Pathogenic References 1-500

Fungal Glossary Pathogenic References as provided by Texas Tech University Health Sciences Center, Department of Microbiology and Immunology.

1Atlas of Clinical Fungi. 2nd edition. G.S. de Hoog, J.Guarro, J.Gene & M.J. Figuerras. - Centraalbureau voor Schimmelcultures/Universitat Rovira I Virgili Reus, Spain. - 2000. 
2Guide to Clinically Significant Fungi. Deanna A.Sutton, Annette W.Fothergill, Michael G.Rinaldi. - Williams & Wilkins A Wavely Company. - 1998. 
3Introduction to food and airborne fungi. Sixth Edition. Robert A. Samson, Ellen. S Hoekstra, Jens C. Frisvad, Ole Filtenborg.Centraalbureau Voor Schimmelcultures Utrecht. An Institute of the Royal Netherlands Academy of Arts and Sciences. Ponsen & Looyen. Wagemimgen, The Netherlands. - 2000. 
4Compendium of Soil Fungi. K.H. Domsch, W. Gams, Traute-Heidi Anderson. Reprint der Ausg. Von 1980 - 1993. 
15

Acrophialophora fusispora brain abscess in a child with acute lymphoblastic leukemia: review of cases and taxonomy. Al-Mohsen IZ, Sutton DA, Sigler L, Almodovar E, Mahgoub N, Frayha H, Al-Hajjar S, Rinaldi MG, Walsh TJ. J Clin Microbiol. 2000 Dec;38(12):4569-76.

A 12-year-old girl with acute lymphoblastic leukemia was referred to King Faisal Specialist Hospital and Research Center. The diagnosis without central nervous system (CNS) involvement was confirmed on admission, and chemotherapy was initiated according to the Children Cancer Group (CCG) 1882 protocol for high-risk-group leukemia. During neutropenia amphotericin B (AMB) (1 mg/kg of body weight/day) was initiated for presumed fungal infection when a computed tomography (CT) scan of the chest revealed multiple nodular densities. After 3 weeks of AMB therapy, a follow-up chest CT revealed progression of the pulmonary nodules. The patient subsequently suffered a seizure, and a CT scan of the brain was consistent with infarction or hemorrhage. Because of progression of pulmonary lesions while receiving AMB, antifungal therapy was changed to liposomal AMB (LAMB) (6 mg/kg/day). Despite 26 days of LAMB, the patient continued to have intermittent fever, and CT and magnetic resonance imaging of the brain demonstrated findings consistent with a brain abscess. Aspiration of brain abscess was performed and the Gomori methenamine silver stain was positive for hyphal elements. Culture of this material grew Acrophialophora fusispora. Lung biopsy showed necrotizing fungal pneumonia with negative culture. The dosage of LAMB was increased, and itraconazole (ITRA) was added; subsequently LAMB was discontinued and therapy was continued with ITRA alone. The patient demonstrated clinical and radiological improvement. In vitro, the isolate was susceptible to low concentrations of AMB and ITRA. A. fusispora is a thermotolerant, fast-growing fungus with neurotropic potential. We report the first case of human infection involving the CNS. Acrophialophora resembles Paecilomyces but differs in having colonies that become dark and in the development of phialides along the sides or at the tips of echinulate brown conidiophores. Conidia are borne in long chains and are smooth or ornamented with fine-to-coarse echinulations, sometimes in spiral bands. The taxonomy of the genus Acrophialophora is reviewed, and Acrophialophora nainiana and Acrophialophora levis are considered as synonyms of A. fusispora.
16Clinical and experimental keratitis caused by the Colletotrichum state of Glomerella cingulata and Acrophialophora fusispora. Shukla PK, Khan ZA, Lal B, Agrawal PK, Srivastava OP. Sabouraudia. 1983 Jun;21(2):137-47.Two cases of mycotic keratitis caused by the Colletotrichum state of Glomerella cingulata and Acrophialophora fusispora are reported for the first time. Both the isolates produced experimental corneal lesions in rabbit eyes but A. fusispora was more pathogenic. The experimental infection was more severe, with both the fungi, in rabbits pretreated with cortisone as compared with untreated animals. In vitro A. fusispora was most sensitive to miconazole and tolciclate followed by clotrimazole, amphotericin B and lactones while clotrimazole exerted maximum inhibitory effect on Colletotrichum followed by miconazole, lactones, amphotericin B and arnebins. Arnebins and tolciclate were inactive respectively against A. fusispora and Colletotrichum. Of the 3 drugs tested in vivo, against A. fusispora keratitis in rabbit, amphotericin B showed better results than tolciclate and miconazole.

 

17Maxillary sinusitis caused by Actinomucor elegans. Davel G, Featherston P, Fernández A, Abrantes R, Canteros C, Rodero L, Sztern C, Perrotta D. J Clin Microbiol. 2001 Feb;39(2):740-2.We report the first case of maxillary sinusitis caused by Actinomucor elegans in an 11-year-old patient. Histopathological and mycological examinations of surgical maxillary sinuses samples showed coenocytic hyphae characteristic of mucoraceous fungi. The fungi recovered had stolons and rhizoids, nonapophyseal and globose sporangia, and whorled branched sporangiophores and was identified as A. elegans. After surgical cleaning and chemotherapy with amphotericin B administered intravenously and by irrigation, the patient became asymptomatic and the mycological study results were negative.
30Infection of the olecranon bursa by Anthopsis deltoidea. Kwon-Chung KJ, Droller DD. J Clin Microbiol. 1984 Aug;20(2):271-3.sAnthopsis deltoidea was found to be the cause of an olecranon bursitis in a 79-year-old golfer. Serial histological sections of the olecranon bursa showed faintly stained, brown-walled, septate, hyphal elements in the centers of the necrotic debris. The combination of bursectomy and flucytosine treatment cured the infection.
31Fungal endocarditis caused by Arnium leporinum following cardiac surgery. Restrepo A, McGinnis MR, Malloch D, Porras A, Giraldo N, Villegas A, Herrera J. Sabouraudia. 1984;22(3):225-34.A case of fungal endocarditis caused by the coprophilous ascomycete Arnium leporinum is reported in a 19-year-old male living in Colombia. The fungus was seen in tissue and recovered in pure culture from peripheral emboli, a mitral valve, pus from an osteolytic lesion, and kidney. The patient died 21 months after cardiac surgery. The range of A. leporinum in the Americas is expanded to include Colombia.
32Immunochemical characterization of somatic and metabolic antigens of 4 species of Aphanoascus: preliminary results. Torres-Rodríguez JM, Madrenys-Brunet N, Fabra M. Mycopathologia. 1998;142(2):51-5. 
33

Dermatophytosis caused by Aphanoascus fulvescens] Marín G, Campos R

Sabouraudia. 1984;22(4):311-4.

Aphanoascus fulvescens was isolated from lesions resembling a dermatophyte infection in a 45-year-old woman who had used steroid cream for several months to treat a dermatosis of the neck. Treatment with griseofulvin and tolnaftate cured the lesions in 6 weeks. The microscopic characteristics of the isolate and its size differed slightly from those described by several other authors, and bore a closer resemblance to isolates previously described from Australia and New Guinea.
34Study of the invasion of human hair in vitro by Aphanoascus spp. Cano J, Guarro J, Figueras MJ. Mycoses. 1991 Mar-Study of the invasion of human hair in vitro by Aphanoascus spp. Cano J, Guarro J, Figueras MJ. Mycoses. 1991 Mar-Apr;34(3-4):145-52.

The course of the destruction of human hair in vitro by three species of the genus Aphanoascus (A. keratinophilus, A. fulvescens and A. verrucosus) was studied with light microscopy, and transmission and scanning electron microscopy. The results obtained show that all the three species develop keratinolytic activity. A. fulvescens and A. verrucosus have similar sequences of degradation, invading the hair through the cuticula, but without the presence of specialized erosive organs. A. keratinophilus, however, shows a different way of invasion, and the keratinolytic activity was mainly located in the cortex and from that point on expanded to the cuticula.

35

Experimental pathogenicity of Aphanoascus spp. Cano J, Mayayo E, Guarro J.

Mycoses. 1990 Jan;33(1):41-5.

Immunodepressed mice were inoculated intraperitonealy with a suspension of conidia and micelia macerate of four species of Aphanoascus (A. keratinophilus, A. fulvescens, A. reticulisporus and A. verrucosus). All produced nodular lesions in the peritoneal cavity, especially in the liver, spleen, diaphragm and peritoneum. The recovery rate of the fungi on phytone-yeast extract agar after one month varied approximately from 20 to 80% depending on the organs. Sections of these revealed the presence of ascospores and hyphal fragments though only in the centre of the nodules. Fungal elements were not detected in organs which were apparently not affected, nor intravascularly.

37

Rhinocerebral mucormycosis caused by Apophysomyces elegans. Brown SR, Shah IA, Grinstead M. Am J Rhinol. 1998 Jul-Aug;12(4):289-92.

