal infection. P roseum showed resistance to amphotericin B and itraconazole and was sensitive to voriconazole. In vivo study demonstrated that P roseum had capacity to developed corneal infection and to penetrate deeper corneal tissue. The global change in fungal infections has emphasised the need to develop better diagnostic mycology laboratories and to recognise the group of potential fungal pathogens.

Isavuconazonium for the treatment of Purpureocillium lilacinum infection in a patient with pyoderma gangrenosum

Purpureocillium lilacinum is a rare but emerging pathogen in immunocompromised patients that primarily infects the skin and subcutaneous tissue. We present a novel case of Purpureocillium lilacinum infection in a patient with pyoderma gangrenosum who was successfully treated with isavuconazonium, followed by a literature review of 13 total cases of infection with Purpureocillium lilacinum gathered from a review of the PubMed database. Previous reports have utilized voriconazole, an antifungal with significant toxic side effects. Our case highlights the importance of culture and biopsy in patients with pyoderma gangrenosum who are unresponsive to standard treatment irrespective of pathergy risk.

Impact of host intraspecies genetic variation, diet, and age on bacterial and fungal intestinal microbiota in tigers

The bacterial microbiota in the gut varies among species, as well as with habitat, diet, age, and other factors. Intestinal microbiota homeostasis allows a host to adjust metabolic and immune performances in response to environmental changes. Therefore, potential implications of the gut microbiota in sustaining the health of the host have gained increasing attention in the field of endangered animal conservation. However, the effect of host intraspecies genetic variation on the gut microbiota is unknown. Moreover, little is known about the complexity of the gut mycobiota. Tigers are listed as endangered species, raising worldwide concern. Potential influences of subspecies, diet, and age on the gut microbiota in tigers were investigated in this study to provide a better understanding of the response of the tiger gut microbiota to external changes. The results revealed that the impacts of the factors listed above on gut bacterial and fungal communities are versatile. Host intraspecies genetic variation significantly impacted only fungal alpha diversity of the gut microbiota. Differences in diet, on the other hand, had a significant impact on alpha diversity of the gut microbiota, but exerted different effects on beta diversity of gut bacterial and fungal communities. Host age had no significant impact on the diversity of the gut fungal communities, but significantly impacted beta diversity of gut bacterial communities. This comprehensive study of tiger gut microbiota is an essential reference for tiger conservation when considering feeding and management strategies, and will contribute to a better understanding of the mycobiota in wildlife.

Biodiversity of Entomopathogenic Fungi in the Soils of South China

The southern part of China, located in tropical and south subtropical areas has unique natural environments, but the distributions of entomopathogenic fungi (EFs) in the soil are not clear. In this research, 198 soil samples were collected from the four Provinces (Autonomous Region) of South China. The results indicated that a total of 292 fungal isolates were obtained from 176 soil samples. Then, based on the morphological and rDNA-ITS sequences analysis, 213 EFs isolates of 19 species in 12 genera were identified. Furthermore, Purpureocillium lilacinum with 75 isolates was recognized as the absolutely dominant EF species, while Isaria javanica, Metarhizium anisopliae, and Beauveria bassiana (respectively with 29, 26, and 26 isolates) were the richer species. The data also indicated that Guangxi Province has the best EFs diversity with the Shannon–Wiener index (SWI) of 2.29, the soils covered with grass had the best EFs diversity with the 2.14 SWI, while the orchard and fallow land had the lowest SWI of 1.52, which suggested that the diversity of plants and insects on ground, as well as the massive application of broad-spectrum fungicides, affect the EFs diversity in the soil. Finally, the rare species, Nectria mauritiicola and Scopulariopsis brumptii were first reported about their entomopathogenic activities against Bemisia tabaci. Our experiment will give new insights to the understanding of EFs distribution characteristics and their biodiversity conservation.

