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Li J, Wu X, Chen B. Indurated Plaque With Ulceration on the Dorsum of the Left Hand. JAMA Dermatol 2022; 158:1442-1443. [PMID: 36350594 DOI: 10.1001/jamadermatol.2022.4889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A man in his 70s presented with a 6-month history of a rash on the left forearm, which gradually increased in severity. What is your diagnosis?
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Affiliation(s)
- Juanjuan Li
- Dermatology Institute of Fuzhou, Dermatology Hospital of Fuzhou, Fuzhou, China
| | - Xiaomo Wu
- Dermatology Institute of Fuzhou, Dermatology Hospital of Fuzhou, Fuzhou, China.,Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Borui Chen
- Dermatology Institute of Fuzhou, Dermatology Hospital of Fuzhou, Fuzhou, China.,Research Center for Medical Mycology, Department of Dermatology, Peking University First Hospital, Peking University, Beijing, China
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Tseng HC, Chen CB, Ho JC, Cheng YW, Huang HW, Sun PL, Lee CH. Clinicopathological features and course of cutaneous protothecosis. J Eur Acad Dermatol Venereol 2018; 32:1575-1583. [PMID: 29356140 DOI: 10.1111/jdv.14804] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 01/10/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Protothecosis is an uncommon infection caused by the achlorophyllic algae found more commonly in tropical areas. Only a limited number of cases have been reported. OBJECTIVE We aimed to evaluate the clinicopathological features and treatment outcomes of cutaneous protothecosis. METHODS We retrospectively identified 20 pathology-confirmed cases of cutaneous protothecosis based on skin biopsies in two tertiary medical centres in Taiwan from 1997 to 2015. RESULTS The age of the patients at the time of diagnosis ranged from 48 to 85 years (mean age of 74 years). All lesions developed on the limbs. Twelve (60%) patients had adrenal insufficiency, but no patients had active malignancy at diagnosis. Interestingly, four (20%) patients had concurrent scabies infestation. Clinically, most lesions were erythematous plaques studded with punctate ulcers. Microscopically, the most common finding was granulomatous inflammation. Nineteen (95%) cases were successfully treated with itraconazole for 14-148 days with only one case of recurrence. Concomitant scabies should be suspected if pruritus is recalcitrant despite itraconazole treatment. CONCLUSION Despite its rarity, cutaneous protothecosis has become more significant due to an increased prevalence of immunocompromised individuals. Steroid overuse or iatrogenic adrenal insufficiency predisposes individuals to high-risk infections. Neglecting the disease leads to a chronic and incurable state. Protothecosis should be suspected in chronic eczematous and ulcerative plaques on the limbs refractory to conventional antibacterial and antiviral treatments, especially in patients with adrenal insufficiency. Clinical suspicion should be confirmed by skin biopsies, and confirmed cases can be successfully treated with itraconazole.
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Affiliation(s)
- H-C Tseng
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,Department of Cosmetic Applications and Management, Yuh Ying Junior College of Healthcare and Management, Kaohsiung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - C-B Chen
- Department of Dermatology, Chang Gung Memorial Hospitals, Linkou, Taipei, and Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - J-C Ho
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Y-W Cheng
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - H-W Huang
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - P-L Sun
- Department of Dermatology, Chang Gung Memorial Hospitals, Linkou, Taipei, and Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - C-H Lee
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Cutaneous Protothecosis in a Patient with Chronic Lymphocytic Leukemia: A Case Report and Literature Review. J Fungi (Basel) 2015; 1:4-12. [PMID: 29376895 PMCID: PMC5770008 DOI: 10.3390/jof1010004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 12/31/2014] [Indexed: 11/17/2022] Open
Abstract
Protothecosis is a rare infection, which has the potential to cause severe disease in patients with underlying immunosuppression. We describe a case of an elderly female with chronic lymphocytic leukemia (CLL), as well as other risk factors, who presented with pustular and erythematous plaques, initially presumed to be leukemia cutis. A biopsy with special stains revealed the lesions to be cutaneous protothecosis, thus presenting a most unusual concurrence of disease entities. The literature to date on this rare infection will be reviewed.