Mucormycosis is an uncommon fungal disease and one of the most fulminant infections known. This is the second report of rhinocerebral mucormycosis caused by Apophysomyces elegans, a newly recognized genus and species classified in the family Mucoraceae. The patient was a 54-year-old man being treated for a severe sinus infection with antibiotics and oral steroids. Recovery occurred in our patient after prompt surgical debridement and drainage of his maxillary sinuses. This case fits the reported characteristics of other A. elegans infections including warm climate, intimate contact with the soil, and an incubation period measured in days. Several reported cases indicate A. elegans can cause mucormycosis in immunocompetent individuals with no underlying medical problems.

38

Necrotizing cellulitis caused by Apophysomyces elegans at a patch test site. Lesueur BW, Warschaw K, Fredrikson L. Am J Contact Dermat. 2002 Sep;13(3):140-2.

Plant material occasionally is used in patch testing to diagnose contact dermatitis. Serious adverse reactions to this practice are extremely uncommon. The authors report on a 68-year-old non-insulin-dependent diabetic gentleman with hand dermatitis in whom severe necrotizing cellulitis developed caused by Apophysomyces elegans, a subtype of mucormycosis, at the site of a patch test to a snapdragon plant from his garden.

39

Systemic zygomycosis caused by Apophysomyces elegans. Lawrence RM, Snodgrass WT, Reichel GW, Padhye AA, Ajello L, Chandler FW. J Med Vet Mycol. 1986 Feb;24(1):57-65.

A case of systemic zygomycosis caused by Apophysomyces elegans in a 56-year-old man is described. The left kidney and the bladder showed presence of broad, nonseptate-to-infrequently septate hyphae in both the bladder lesion and in the septic kidney. Surgical debridement and treatment with amphotericin B cured the infection. No underlying immune defect was ever demonstrated, and the patient was not hyperglycemic or acidotic at any time. This zygomycetous fungus closely resembles Absidia corymbifera, but is distinguished by its distinctive morphological features.

43

Keratitis due to Arthrobotrys oligospora Fres. 1850. Thomas PA, Kuriakose T.J Med Vet Mycol. 1990;28(1):47-50.

Mycotic keratitis caused by Arthrobotrys oligospora is reported in a 62-year-old Indian male patient. The diagnosis was made by direct microscopic examination, isolation of large quantities of the fungus on multiple media and the response of the lesion to an antifungal compound. This is believed to be the first documented case of keratitis due to an Arthrobotrys species.

47

First report of mycetoma caused by Arthrographis kalrae: successful treatment with itraconazole. Degavre B, Joujoux JM, Dandurand M, Guillot B. J Am Acad Dermatol. 1997 Aug;37(2 Pt 2):318-20.

We report the first case of eumycetoma of the hand caused by Arthrographis kalrae. Cure was obtained with a 4-month course of itraconazole.

48

Invasive fungal sinusitis and meningitis due to Arthrographis kalrae in a patient with AIDS. Chin-Hong PV, Sutton DA, Roemer M, Jacobson MA, Aberg JA. J Clin Microbiol. 2001 Feb;39(2):804-7.

We report the first described case of Arthrographis kalrae pansinusitis and meningitis in a patient with AIDS. The patient was initially diagnosed with Arthrographis kalrae pansinusitis by endoscopic biopsy and culture. The patient was treated with itraconazole for approximately 5 months and then died secondary to Pneumocytis carinii pneumonia. Postmortem examination revealed invasive fungal sinusitis that involved the sphenoid sinus and that extended through the cribiform plate into the inferior surfaces of the bilateral frontal lobes. There was also an associated fungal meningitis and vasculitis with fungal thrombosis and multiple recent infarcts that involved the frontal lobes, right caudate nucleus, and putamen. Post mortem cultures were positive for A. kalrae.

49

Lethality of yeasts with low pathogenicity in mice immunocompromised by cyclophosphamide treatment. Okawa Y, Yamada Y. Biol Pharm Bull. 2002 Jul;25(7):940-2.

One strain each of Arxiozyma telluris, Saccharomyces cerevisiae, and S. kluyveri showed lethal activity in cyclophosphamide (CY)-treated mice. Accumulation of these yeast cells in the kidneys and elevation of the levels of cytokines, tumor necrosis factor-alpha, and interleukin-1alpha in the sera were recognized in the CY-treated infected-debilitated mice.

52

Maxillary sinusitis caused by Ascotricha chartarum Berk. (anamorph Dicyma ampullifera Boul.): a new phaeoid opportunistic human pathogen. Singh SM, Naidu J, Jain S, Nawange SR, Dhindsa MK. J Med Vet Mycol. 1996 Jun-Jul;34(3):215-8.

The first human infection caused by Ascotricha chartarum of the maxillary sinus is described. The patient, a 35-year-old woman, developed a hard bony swelling on the right cheek. Her maxillary X-ray showed complete opacity of the right maxillary antrum with a shadow of erosion. C.T. scan revealed a radio opaque mass having vacuolated appearance in the antrum. The debris removed from the antrum contained phaeoid fungal elements. At places, softening of the bone was observed. The mucoperiosteum exhibited acute inflammatory reaction and invasion by the pathogen. The pale brown to subhyaline fungal elements in biopsy tissue grew Ascotricha chartarum, a phaeoid ascomycetous fungus in culture. The patient had a smooth recovery when treated with betadine lavage and itraconazole after surgical intervention.

66

Mycosis in man due to Arthrinium phaeospermum var. indicum. First case report. Rai MK. Mycoses. 1989 Sep;32(9):472-5.

Arthrinium phaeospermum var. indicum Kan & Sullia was repeatedly isolated from erythematous nodules of a patient. Scrapings of the experimental infection developed on rabbits revealed fungal filaments and few spores similar to those of A. phaeospermum var. indicum. The identity of the pathogen is discussed and it is being reported for the first time from human being. In vitro sensitivity of A. phaeospermum var. indicum to miconazole nitrate exhibited a minimum inhibition concentration of 6.25 micrograms/ml.

87

Aspergillus clavatus endocarditis involving a normal aortic valve following coronary artery surgery. Opal SM, Reller LB, Harrington G, Cannady P Jr. Rev Infect Dis. 1986 Sep-Oct;8(5):781-5.

Aspergillus species causing endocarditis on a native heart valve is a rare occurrence with an exceedingly high mortality. This report describes a 60-year-old man who developed Aspergillus clavatus endocarditis of the aortic valve 18 months after coronary artery bypass surgery. The aortic valve was angiographically normal on cardiac catheterization performed before coronary artery surgery. Despite aortic valve replacement and amphotericin B therapy, the patient died as a result of Aspergillus species aortitis with occlusion of the coronary ostia and bypass grafts. Coronary artery surgery may be complicated by this highly lethal infection, which is difficult to diagnose and treat.

91

[A case of bronchopulmonary aspergillosis recurring in a residual tuberculous cavity] Yokoyama S, Taniguchi H, Kondo Y, Matsumoto K, Okada A. Kekkaku. 1989 Sep;64(9):579-84.

A 52-year-old man, who had undergone right upper lobectomy because of active tuberculosis 29 years before, was admitted with complaints of severe cough and expectation. Two years ago, he had pulmonary aspergillosis and was successfully treated with some anti-mycotic agents. This time his chest X-P showed fungus ball in a residual tuberculous cavity in the right upper field and he was diagnosed as pulmonary aspergilloma from the results of radiological findings, sputum culture, and serologic test. By bronchofiberscopy fungus ball was observed. With transbronchial infusion of Amphotericin B, intravenous administration of Miconazole and oral administration of Flucytosine, clinical symptoms have improved and lysis of fungus ball was observed. Sputum culture revealed Aspergillus flavipes group. Bronchopulmonary aspergillosis, which was incurable by surgical treatment because of underlying disease, was successfully treated with transbronchial infusion of Amphotericin B and administration of some anti-mycotic agents.

92

Aspergillus flavipes group osteomyelitis. Roselle GA, Baird IM.

Arch Intern Med. 1979 May;139(5):590-2.

Lumbar vertebral osteomyelitis caused by Aspergillus Flavipes group organisms developed in a nonchronically immunosuppressed patient. Diagnosis was confirmed morphologically and culturally from both closed needle biopsy of the vertebrae and subsequent lumbar laminectomy. The patient was treated with 3 g of amphotericin B with apparent eradication of the organism.

106

Systemic aspergillosis caused by an aflatoxin-producing strain of Aspergillus flavus.Mori T, Matsumura M, Yamada K, Irie S, Oshimi K, Suda K, Oguri T, Ichinoe M. Med Mycol. 1998 Apr;36(2):107-12.