Identification of hypocrealean reptile pathogenic isolates with MALDI-TOF MS

Biotyper analysis of Nannizziopsis guarroi, a fatal fungal pathogen in lizards, was described recently. Hypocrealean fungal infections in captive reptiles appear with an increasing frequency during the last decade. Therefore, the aim of this study was to proof Matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS) as diagnostic tool for the identification of reptile pathogenic hypocrealean fungi. Ten fungal isolates obtained from nine reptiles with fungal glossitis, disseminated visceral mycosis, pneumomycosis, and fungal keratitis were analyzed. Phylogeny consisted of fragments of the large subunit of nuclear encoded ribosomal DNA (D1/D2, LSU) and the internal transcribed spacer region 1 of nuclear encoded ribosomal DNA (ITS1) as well as the protein coding gene translation elongation factor 1 alpha (TEF). Results revealed unanimously two Metarhizium granulomatis genotypes in a total of three isolates, various M. viride genotypes (n = 3), two different Purpureocillium lilacinum isolates as well as one isolate of each P. lavendulum and Beauveria bassiana. Purpureocillium lilacinum and B. bassiana are likewise frequently employed as a mycoinsecticide and mycoacaricide in agriculture on a worldwide scale and have occasionally been reported in man, causing fungal keratitis, sclerokeratitis, nosocomial infections in immunosuppressed patients, as well as cavitary pulmonary disease and cutaneous hyalohyphomycosis in immunocompetent patients. According to the results establishment of Biotyper analysis for faster differentiation of reptile-associated fungal pathogens is entirely justified.

[Uncommon mycoses]

BACKGROUND

Fungal infections should be suspected in severe wounds that have been contaminated with organic material or soil, even when the patient is immunocompetent. The aim of this article is to contribute to a better understanding and knowledge of the antifungal sensitivity and epidemiology of some rare pathogens that may trigger severe infections.

CASE REPORT

Four different moulds were isolated from the wounds of an immunocompetent woman who was involved in a road accident: Lichtheimia corymbifera, Scedosporium boydii, Fusarium solani and Purpureocillium lilacinum. Some of them were isolated from different sites. A profile of in vitro resistance was performed with an Epsilometer (Etest™) using five antifungal agents: voriconazole, posaconazole, itraconazole, anidulafungin an amphotericin B. The results obtained were consistent with those from other cases reported in the literature.

CONCLUSIONS

Early aggressive surgery, antifungal therapy and, above all, frequent debridement of necrotic tissue, are the tools against filamentous fungi infections. Antifungal sensitivity of any mould involved in an infection has to be determined, in order to a better understanding of these rare pathogens whose incidence is increasing.

Human Pathogenic Paecilomyces from Food

Paecilomyces spp. and Byssochlamys spp. are heat-resistant fungi important to industry because they can cause food and beverage spoilage, incurring economic loss. The consequences of food or beverage fungal colonization is the loss of nutritional value, structure and taste, and the possibility of producing toxic secondary metabolites that may result in medical problems. Furthermore, these fungi can infect animals and humans and it is unknown if contaminated foods may be fomites. P. variotii is the principal agent of food spoilage or contamination and it is most frequently associated with human hyalohyphomycosis with clinical manifestations including peritonitis, cutaneous and disseminated infections, among others. Byssochlamys spp. had not been identified as a cause of systemic infection until the case of a dog with a fungal infection, after immunosuppressive therapy. P. variotii has clinical importance because it causes severe infection in immunosuppressed patients and also because the number of immunocompetent infected patients is increasing. This review draws attention to the ability of these species to grow at high temperatures, to colonize food products, and to cause human disease.

Fatal Purpureocillium lilacinum pneumonia in a green tree python

A 10-y-old female green tree python ( Morelia viridis) died of fungal pneumonia caused by Purpureocillium lilacinum, which was confirmed histologically and by PCR and subsequent DNA sequencing. The same fungal species was cultivated from a swab taken from the terrarium in which the snake was housed. Clinical and environmental P. lilacinum isolates were indistinguishable by the typing method applied, strongly suggesting clonal relatedness of both isolates. Because no other underlying predisposing respiratory infection could be detected by virus-specific PCR or histopathology, P. lilacinum was considered a primary pulmonary pathogen in this tree python.