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Todd JR, King JW, Oberle A, Matsumoto T, Odaka Y, Fowler M, Pore RS, Shahan TA, Yin L, Sanusi ID. Protothecosis: report of a case with 20-year follow-up, and review of previously published cases. Med Mycol 2012; 50:673-89. [DOI: 10.3109/13693786.2012.677862] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Human protothecosis is a rare infection caused by members of the genus Prototheca. Prototheca species are generally considered to be achlorophyllic algae and are ubiquitous in nature. The occurrence of protothecosis can be local or disseminated and acute or chronic, with the latter being more common. Diseases have been classified as (i) cutaneous lesions, (ii) olecranon bursitis, or (iii) disseminated or systemic manifestations. Infections can occur in both immunocompetent and immunosuppressed patients, although more severe and disseminated infections tend to occur in immunocompromised individuals. Prototheca wickerhamii and Prototheca zopfii have been associated with human disease. Usually, treatment involves medical and surgical approaches; treatment failure is not uncommon. Antifungals such as ketoconazole, itraconazole, fluconazole, and amphotericin B are the most commonly used drugs to date. Among them, amphotericin B displays the best activity against Prototheca spp. Diagnosis is largely made upon detection of characteristic structures observed on histopathologic examination of tissue.
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Affiliation(s)
- Cornelia Lass-Flörl
- Department of Hygiene, Microbiology and Social Medicine, Innsbruck Medical University, Fritz Pregl Str. 3/III, 6020 Innsbruck, Tyrol, Austria.
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Stenner VJ, Mackay B, King T, Barrs VRD, Irwin P, Abraham L, Swift N, Langer N, Bernays M, Hampson E, Martin P, Krockenberger MB, Bosward K, Latter M, Malik R. Protothecosis in 17 Australian dogs and a review of the canine literature. Med Mycol 2007; 45:249-66. [PMID: 17464846 DOI: 10.1080/13693780601187158] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Systemic protothecosis was diagnosed in 17 Australian dogs between 1988 and 2005. There was a preponderance of young-adult (median 4 years), medium- to large-breed dogs. Females (12/17 cases) and Boxer dogs (7 cases, including 6 purebreds and one Boxer cross) were over-represented. Sixteen of 17 dogs died, with a median survival of four months. A disproportionate number of cases were from coastal Queensland. In most patients, first signs were referable to colitis (11/17 cases), which varied in severity, and was often present for many months before other symptoms developed. Subsequent to dissemination, signs were mostly ocular (12 cases) and/or neurologic (8 cases). Two dogs had signs due to bony lesions. Once dissemination was evident, death or euthanasia transpired quickly. Prototheca organisms had a tropism for the eye, central nervous system (CNS), bone, kidneys and myocardium, tissues with a good blood supply. Microscopic examination and culture of urine (5 cases), cerebrospinal fluid (CSF;1 case), rectal scrapings (4 cases), aspirates or biopsies of eyes (5 cases) and histology of colonic biopsies (6 cases) as well as skin and lymph nodes (2 cases) helped secure a diagnosis. Of the cases where culture was successful, P wickerhamii was isolated from two patients, while P zopfii was isolated from five. P zopfii infections had a more aggressive course. Treatment was not attempted in most cases. Combination therapy with amphotericin B and itraconazole proved effective in two cases, although in one of these treatment should have been for a longer duration. One surviving dog is currently still receiving itraconazole. Protothecosis should be considered in all dogs with refractory colitis, especially in female Boxers.
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Affiliation(s)
- V J Stenner
- University of Queensland Veterinary Teaching Hospital, Queensland, Brisbane, Australia
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Sheikh-Ahmad M, Goldstein S, Potasman I. Prototheca wickerhamii hand infection successfully treated by itraconazole and voriconazole. J Travel Med 2006; 13:321-3. [PMID: 16987132 DOI: 10.1111/j.1708-8305.2006.00062.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Muhammad Sheikh-Ahmad
- Infectious Diseases and Travel Clinic, Bnai Zion Medical Centre, Rappaport Faculty of Medicine, Technion, 47 Golomb Street, Haifa 31048, Israel
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Kiyohara N, Osafune T, Ehara T, Hachisuka H, Ito-Kuwa S, Aoki S. Immuno-Electron Microscopic Studies on Plastid DNA and Photosynthetic Proteins in Prototheca wickerhamii. CYTOLOGIA 2006. [DOI: 10.1508/cytologia.71.309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Tomoko Ehara
- Department of Life Science, Nippon Sport Science University
- Department of Microbiology, Tokyo Medical University
| | | | | | - Shigeji Aoki
- Advanced Research Center, Nippon Dental University
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Affiliation(s)
- M A Pfaller
- Medical Microbiology Division, C606 GH, Department of Pathology, University of Iowa College of Medicine, Iowa City, IA 52242, USA.