The first case of human systemic infection by an Aspergillus flavus isolate demonstrated to produce aflatoxins in vitro and in vivo is described. The patient, a 41-year-old man with acute myelogenous leukaemia, developed a complication of suspected pulmonary Aspergillus infection during remission induction therapy. Antifungal chemotherapy brought about a considerable degree of improvement, but remission of the underlying disease was not attained. Bone marrow transplantation was also not effective. The patient showed recovery from neutropenia but died despite aggressive antifungal chemotherapy. The autopsy revealed lesions in the lungs, myocardium, kidneys, brain, thyroid gland and skin due to a suspected Aspergillus sp. A fungus isolated from the right lung and the skin lesions was identified as A. flavus. Aflatoxins B1, B2 and M1 were detected in culture filtrates of the isolated A. flavus, and in an extract of lung lesions. These aflatoxins are considered to have played an important role in damaging the immune system of the patient through their toxic effects.

107

Otomycosis in Nigeria: treatment with mercurochrome. Mgbor N, Gugnani HC.

Mycoses. 2001 Nov;44(9-10):395-7.

Seventy-two mycologically proven cases of otomycosis (38 males, 34 females) aged 8-80 years were investigated. Aspergillus niger was the commonest aetiological agent (43.1%) followed by Candida spp. (22.2%), A. flavus (19.4%) and A. fumigatus (15.3%). Three topical drugs, namely mercurochrome, clotrimazole and locacorten-vioform, were evaluated for otomycosis therapy in separate groups of 24 patients each. Mercurochrome was found to be the most efficacious in terms of healing, relief from symptoms of the disease and production of negative fungal cultures. Mercurochrome is recommended as a safe and economical drug for the topical treatment of otomycosis in developing countries like Nigeria.

108

Primary cutaneous aspergillosis associated with Hickman intravenous catheters. Allo MD, Miller J, Townsend T, Tan C. N Engl J Med. 1987 Oct 29;317(18):1105-8.

We describe nine patients with underlying hematologic cancer in whom primary cutaneous aspergillosis developed at the sites of Hickman intravenous catheters. Our patients, 17 to 74 years of age, were all immunocompromised either from their primary disease or from chemotherapy, and the Hickman catheters had been placed to provide venous access for chemotherapy or hyperalimentation or both. Clinical signs of infection included erythema, induration, and cutaneous or subcutaneous necrosis at the point of entry into the subclavian vein, in the subcutaneous tunnel, or at the exit site from the skin. Diagnosis was confirmed by positive wound culture for Aspergillus flavus in all but one patient. Treatment consisted of intravenous amphotericin B, oral flucytosine, and local wound care. Three patients recovered completely without operative débridement; three others recovered after operative débridement and delayed grafting. Two patients died of disseminated aspergillosis, and one died of unrelated causes while recovering from primary cutaneous aspergillosis. Successful treatment required resolution of aplasia or leukopenia, catheter removal, systemic treatment with amphotericin B, and local wound care. We conclude that primary cutaneous aspergillosis, a rare infection, may occur at the sites of Hickman catheters in immunocompromised patients, and that it is a serious complication requiring prompt diagnosis and treatment.

109

[Systemic aspergillosis caused by an aflatoxin-producing strain of Aspergillus in a post-bone marrow transplant patient with acute myeloid leukemia] Yamada K, Mori T, Irie S, Matsumura M, Nakayama M, Hirano T, Suda K, Oshimi K. Rinsho Ketsueki. 1998 Nov;39(11):1103-8.

We report a case in which an aflatoxin-producing strain of Aspergillus flavus (A. flavus) caused systemic aspergillosis in a post-transplant 41-year-old man with acute myeloid leukemia. The leukemia was initially resistant to two courses of induction chemotherapy. The third course of chemotherapy, however, induced complete remission. Thereafter, the patient underwent bone marrow transplantation from his HLA identical brother. Pulmonary aspergillosis was suspected as a complication during induction chemotherapy. Twenty days after the transplant, the patient's absolute neutrophil count had increased to 500/microliter. However, the symptoms of pulmonary aspergillosis were aggravated following neutrophil and monocyte recovery. The patient died of sinus arrest due to complete atrioventricular block 31 days after his transplant. At autopsy, we found that the fungus had invaded the brain, lungs, spleen, kidneys, skin, and myocardium, including the sinoatrial conduction system. There was no sign of acute graft-versus-host disease. A strain of A. flavus was isolated from cultured tissue samples of fungal lesions and shown by thin-layer chromatography to produce aflatoxins. To our knowledge, this is the first case report describing an infection by an aflatoxin-producing A. flavus.

110

Chronic invasive aspergillosis of the paranasal sinuses in immunocompetent hosts from Saudi Arabia. Alrajhi AA, Enani M, Mahasin Z, Al-Omran K. Am J Trop Med Hyg. 2001 Jul;65(1):83-6.

In immunocompetent patients, paranasal invasive aspergillosis is rare and has a high recurrence rate. Twenty-three cases of paranasal invasive aspergillosis, involving 14 male and nine female immunocompetent patients were reviewed. All patients were cancer-free, HIV-negative, with normal WBC, and none of the patients had received immunosuppressive therapy or corticosteroids. Mean duration of symptoms before diagnosis was 18 months. Aspergillus flavus was the species most frequently isolated. Surgical debridement was performed in all patients followed by antifungal therapy in 18 patients. Mean follow-up duration was 30 months. Fourteen patients relapsed after a mean of 13 months and required an average of 4.3 admissions for repeat surgical evacuation. In a logistic regression model, relapse was not associated with age, duration of symptoms, clinical findings, extent of disease, or mode of therapy. However, patients who were relapse-free tended to have had complete surgical evacuation followed by antifungal therapy.

111

Invasive mold sinusitis: 17 cases in immunocompromised patients and review of the literature. Clin Infect Dis. 1997 Jun;24(6):1178-84.

A 10-year retrospective analysis of invasive mold infections in hospitalized patients was performed to characterize the epidemiology and clinical features of invasive fungal sinusitis. Seventeen cases of invasive mold sinusitis were identified. Eleven cases were caused by Aspergillus flavus, three were caused by unspecified species, and one each was caused by Aspergillus fumigatus, Rhizopus species, and Alternaria species, respectively. Fifteen patients had hematologic malignancies, and two had end-stage liver disease. The most common presenting symptom was periorbital swelling (seven patients). Sinusitis was diagnosed a median of 19 days after admission. Eight patients (47%) survived; six of these patients were treated with both amphotericin B and surgery. Postmortem examination of six patients showed evidence of disseminated disease; the brain was the most common extrapulmonary site (four patients). To our knowledge, this is the largest currently reported series on invasive mold sinusitis; our report extends the information on 
invasive mold sinusitis and shows that aggressive therapeutic and surgical interventions are needed to prevent rapid progression of disease in immunocompromised patients.

112

Recurrent aspergilloma of the frontoethmoid sinus in a nonmmunocompromised patient. Tierney P, Thomas M, Samuel D, Patel KS, Stafford N.

J R Soc Med. 1996 Mar;89(3):165P-6P.

Management of invasive aspergillosis of the paranasal sinuses requires sufficient experience to initiate appropriate investigations and then utilize the correct treatment protocol. Computed tomography (CT) or magnetic resonance imaging (MRI) is essential to show the extent of the disease and diagnosis is confirmed by histological analysis. Aspergillus flavus is a ubiquitous soil saprophyte in the Sudan and is responsible for many cases originating from this area. The literature is reviewed and treatment options discussed.

113

Invasive Aspergillus stomatitis in patients with acute leukemia: report of 12 cases. Myoken Y, Sugata T, Kyo T, Fujihara M, Kohara T, Katsu M, Tamura M, Mikami Y. Clin Infect Dis. 2001 Dec 15;33(12):1975-80.

Comment in: Clin Infect Dis. 2002 Jul 1;35(1):105-6; discussion 106-7 PMID: 12060886

An 8-year retrospective analysis of invasive Aspergillus stomatitis in neutropenic patients with acute leukemia was performed to characterize the epidemiology and clinical features of the infection. Twelve cases of invasive Aspergillus stomatitis were identified with both clinicohistological and microbiological evidence, and the majority of cases were caused by Aspergillus flavus (10 [83%] of 12 patients). The infection was strongly suspected when a neutropenic patient developed persistent fever without a known source, symptoms of gingival pain and facial swelling, and a solitary ulcerating lesion of mucogingiva covered with a gray necrotic pseudomembrane. Aspergillus stomatitis was diagnosed a median 23 days after admission. In all 12 patients, the diagnosis was made during the period of neutropenia. Ten patients (83%) were treated with amphotericin B and surgery and survived with recovery of neutrophils. Two patients died, and disseminated aspergillosis was identified in 1 patient.

114

12. Rhinocerebral invasive mycosis: occurrence in immunocompetent individuals. Hussain S, Salahuddin N, Ahmad I, Salahuddin I, Jooma R. Eur J Radiol. 1995 Jul;20(2):151-5.