Experimental Hyalohyphomycosis by Purpureocillium lilacinum: Outcome of the Infection in C57BL/6 Murine Models

Purpureocillium lilacinum is a filamentous, hyaline fungus considered an emerging pathogen in humans. The aim of our study was to evaluate the outcome of hyalohyphomycosis in C57BL/6 murine models inoculated with two clinical P. lilacinum isolates (S1 and S2). Each isolate was inoculated in mice randomly distributed in immunocompetent (CPT) and immunosuppressed (SPS) groups. Mice were evaluated at day 7, 21, and 45 after inoculation for histopathological analysis, recovery of fungal cells, and immunological studies. Histological analysis showed scarce conidia-like structures in lung tissue from CPT mice and a lot of fungal cells in SPS mice inoculated with S2 compared to mice inoculated with S1. The maximum recovery of fungal cells was seen in CPT mice inoculated with both isolates at day 7, but with mean significantly higher in those inoculated with S2 isolate. Phenotypical characterization of T cells showed TCD8⁺ lymphocytes predominance over TCD4⁺ in immunosuppressed mice infected and control groups. We also observed higher percentages of the central and effector memory/effector phenotype in CPT mice infected with S2 strain, especially in TCD8⁺ in the initial period of infection. Regulatory T cells showed higher percentages in immunosuppressed, predominantly after the acute phase. Our results showed that the P. lilacinum is a fungus capable to cause damages in competent and immunosuppressed experimental hosts. Furthermore, S2 isolate seems to cause more damage to the experimental host and it was possible to identify different cellular subsets involved in the mice immune response.

Purpureocillium lilacinum, potential agent for biological control of the leaf-cutting ant Acromyrmex lundii

Many leaf-cutter ant species are well known pests in Latin America, including species of the genera Acromyrmex and Atta. An environmentally friendly strategy to reduce the number of leafcutter ants and avoid indiscriminate use of chemical pesticides is biological control. In this work we evaluated the effectiveness of a strain of the entomopathogen Purpureocillium lilacinum, against worker ants from six Acromyrmex lundii field colonies, after immersions in pure suspensions at a concentration of 1×10(6)conidiaml(-1). Survival of ants treated with P. lilacinum was significantly lower than that recorded in controls, and median lethal time (LT50) was 6-7days. P. lilacinum was responsible for 85.6% (80.6-89.7) of the mortality in inoculated ants, in which we found that the percentage of other entomopathogens that naturally infected ants decreased also, suggesting a good competitive capability of the fungus. Horizontal transmission to non-inoculated ants was also evidenced, given that 58.5% (41.9-64.2) of them died because of P. lilacinum. Moreover, we tested pathogenicity for three concentrations of this strain (1.0×10(4), 10(6) and 10(8)conidiaml(-1)) and found a significantly faster mortality of ants and greater median percentage of infection at 10(8)conidiaml(-1) of P. lilacinum. CL50 value was 2.8×10(5)conidiaml(-1). We thus propose the use of P. lilacinum as a biological control agent of leafcutter ants in crops and plantations.

ESCMID and ECMM joint guidelines on diagnosis and management of hyalohyphomycosis: Fusarium spp., Scedosporium spp. and others

Mycoses summarized in the hyalohyphomycosis group are heterogeneous, defined by the presence of hyaline (non-dematiaceous) hyphae. The number of organisms implicated in hyalohyphomycosis is increasing and the most clinically important species belong to the genera Fusarium, Scedosporium, Acremonium, Scopulariopsis, Purpureocillium and Paecilomyces. Severely immunocompromised patients are particularly vulnerable to infection, and clinical manifestations range from colonization to chronic localized lesions to acute invasive and/or disseminated diseases. Diagnosis usually requires isolation and identification of the infecting pathogen. A poor prognosis is associated with fusariosis and early therapy of localized disease is important to prevent progression to a more aggressive or disseminated infection. Therapy should include voriconazole and surgical debridement where possible or posaconazole as salvage treatment. Voriconazole represents the first-line treatment of infections due to members of the genus Scedosporium. For Acremonium spp., Scopulariopsis spp., Purpureocillium spp. and Paecilomyces spp. the optimal antifungal treatment has not been established. Management usually consists of surgery and antifungal treatment, depending on the clinical presentation.