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Zhao J, Liu W, Lv G, Shen Y, Wu S. Protothecosis successfully treated with amikacin combined with tetracyclines. Fallbericht. Protothecose erfolgreich mit Amikacin plus Tetracyclinen behandelt. Mycoses 2004; 47:156-8. [PMID: 15078433 DOI: 10.1046/j.1439-0507.2003.00955.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Summary We report a case of protothecosis in an 18-year-old female student caused by Prototheca zopfii successfully treated with amikacin combined with tetracyclines. Zusammenfassung Es wird über eine Protothecose, verursacht durch Prototheca zopfii, bei einer 18-jährigen Studentin berichtet, die erfolgreich mit Amikacin in Kombination mit Tetracyclinen behandelt wurde.
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Affiliation(s)
- J Zhao
- Department of Medical Mycology, Institute of Dermatology, Peking Union Medical College and Chinese Academy of Medical Sciences, Nanjing, China
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Torres HA, Bodey GP, Tarrand JJ, Kontoyiannis DP. Protothecosis in patients with cancer: case series and literature review. Clin Microbiol Infect 2004; 9:786-92. [PMID: 14616698 DOI: 10.1046/j.1469-0691.2003.00600.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To review our recent experience with protothecosis in patients with cancer at The University of Texas MD Anderson Cancer Center, and compare these cases with others reported in the literature. METHODS We report on three patients with protothecosis and cancer who were seen at The University of Texas MD Anderson Cancer Center from January 1979 to May 2002, and reviewed all cases of protothecosis in patients with cancer reported in the literature since 1966. RESULTS Overall, 13 cases of protothecosis complicating cancer were evaluated. The median age of the patients was 41 years (range, 7-73 years). Seven patients (54%) had an underlying hematologic malignancy, and one infection occurred after bone marrow transplantation. Neutropenia was uncommon in these patients (14%). Prototheca wickerhamii was the most common Prototheca species identified as the causative agent of infection. Skin infection was the most common presentation of protothecosis, occurring in five patients (38%), followed by disseminated disease in three patients (23%), algaemia in three patients (23%), pulmonary infection in one patient (8%), and olecranon bursitis in one patient (8%). Information on the use of antifungal therapy was available for ten patients. Seven of the ten patients received amphotericin B, while three received triazoles (fluconazole in two, itraconazole in one). Breakthrough protothecosis occurred during the administration of systemic antifungal therapy with itraconazole in one patient. All seven patients who received amphotericin B showed a response, as did one of the three patients given triazoles. Seven (58%) of the patients died during the study period, only one (17%) of protothecosis. CONCLUSIONS Protothecosis is an uncommon infection in cancer patients, implying that Prototheca spp. have a low pathogenic potential in this population. Pulmonary involvement in particular is uncommon in these patients. Amphotericin B appears to be the most effective antifungal agent; the role of triazoles in treating protothecosis is uncertain, but they may be less effective.
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Affiliation(s)
- H A Torres
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Abstract
Intravenous amphotericin B remains the most effective drug for eradicating Prototheca infections. It should be used as a first-line agent in cases of disseminated disease and in patients with severe underlying illness or with immunosuppression or immunocompromise. Azole antifungals and surgery should be reserved for patients with more localized disease. Itraconazole appears to be the most effective agent of this drug class, and it should be administered at 200 mg/day for 2 months. Surgical excision should be considered as a first-line therapy in patients who present with olecranon bursal infections.
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Affiliation(s)
- Sara M Kantrow
- Division of Dermatology, Department of Pathology, Vanderbilt University, Dermatology 3900, The Vanderbilt Clinic, Nashville, TN 37232, USA
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