We report the computed tomographic appearance of invasive fungal disease of the paranasal sinuses in 13 patients. Coronal and axial computed tomographic images were obtained in each patient and data were analysed. Eight patients had Aspergillus flavus infection, four had Mucormycosis, and one had mixed Candida and Mucor. Our experience was different from that of other workers in many respects. All of our patients were immunocompetent. On radiological imaging by computed tomography, ethmoid sinuses were involved in 85% of our patients. In previously reported series maxillary sinuses were most frequently affected. Calcification in the inflammatory mass was not encountered in any of our patients, whereas this feature was present in many reported cases. Features in our patients that were similar to other studies were contrast enhancement, extension of the disease into the orbit and cranial cavity and a high mortality. The clinical course and radiological features of invasive mycosis simulate malignancy. Certain features that may help to differentiate invasive fungal infection from malignancy are discussed. We conclude that invasive fungal infection can affect immunocompetent individuals and should be considered in the differential diagnosis in appropriate clinical settings.

115

Rhinocerebral aspergillosis. Kameswaran M, al-Wadei A, Khurana P, Okafor BC. J Laryngol Otol. 1992 Nov;106(11):981-5.

Aspergillosis is increasingly being recognised as a common fungal infection of the paranasal sinuses. Although the disease is almost endemic in neighbouring Sudan, there are few reported cases from the Kingdom of Saudi Arabia. We report four cases of sinus aspergillosis with involvement of the skull bases and/or intracranial spread; a condition we have termed rhinocerebral aspergillosis. Invasive aspergillosis in our subgroup of patients occurs in otherwise healthy patients with normal immune status, quite unlike most reported cases in the western literature. The causative agent in all our patients was identified as aspergillus flavus, similar to patients reported from Sudan. This is again at variance with the case reports from other geographical locations, where aspergillus fumigatus is the commonest causative agent. Saudi Arabia would appear to represent a distinct geographical enclave, together with Sudan, where rhinocerebral aspergillosis of the sinuses and skull base may be more common than has previously been realised.

116

Medical management of Aspergillus flavus endocarditis. Rao K, Saha V.

Pediatr Hematol Oncol. 2000 Jul-Aug;17(5):425-7.

An 11-year-old boy underwent a matched unrelated bone marrow transplant for refractory acute myeloid leukemia. He developed invasive aspergillus pneumonia and endocarditis post-transplant. The fungal endocarditis was successfully eradicated with liposomal amphotericin at the dose of 10 mg/kg/day. Surgical intervention was not required and no serious side effects of liposomal amphotericin were observed at this dose.

117

Aspergillus flavus endocarditis in a child with neuroblastoma. Kennedy HF, Simpson EM, Wilson N, Richardson MD, Michie JR. J Infect. 1998 Jan;36(1):126-7.

We report a case of Aspergillus flavus endocarditis in a 6-year-old boy with stage IV neuroblastoma with no pre-existing cardiac disease. The infection was successfully treated with high-dose liposomal amphotericin (AmBisome) once daily. Recurrence was prevented with itraconazole oral solution once daily as maintenance therapy. Adjunctive surgery was not required. The patient's cardiac function was uncompromised, but subsequent death from progressive neuroblastoma prevented long-term follow-up.

118

Case report. Fatal Aspergillus flavus pericarditis in a patient with acute myeloblastic leukaemia. Gökahmetoğlu S, Koç AN, Patiroğlu T. Mycoses. 2000;43(1-2):65-6.

We report a case of Aspergillus flavus pericarditis treated with fluconazole for oral candidosis. The patient with acute myeloblastic leukaemia developed tachypnoea after antileukaemic chemotherapy. Pericardial effusion was seen in the echocardiogram. Aspergillus flavus was isolated from the pericardial fluid. The patient died from aspergillosis, before the antimycotic treatment could be changed to amphotericin B.

119

Aspergillus osteomyelitis after liver transplantation: conservative or surgical treatment? Tang TJ, Janssen HL, van der Vlies CH, de Man RA, Metselaar HJ, Tilanus HW, de Marie S. Eur J Gastroenterol Hepatol. 2000 Jan;12(1):123-6.

We report on a liver transplant recipient who developed coxarthritis and lumbar spondylodiscitis due to Aspergillus flavus. He was treated with high-dose liposomal amphotericin B for 2 months followed by itraconazole. Because of intractable pain and severe, irreversible damage of the left hip, a Girdlestone resection was performed. The spondylodiscitis was treated successfully with anti-fungal agents only, which indicates that, in the absence of neurological impairment, good clinical outcome can be achieved without surgery. This case demonstrates that surgical therapy, which is often proclaimed as unavoidable for the treatment of Aspergillus osteomyelitis, should be considered in particular in the case of intolerable pain due to irreversible joint damage or involvement of vital organs.

120

Clinical and microbial spectrum of fungal keratitis in Singapore: a 5-year retrospective study. Wong TY, Fong KS, Tan DT.Int Ophthalmol. 1997;21(3):127-30.

BACKGROUND: The epidemiology of fungal keratitis varies geographically, but commonly occurs in warm, tropical climates. To determine the microbial and clinical characteristics of this disease in Singapore, we conducted a 5-year hospital-based retrospective study. METHODS: A retrospective review of culture-positive fungal keratitis at the Singapore National Eye Center and Singapore General Hospital, from January 1991 to December 1995. RESULTS: Twenty-nine consecutive cases of culture-positive fungal keratitis were seen over the study period. The mean age of the cases was 41 years and 23 were males. Amongst the varied occupations, 9 were construction workers. The most common cultured organisms were Fusarium sp. (52%) and Aspergillus flavus (17%). More than half had a history of ocular trauma prior to the development of keratitis, while a quarter had antecedent topical corticosteroid therapy. In contrast, only 2 patients were contact-lens wearers. Despite medical therapy, 10 patients eventually required therapeutic penetrating keratoplasties; of these, 6 were caused by Fusarium species. CONCLUSION: Fusarium is the commonest cultured organism in fungal keratitis in Singapore and is associated with significant ocular morbidity.

121

Fungal keratitis in Saudi Arabia. Khairallah SH, Byrne KA, Tabbara KF.

Doc Ophthalmol. 1992;79(3):269-76.

We studied a total of 27 cases of fungal keratitis is Saudi Arabia. History of trauma was found in 9 patients, and previous use of topical steroids in 6 patients. In the majority of patients the onset of the disease was in fall and spring. The most frequent cause of fungal keratitis was found to be Aspergillus spp., and these were isolated from 11 cases (41%). Eight of the 11 isolates were Aspergillus flavus. Other causes of keratomycosis included: Fusarium, Candida, and Mycelia sterilia. All patients were treated with antifungal therapy and 18 patients required surgical intervention. Vision improved among 11 patients, remained the same in 4 patients, and deteriorated after treatment in 6 patients. (6 patients failed to return for follow-up.) Four of the 27 patients developed fungal endophthalmitis. The high prevalence of Aspergillus spp. may be due to the fact that spores of Aspergillus can survive the hot and dry weather of Saudi Arabia.

122

Fungal and Parasitic Infections of the Eye. Stephen A. Klotz, Christopher C. Penn, Gerald J. Negvesky, and Salim I. Butrus . Clin. Microbiol. Rev. 2000 13: 662-685.

The unique structure of the human eye as well as exposure of the eye directly to the environment renders it vulnerable to a number of uncommon infectious diseases caused by fungi and parasites. Host defenses directed against these microorganisms, once anatomical barriers are breached, are often insufficient to prevent loss of vision. Therefore, the timely identification and treatment of the involved microorganisms are paramount. The anatomy of the eye and its surrounding structures is presented with an emphasis upon the association of the anatomy with specific infection of fungi and parasites. For example, filamentous fungal infections of the eye are usually due to penetrating trauma by objects contaminated by vegetable matter of the cornea or globe or, by extension, of infection from adjacent paranasal sinuses. Fungal endophthalmitis and chorioretinitis, on the other hand, are usually the result of antecedent fungemia seeding the ocular tissue. Candida spp. are the most common cause of endogenous endophthalmitis, although initial infection with the dimorphic fungi may lead to infection and scarring of the chorioretina. Contact lens wear is associated with keratitis caused by yeasts, filamentous fungi, and Acanthamoebae spp. Most parasitic infections of the eye, however, arise following bloodborne carriage of the microorganism to the eye or adjacent structures. 
Candida sp., Fusarium, Acremonium killense, Alternaria, A.flavus, A.niger, A.fumigatus, A.terreus, A.glaucus, A.nidulans, Pseudallesheria boydii, H. capsulatum, B. dermatitidis, Sporotrix schenskii, Coccidioides immitis, Cryptococcus neoformans, Exophiala jeanselmei, Lasiodiplodia theobromae, Pneumocystis carinii, Paecilomyces lilacinus, Penicillium chrysogenum, Curvularia, Phialophora , Malassezia, Rhodotorula, Microsporum spp. can be cause of infection of the eye after eye trauma in immunocompromised hosts.

123

Isolated renoureteric aspergilloma due to Aspergillus flavus: case report and review of the literature. Pérez-Arellano JL, Angel-Moreno A, Belón E, Francès A, Santana OE, Martín-Sánchez AM. J Infect. 2001 Feb;42(2):163-5.

In this paper we describe a case in which acute renal colic was associated with elimination of multiple hyphal masses of Aspergillus flavus. Also, we reviewed the literature on similar cases and we found a similar pattern characterized by a marked male predominance, association with at least one underlying medical condition that predisposes to fungal infection, the presence of local symptoms resembling acute ureteral colic, and the absence of systemic manifestations. Moreover, our data suggest that Aspergillus balls must be suspected when a diabetic and intravenous drug user presents with acute renal colic and that non-obstructive renal aspergillosis may be initially treated with itraconazole.

124

Aspergillus flavus mycetoma and epidural abscess successfully treated with itraconazole. Witzig RS, Greer DL, Hyslop NE Jr. J Med Vet Mycol. 1996 Mar-Apr;34(2):133-7.

Aspergillus spp. rarely cause mycetomata. We report a patient with diabetes and nephrotic syndrome with Aspergillus flavus mycetoma of the back, with the development of an epidural abscess, diskitis and vertebral osteomyelitis. The patient was successfully treated with decompressive laminectomy and a 14-month itraconazole regimen. Serial serum itraconazole levels and quantitative Aspergillus antigen levels were performed. This is the second reported and first extrapedal case of mycetoma caused by A. flavus.

143

Pulmonary cavitation lesions in patients infected with the human immunodeficiency virus: an analysis of a series of 78 cases] Rodríguez Arrondo F, von Wichmann MA, Arrizabalaga J, Iribarren JA, Garmendia G, Idígoras P. Med Clin (Barc). 1998 Dec 5;111(19):725-30.

The unique structure of the human eye as well as exposure of the eye directly to the environment renders it vulnerable to a number of uncommon infectious diseases caused by fungi and parasites. Host defenses directed against these microorganisms, once anatomical barriers are breached, are often insufficient to prevent loss of vision. Therefore, the timely identification and treatment of the involved microorganisms are paramount. The anatomy of the eye and its surrounding structures is presented with an emphasis upon the association of the anatomy with specific infection of fungi and parasites. For example, filamentous fungal infections of the eye are usually due to penetrating trauma by objects contaminated by vegetable matter of the cornea or globe or, by extension, of infection from adjacent paranasal sinuses. Fungal endophthalmitis and chorioretinitis, on the other hand, are usually the result of antecedent fungemia seeding the ocular tissue. Candida spp. are the most common cause of endogenous endophthalmitis, although initial infection with the dimorphic fungi may lead to infection and scarring of the chorioretina. Contact lens wear is associated with keratitis caused by yeasts, filamentous fungi, and Acanthamoebae spp. Most parasitic infections of the eye, however, arise following bloodborne carriage of the microorganism to the eye or adjacent structures. 
Candida sp., Fusarium, Acremonium killense, Alternaria, A.flavus, A.niger, A.fumigatus, A.terreus, A.glaucus, A.nidulans, Pseudallesheria boydii, H. capsulatum, B. dermatitidis, Sporotrix schenskii, Coccidioides immitis, Cryptococcus neoformans, Exophiala jeanselmei, Lasiodiplodia theobromae, Pneumocystis carinii, Paecilomyces lilacinus, Penicillium chrysogenum, Curvularia, Phialophora , Malassezia, Rhodotorula, Microsporum spp. can be cause of infection of the eye after eye trauma in immunocompromised hosts.

144

Cluster of cases of invasive aspergillosis in a transplant intensive care unit: evidence of person-to-person airborne transmission. Pegues DA, Lasker BA, McNeil MM, Hamm PM, Lundal JL, Kubak BM. Clin Infect Dis. 2002 Feb 1;34(3):412-6.

In October 1998, a patient developed deep surgical-site and organ-space infection with Aspergillus fumigatus 11 days after undergoing liver retransplantation; subsequently, 2 additional patients in the transplant intensive care unit had invasive pulmonary infection with A. fumigatus diagnosed. It was determined that debriding and dressing wounds infected with Aspergillus species may result in aerosolization of spores and airborne person-to-person transmission.

145

Sternal osteomyelitis caused by Aspergillus fumigatus in a patient with previously treated Hodgkin's disease. Allen D, Ng S, Beaton K, Taussig D. J Clin Pathol. 2002 Aug;55(8):616-8.

This report details the case of a 67 year old woman with sternal osteomyelitis caused by Aspergillus fumigatus. She was diagnosed with Hodgkin's disease in 1975 and was successfully treated with chemotherapy. A lobectomy for recurrence localised to the left lung was complicated nine years later by severe bronchiectasis, for which she required a total left sided pneumonectomy. At surgery, a non-invasive aspergillus was found. She presented eight years later with symptoms that were initially attributed to recurrence of Hodgkins's disease, but on investigation were found to be caused by fungal sternal osteomyelitis. Treatment with itraconazole suspension at a dose of 400 mg daily was successful.

 

 

146

Aspergillus osteomyelitis in a child who has p67-phox-deficient chronic granulomatous disease. Tsumura N, Akasu Y, Yamane H, Ikezawa S, Hirata T, Oda K, Sakata Y, Shirahama M, Inoue A, Kato H. Kurume Med J. 1999;46(1):87-90.

Here we describe Aspergillus osteomyelitis of the tibia in a 9-year-old boy who has an autosomal recessive form of chronic granulomatous disease (CGD). The patient showed a p67-phagocyte oxidase (phox) deficiency, which is rare type of CGD in Japan. The initial treatment which consisted of surgical debridement and antibiotic therapy with amphotericin B (AMPH), did not control the infection. Aspergillus fumigatus (A. fumigatus) pure isolated from drainage fluid and necrotic bone tissue demonstrated less susceptible to antifungal agents, including AMPH, fluconazole and flucytosine. Recombinant interferon gamma was then administrated, and it was effective in controlling the course of severe invasive aspergillosis. This report indicates the use of interferon gamma might be helpful in control for Aspergillus osteomyelitis of the tibia in a child with CGD demonstrated p67-phox deficiency refractory to conventional therapy with AMPH.

147

Hospital construction-associated outbreak of ocular aspergillosis after cataract surgery. Tabbara KF, al Jabarti AL. Ophthalmology. 1998 Mar;105(3):522-6.

OBJECTIVE: This study aimed to report an outbreak of Aspergillus endophthalmitis after cataract extraction during hospital construction. DESIGN: The study design is a case series of an outbreak of Aspergillus endophthalmitis. PARTICIPANTS: Five patients in whom Aspergillus endophthalmitis developed during a period of hospital construction in Jeddah, Saudi Arabia, participated. Severe postoperative uveitis occurred in all five patients and failed to subside with topical steroid therapy. The patients were referred to the King Khaled Eye Specialist Hospital for treatment. The causative organism was identified as Aspergillus fumigatus in each case. INTERVENTION: All five patients were subjected to aqueous or vitreous tap. Three patients had vitrectomy. Patients were given systemic, periocular, and intravitreous antifungal agents. MAIN OUTCOME: The final outcome in each patient was evisceration or enucleation, despite an intensive course of antifungal therapy. RESULTS: There were five patients, three females and two males, ranging in age from 51 to 65 years. Postoperative signs of infection developed in the patients 4 to 15 days after surgery. In all five cases, cultures of aqueous or vitreous grew A. fumigatus. CONCLUSION: Aspergillus endophthalmitis is a serious and devastating complication of ocular surgery. The outbreak, herewith, may have been related to hospital construction. The infection can be prevented, notably, by proper maintenance of old, "sick" buildings and by following certain procedures during hospital construction.

148

[Fungal myocarditis in acquired immunodeficiency syndrome] Hofman P, Gari-Toussaint M, Bernard E, Michiels JF, Gibelin P, Le Fichoux Y, Morand P, Loubiere R. Arch Mal Coeur Vaiss. 1992 Feb;85(2):203-8.

The authors report 8 cases of fungal myocarditis discovered at autopsy of a series of 118 patients with AIDS. The cardiac disease was symptomatic and responsible for death in 2 cases. Antemortem diagnosis of fungal infection was made on examination of bronchioloalveolar lavage, the cerebrospinal fluid or gastrointestinal biopsy. The demonstration of intramyocardial pathogens was postmortem in all cases. The organism was Candida albicans in 3 cases, Cryptococcus neoformans in 3 cases, and Aspergillus fumigatus in 2 cases. The lesions were not confined to the heart; multi-visceral fungal involvement was diagnosed at autopsy in all cases. Cryptococcal and Candida myocarditis have already been described in most autopsy series in AIDS, but Aspergillus myocarditis is very rare. These fungal myocarditis are usually clinically latent or masked by neurological or respiratory symptoms.

149

Aspergillus fumigatus endocarditis on a normal heart valve. Vishniavsky N, Sagar KB, Markowitz SM. South Med J. 1983 Apr;76(4):506-8.

We have described an elderly man with no known underlying predisposing systemic or valvular disease who had mitral valve infection and endophthalmitis due to Aspergillus fumigatus. Two-dimensional echocardiography was valuable in detecting fungal vegetations.

150

Invasive rhinosino-orbital aspergillosis with precipitous visual loss. Mauriello JA Jr, Yepez N, Mostafavi R, Barofsky J, Kapila R, Baredes S, Norris J. Can J Ophthalmol. 1995 Apr;30(3):124-30.

OBJECTIVE: To describe the clinicopathological and radiologic features in five cases of primary and secondary orbital aspergillosis. DESIGN: Case series. SETTING: Ophthalmology department of a university hospital. PATIENTS: Five patients over 65 years of age with invasive rhinosino-orbital aspergillosis. RESULTS: Presenting features were abrupt onset of proptosis, ophthalmoplegia and blepharoptosis with precipitous visual loss. All had debilitating periorbital pain or headache, but none had orbital inflammatory signs or appeared "toxic." Predisposing causes included alcoholism, low-dose prednisone therapy and insulin-dependent diabetes mellitus. One patient, suspected of having mucormycosis based on tissue biopsy and results of potassium hydroxide preparations, harboured Aspergillus fumigatus, which grew on culture. Secondary bacterial infections developed in three patients. Three patients died from their disease despite aggressive surgical treatment, including exenteration and sinus extirpation. The one patient with primary orbital aspergillosis survived after exenteration. CONCLUSIONS: Sinonasal aspergillosis with orbital extension and primary orbital aspergillosis have a precipitous clinical course that mimics that of mucormycosis and may be fatal despite early exenteration. Computed tomography and magnetic resonance imaging of the sinuses, orbit and head provide complementary diagnostic signs. While results of potassium hydroxide preparations and tissue biopsy guide treatment of fungal infection, definitive diagnosis requires fungal culture. Relatively good vision may be associated with massive orbital and secondary intracranial extension.

151

Aspergillosis of the nose and paranasal sinuses in neutropenic patients at an oncology center. Landoy Z, Rotstein C, Shedd D. Head Neck Surg. 1985 Nov-Dec;8(2):83-90.

Invasive aspergillosis of the nose and paranasal sinuses is one of the presentations of aspergillosis in granulocytopenic patients with neoplastic disorders. It is most prevalent among patients with leukemia and granulocytopenia and is associated with a high mortality rate. We report five cases of invasive aspergillosis of the nose and paranasal sinuses in profoundly neutropenic patients treated with broad spectrum antibiotics. Both Aspergillus fumigatus and Aspergillus flavus were cultured and identified in this entity. Awareness of this disease and early diagnosis made by culture and histologic examinations of biopsy material are essential. Treatment consisting of amphotericin B therapy and surgical debridement can be effective in eradicating this form of aspergillosis.

152

. Aspergillus fumigatus infection of the optic nerve with mycotic arteritis of cerebral vessels. Fernando SS, Lauer CS. Histopathology. 1982 Mar;6(2):227-34.

A 56-year-old Caucasian male, with no obvious immune deficit or systemic disease, presented with unilateral loss of vision due to A. fumigatus infection involving the right optic nerve. There was no proptosis. Despite fungal chemotherapy he developed central nervous system involvement with mycotic arteritis of the branches of the right middle cerebral artery, temporal lobe infarction and rupture of a mycotic aneurysm of the right internal carotid artery, and died. Review of the literature concerning orbital Aspergillus infection showed both this form of presentation and a rapidly fatal course to be unusual.

153

Aspergillus fumigatus keratitis with wreath pattern infiltrates.

Sridhar MS, Gopinathan U, Garg P, Rao GN. Cornea. 2001 Jul;20(5):534-5.

PURPOSE: To report a case of Aspergillus fumigatus keratitis with clinical features simulating Nocardia keratitis and to highlight the utility of microbiologic investigation in the successful management of infectious keratitis. METHOD: Case report. RESULTS: A 62-year-old man presented with complaints of pain, redness, and watering of 10 days' duration in his right eye. Direct microscopic observation of smears of corneal scrapings revealed a fungal etiology. The patient was treated with 5% natamycin eye drops and 1% atropine sulphate eye drops and was advised to visit the hospital for observation. During his visit to the hospital on day 10 after medication, the eye demonstrated a wreath pattern corneal infiltrate that simulated Nocardia keratitis. The fungus grown from culture of corneal scraping was identified as A. fumigatus. CONCLUSION: This report highlights the significance of subjecting corneal scrapings from suspected cases of infectious keratitis to microbiologic evaluation and emphasizes the fact that a complete microbiologic work-up helps in establishing a definitive etiologic diagnosis and initiating specific antimicrobial therapy.

161

Mycotic keratitis in Madras. Venugopal PL, Venugopal TL, Gomathi A, Ramakrishna ES, Ilavarasi S. Indian J Pathol Microbiol. 1989 Jul;32(3):190-7.

Corneal scrapings from 698 clinically suspected cases of mycotic keratitis were investigated for evidence of fungal infection. Of these, 322 were found to be positive by direct examination and/or culture. The infection was predominantly seen in the age group 21-50. Men were more frequently affected than women. Majority of the patients were either agricultural workers or out door manual labourers and 66.8% of them gave a definite history of antecedent corneal trauma due to vegetable or soil matter. Aspergillus flavus was the commonest causal agent isolated from 55 cases (17.1%), followed by A. niger (13.7%), A. fumigatus (10.9%), A. terreus (1.2%), A. glaucus (0.9%), and Pseudoallescheria boydii (0.6%). The order of occurrence of the genera of fungi isolated was Aspergillus, Acremonium, Curvularia, Fusarium, Candida, Syncephalastrum, Penicillium, Aureobasidium, Drechslera, Cladosporium, Rhizopus, Alternaria, Mucor, Pseudoallescheria and lastly Paecilomyces and Trichoderma from one case each.

162

Cutaneous Aspergillosis . Jo-Anne H. van Burik,1,2,* Roy Colven,3 and David H. Spach1. Journal of Clinical Microbiology, November 1998, p. 3115-3121, Vol. 36, No. 11

Although extensive investigation has clarified multiple aspects of pulmonary aspergillosis in immunocompromised patients, cutaneous aspergillosis occurs relatively less frequently and therefore remains poorly characterized. Previous reports have described cutaneous aspergillosis as either primary (2, 17, 25, 38) or secondary (15, 19) infection. Primary cutaneous aspergillosis usually involves sites of skin injury, namely, at or near intravenous access catheter sites, at sites of traumatic inoculation, and at sites associated with occlusive dressings, burns, or surgery. Secondary cutaneous lesions result either from contiguous extension to the skin from infected underlying structures or from widespread blood-borne seeding of the skin. Herein, we present a review of cutaneous aspergillosis among immunocompromised patient populations. With this review, we have attempted to better define risk factors and common clinical presentations, as well as to formulate a reasonable approach to the diagnosis and management of cutaneous aspergillosis. Numerous reports have described primary or secondary cutaneous aspergillosis in an array of non-HIV-infected immunocompromised patients, including burn victims, neonates, individuals with cancer, and bone marrow and solid-organ transplant recipients (1, 2, 4, 6-9, 11, 20, 22-24, 26, 32-38, 43-46, 48-51, 53, 55, 56, 59, 60, 62, 66, 68). In addition, otherwise healthy hosts can develop cutaneous aspergillosis in surgical wounds (3, 8, 40), by traumatic inoculation (5, 12, 13, 27, 41, 42), or by exposure to high spore counts in occupations such as farming (10, 19, 61, 64), although such infections are rare. In general, burn victims, neonates, and solid-organ transplant recipients develop cutaneous inoculation after prolonged local skin injury, whereas bone marrow transplant recipients tend to develop secondary cutaneous aspergillosis lesions either from contiguous extension from infected structures underlying the skin, such as the paranasal sinuses, nasal cavity, or orbit, or from hematogenously disseminated embolic lesions. Cancer patients, particularly leukemia patients, develop both primary and secondary infections. The different classifications of both primary and secondary cutaneous aspergillosis infections are as follows. Primary infections include those at intravenous catheter sites (cutaneous exit sites and subcutaneous tunnels), infections associated with adhesives such as occlusive dressings and tape, and infections associated with burn wounds, surgical wounds, and trauma wounds. Secondary infections include those caused by direct extension and embolic lesions. Among patients with HIV-related cutaneous aspergillosis, seven patients had A. fumigatus infection, one had A. glaucus infection, and two had aspergillosis demonstrated by histopathology alone. The reason for this high proportion of primary A. fumigatus isolates is not known. In contrast, among cases of cutaneous aspergillosis that did not involve HIV-infected or burn patients, the following organisms accounted for the indicated proportion of cases: Aspergillus flavus, 44%; A. fumigatus, 26%; Aspergillus spp. (the species of Aspergillus was not determined), 10%; Aspergillus terreus, 6% (13, 38, 45, 61); Aspergillus niger, 6% (10, 25, 32, 38, 55); A. glaucus, 4% (15, 66, 68); Aspergillus chevalieri, 3% (42); and Aspergillus ustus, 1% (59). The proportions of species differed by at-risk populations: A. flavus accounted for approximately one-half of non-burn-related primary infection, whereas A. flavus and A. fumigatus each accounted for approximately one-third of secondary or metastatic skin lesions. Determination of the species causing aspergillosis did not guide therapy in any of the reports reviewed. 

167

Aspergillus nidulans infection in chronic granulomatous disease. Segal BH, DeCarlo ES, Kwon-Chung KJ, Malech HL, Gallin JI, Holland SM. Medicine (Baltimore). 1998 Sep;77(5):345-54.

Chronic granulomatous disease (CGD) is a rare inherited disorder of the NADPH oxidase complex in which phagocytes are defective in generating reactive oxidants. As a result, patients with CGD suffer from recurrent bacterial and fungal infections. The most common fungal infections are caused by Aspergillus species. Aspergillus nidulans is a rare pathogen in most patient populations with quantitative or qualitative neutrophil defects. We have reviewed all cases in which A. nidulans was isolated from patients at the National Institutes of Health (Bethesda, MD) between 1976 and 1997. A. nidulans infection occurred in 6 patients with CGD, but was not a pathogen in any other patient group. Aspergillus fumigatus was a more common pathogen in CGD compared with A. nidulans, but A. nidulans was more virulent. A. nidulans was significantly more likely to result in death compared with A. fumigatus, to involve adjacent bone, and to cause disseminated disease. Patients with A. nidulans received longer courses of amphotericin B therapy than patients with A. fumigatus, and were treated with surgery more often. In contrast to A. fumigatus, A. nidulans was generally refractory to intensive antifungal therapy, suggesting that early surgery may be important. These data show that A. nidulans is a distinct pathogen in CGD and its isolation carries more severe implications than that of A. fumigatus.

168

Aspergillus nidulans infection in a patient with chronic granulomatous disease. Kim M, Shin JH, Suh SP, Ryang DW, Park CS, Kim C, Kook H, Kim J. J Korean Med Sci. 1997 Jun;12(3):244-8.

Aspergillus nidulans is one of the several species of Aspergillus with low pathogenicity. The significant infections of A. nidulans in human have rarely been reported, almost exclusively in patients with chronic granulomatous disease (CGD). CGD is a primary immunodeficiency disease which results from the absence of the NADPH oxidase in the phagocytic cells, leading to recurrent pyogenic infection and granuloma and abscess formation. Here we report a fatal case A. nidulans infection in a six-year-old boy with chronic granulomatous disease. A. nidulans was isolated from the culture of a paraspinal abscess and Aspergillus was detected in the surgical tissue by in situ hybridization. The patient succumbed despite prolonged treatment with high-dose amphotericin B, itraconazole and interferon-alpha. To our knowledge, this is the first report of A. nidulans infection in Korea.

169

A case of chronic necrotizing pulmonary aspergillosis due to Aspergillus nidulans. Mizuki M, Chikuba K, Tanaka K. Mycopathologia. 1994 Nov;128(2):75-9.

A 55-year old man without immunosuppression clinically showed a coin lesion in the right lower lung on the chest radiographs. Aspergillus nidulans was isolated and identified in both trans-bronchial lung biopsy specimen and resected tissue. The specimens revealed characteristics of chronic necrotizing pulmonary aspergillosis pathologically. Very few reports on cases of pulmonary aspergillosis due to A. nidulans exist, and we were not able to find any reports of similar cases. This case may be the first reported case of chronic necrotizing pulmonary aspergillosis due to A. nidulans.

170

Chronic granulomatous disease of childhood. An unusual case of infection with Aspergillus nidulans var. echinulatus. White CJ, Kwon-Chung KJ, Gallin JI. Am J Clin Pathol. 1988 Sep;90(3):312-6.

Aspergillus nidulans var. echinulatus was the sole agent cultured from the left lung, a paraspinal abscess, left ribs, and thoracic vertebral bodies from a patient with chronic granulomatous disease. Hyphal elements were present in histologic sections of lung, vertebral bodies, and infected ribs along with granuloma formation. The patient was treated with two debridement procedures and insertion of a Harrington rod followed by a long course of amphotericin B, flucytosine, and daily white blood cell transfusions.

171

Aspergillus endocarditis in chronic granulomatous disease. Casson DH, Riordan FA, Ladusens EJ. Acta Paediatr. 1996 Jun;85(6):758-9.

Department of Paediatric Gastroenterology, Royal Free Hospital, London.

We report the first case, to our knowledge, of Aspergillus endocarditis in chronic granulomatous disease in a patient who also had an atrial septal defect. A diagnosis was made on culture of the organism from the mass despite extensive prior investigation. The presence of distinctive skin lesions as a diagnostic clue of fungaemia is highlighted. Possible advances in diagnosis by detection of fungal cell wall components and in prophylaxis by use of itraconazole are referred to. We conclude that fungal endocarditis should be considered in this condition, especially in the presence of a structural heart defect.

 

172

Osteomyelitis and pneumonia in a boy with chronic granulomatous disease of childhood caused by a mutant strain of Aspergillus nidulans. Bujak JS, Kwon-Chung KJ, Chusid MJ. Am J Clin Pathol. 1974 Mar;61(3):361-7.

 

183

Mycotic infection of the ear (otomycosis): a prospective study. Paulose KO, Al Khalifa S, Shenoy P, Sharma RK. J Laryngol Otol. 1989 Jan;103(1):30-5.

Otomycosis (fungal infection of the ear) is not uncommon clinical problem encountered in our ENT practice. It makes up to 6 per cent of all patients with symptoms of ear disease seen in the Outpatient Clinic. Of the 193 patients with a clinical diagnosis of otomycosis, 171 cases produced positive fungal isolates. In this study Aspergillus species (niger and fumigatus) have been the most common fungal pathogens. Various aetiopathological factors have been examined in detail, and the available literature reviewed. The results of the treatment by nine antifungal agents currently available in Bahrain have been analysed.

184

Pathogenic organisms in chronic suppurative otitis media in Enugu, Nigeria. Ibekwe AO, Okafor JI. Trop Geogr Med. 1983 Dec;35(4):389-91.

Pathogenic organisms in chronic suppurative otitis media from 62 patients were identified. Pseudomonas aeruginosa was responsible in 46%, Staphylococcus aureus in 29%. Proteus mirabilis in 13%, Streptococcus pyogenes in 6%, Aspergillus niger in 5% and Mucor sp. in 2%. The most prevalent organism in children was Staphylococcus aureus. The role of fungi in chronic suppurative otitis media is discussed.

185

Otomycosis in Nigeria: treatment with mercurochrome. Mgbor N, Gugnani HC. Mycoses. 2001 Nov;44(9-10):395-7.

Seventy-two mycologically proven cases of otomycosis (38 males, 34 females) aged 8-80 years were investigated. Aspergillus niger was the commonest aetiological agent (43.1%) followed by Candida spp. (22.2%), A. flavus (19.4%) and A. fumigatus (15.3%). Three topical drugs, namely mercurochrome, clotrimazole and locacorten-vioform, were evaluated for otomycosis therapy in separate groups of 24 patients each. Mercurochrome was found to be the most efficacious in terms of healing, relief from symptoms of the disease and production of negative fungal cultures. Mercurochrome is recommended as a safe and economical drug for the topical treatment of otomycosis in developing countries like Nigeria.

186

[Chronic necrotizing pulmonary aspergillosis caused by Aspergillus niger] Arévalo M, Solera J, Rodríguez F, Vizcaya M, Vercher R, Martínez-Moratalla J. Med Clin (Barc). 1991 Nov 9;97(16):620-2.

Chronic necrotizing pulmonary aspergillosis (CNPA), also known as semi-invasive pulmonary aspergillosis , is a recently defined entity. CNPA is characterized by a pulmonary infiltration with cavitation of chronic evolution in patients with chronic pulmonary disease, slight immunodeficiency or healthy patients. Good evolution is obtained with antimicotic treatment. The isolation of Aspergillus niger as a cause of CNPA is infrequent and may bear worse prognosis. A patient who presented CNPA by Aspergillus niger is described. The patient had received radiotherapy for epidermal carcinoma of the esophagus. Three other cases have been reported in the literature. The diagnostic aspects, treatment and prognostic factors of CNPA are commented upon.

187

A case of secondary invasive pulmonary aspergillosis originating from an aspergilloma, successfully treated with itraconazole] Nakagawa Y, Shimazu K, Ebihara M, Amann K. Nihon Kokyuki Gakkai Zasshi. 1998 Mar;36(3):294-8.

A 65-year-old man was admitted to our division with of productive cough and hemosputum. Chest radiographs and chest CT on admission showed old inflammatory shadows in both upper lung fields and a fungus ball in the left upper lung field. Despite antibiotic treatment, the patient's sputum volume increased and Aspergillus niger was repeatedly cultured from his sputum. Chest radiographs showed deterioration around the intracavitary fungus ball and a test for serum aspergillus antigen was positive. Secondary invasive pulmonary aspergillosis originating from aspergilloma was diagnosed based on his clinical symptoms, radiographic features and laboratory data. Administration of fluconazole failed to improve his clinical course and amphotericin B was discontinued because of hypokalemia. Oral administration of itraconazole was a successful treatment.

188

Chronic necrotising pneumonia caused by Aspergillus niger. Wiggins J, Clark TJ, Corrin B. Thorax. 1989 May;44(5):440-1.

A woman with asthma developed chronic necrotising semi-invasive pneumonia due to mixed Aspergillus niger and Candida albicans infection; though not severely immunosuppressed, she may have been predisposed by long term oral corticosteroid and recurrent oral antibiotic treatment. The diagnosis should be considered in patients with chronic airflow limitation who develop cavitating pneumonia.

189

Invasive Aspergillus niger with fatal pulmonary oxalosis in chronic obstructive pulmonary disease. Kimmerling EA, Fedrick JA, Tenholder MF. Chest. 1992 Mar;101(3):870-2.

The ubiquitous Aspergillus fungus has numerous manifestations when associated with lung disease (primary Aspergillus pneumonia, aspergilloma, allergic bronchopulmonary aspergillosis, and invasive Aspergillus). This fungus also can colonize preexisting lung disease in an indolent manner and then acutely assume a more invasive nature. Although the species Aspergillus niger is infrequently encountered, the endobronchial visualization of black necrotic debris or a fungus ball or the finding of black acidic sputum or pleural fluid suggests the presence of A niger and the destructive by-product of its fermentation, oxalic acid.

190

Invasive aspergillosis presenting as pericarditis and cardiac tamponade. Luce JM, Ostenson RC, Springmeyer SC, Hudson LD. Chest. 1979 Dec;76(6):703-5.

A 38-year-old leukemic patient developed pericarditis and cardiac tamponade due to Aspergillus niger one month after undergoing bone marrow transplantation. She failed to improve even though amphotericin B and rifampin therapy had been initiated before infection was evident. Her unique case illustrates both the unusual presentations of invasive aspergillosis and the difficulty of diagnosing and treating this increasingly common disease.

191

Nasosinus aspergillosis in Sudanese patients: clinical features, pathology, diagnosis, and treatment. Yagi HI, Gumaa SA, Shumo AI, Abdalla N, Gadir AA. J Otolaryngol. 1999 Apr;28(2):90-4.

OBJECTIVE: The objective of this study was a prospective analysis of the clinical features, pathology, diagnosis, and treatment of patients treated between 1993 and 1996 for nasosinus aspergillosis in the Sudan. METHOD: Clinical examinations and laboratory tests for serologic, mycologic, and histologic analysis were conducted on all patients, as were radiologic and computerized tomographic studies when external swelling of any of the paranasal sinuses was evident. RESULTS: The age group 11 to 50 years were predominantly affected, with a peak in those aged 21 to 30 years. Females were affected more often than were males. The clinical features were mainly nasal polyposis, external swelling of the ethmoid sinus medial to the inner canthus, or maxillary cheek swelling and/or proptosis. In the paranasal sinuses, the ethmoids were the most frequently affected. Intracranial extension of the disease occurred in two patients. Serologic examinations and mycological cultures showed more incidence of positive results than did histopathology. Aspergillus flavus was grown in all the positive mycologic cultures except one, where Aspergillus niger was grown. The treatment was mainly surgical, supplemented by an antifungal drug (itraconazole). The incidence of recurrence was 9.3%, and it was noticed that the recurrence occurred in those patients who were not taking their medicines regularly. CONCLUSION: Nasosinus aspergillosis is a common disease in Sudan. Nasal polyposis is the commonest mode of clinical presentation. Serology and mycologic cultures are quite helpful in the diagnosis. Surgical and medical treatment are complementary of each other.

197

Inhaled mycotoxins lead to acute renal failure. Di Paolo N, Guarnieri A, Garosi G, Sacchi G, Mangiarotti AM, Di Paolo M. Nephrol Dial Transplant. 1994;9 Suppl 4:116-20.

Mysterious deaths of archeologists after opening Egyptian tombs have been suspected, but never proved, to be secondary to inhalation of mycotoxin. We observed a case of acute renal failure (ARF) due to inhalation of ochratoxin A produced by a mould of the species Aspergillus ochraceus. After working 8 h in a granary closed for several months, a farmer and his wife suffered respiratory distress; the woman developed non-oliguric ARF and biopsy revealed tubulonecrosis. A strain of Aspergillus ochraceus producing ochratoxin was isolated from the wheat.

198

Ochratoxin A genotoxicity, relation to renal tumors] Maaroufi K, Pfohl-Leszkowicz A, Achour A, el May M, Grosse Y, Hammami M, Ellouz F, Creppy EE, Bacha H. Arch Inst Pasteur Tunis. 1994 Jan-Apr;71(1-2):21-31.

Ochratoxin A (OTA) is a mycotoxin which has been implicated in Balkan Endemic Nephropathy (BEN), a disease characterized by tubulonephritis and may be involved in the high incidence of urinary tract tumors associated to BEN. The prevalence of human ochratoxicosis is being determined in Tunisia. 100% of people suffering from chronic interstitial nephropathy of unknown etiology were ochratoxin A positive. These nephropathies are similar to Balkan Endemic Nephropathy. We prove an OTA genotoxic effects in patient suffering from this kind of nephropathy. OTA-DNA adducts formation has been detected in DNA of kidney tissues (biopsy). DNA adducts which are covalent complex between OTA and DNA base (Guanine), constitute first steps of the carcinogenesis process.

205

[Aspergillus restrictus and Candida parapsilosis--agents of endocarditis following heart valve replacement] Mencl K, Otcenásek M, Spacek J, Rehulová E. Mykosen. 1985 Mar;28(3):127-33.

 

206

[Mycotic ulcerative aortitis after replacement of the aortic valve caused by the fungus Aspergillus restrictus] Pospísil K, Straka V, Otcenásek M, Mencl K, Pospísil M, Spacek J, Hamet A, Pidrman V. Vnitr Lek. 1984 Mar;30(3):292-7.

 

207

[Mycotic ulcerative aortitis after replacement of the aortic valve caused by the fungus Aspergillus restrictus] Pospísil K, Straka V, Otcenásek M, Mencl K, Pospísil M, Spacek J, Hamet A, Pidrman V. Vnitr Lek. 1984 Mar;30(3):292-7.

 

208

[ Pulmonary aspergillosis with generalized spreading caused by Aspergillus restrictus] MARSALEK E, ZIZKA Z, RIHA V, DUSEK J, DVORACEK C. Cas Lek Cesk 1960 Oct 7;99:1285-92.

 

219

Fatal disseminated infection with Aspergillus terreus in immunocompromised hosts. Tritz DM, Woods GL. Clin Infect Dis. 1993 Jan;16(1):118-22.

Aspergillus terreus is widespread in the environment but only uncommonly infects humans. It can cause cutaneous and subcutaneous infections, and several cases of local invasive disease have been reported; to our knowledge, however, only five cases of disseminated disease have been documented previously. We describe here four additional patients with disseminated disease caused by A. terreus. All four had an underlying hematologic or lymphoreticular malignancy, were immunocompromised secondary to prolonged neutropenia or immunosuppressive therapy, and had invasive pulmonary disease (a circumstance supporting a respiratory route of infection). Despite treatment with amphotericin B, all four patients died. When recovered from clinical specimens, A. terreus should not routinely be dismissed as a saprobe, particularly in immunocompromised hosts.

220

Endocarditis and aortal embolization caused by Aspergillus terreus in a patient with acute lymphoblastic leukemia in remission: diagnosis by peripheral-blood culture. Schett G, Casati B, Willinger B, Weinlander G, Binder T, Grabenwoger F, Sperr W, Geissler K, Jager U.J Clin Microbiol. 1998 Nov;36(11):3347-51.

 

221

Invasive pulmonary aspergillosis due to Aspergillus terreus: 12-year experience and review of the literature. Iwen PC, Rupp ME, Langnas AN, Reed EC, Hinrichs SH. Clin Infect Dis. 1998 May;26(5):1092-7.

A 12-year retrospective analysis was done to identify and evaluate in detail cases of invasive pulmonary aspergillosis (IPA) caused by Aspergillus terreus. We identified 13 A. terreus infections among 133 total cases of confirmed invasive aspergillosis; 11 were IPA and 2 were primary peritoneal infections. Of the 11 patients with IPA, 7 developed neutropenia during hospitalization, and the remaining four were receiving immunosuppressive agents. Ten patients with IPA died; one liver transplantation patient without neutropenia survived after treatment with amphotericin B, itraconazole, and a pulmonary lobectomy. Six patients developed disseminated disease, with the heart the most common extrapulmonary site identified (four patients). These cases demonstrate that IPA caused by A. terreus rapidly progresses in immunocompromised patients receiving amphotericin B and illustrate the need for sensitive diagnostic tests and more effective antifungal agents.

222

Aspergillus terreus infections in haematological malignancies: molecular epidemiology suggests association with in-hospital plants. Lass-Florl C, Rath P, Niederwieser D, Kofler G, Wurzner R, Krezy A, Dierich MP. J Hosp Infect. 2000 Sep;46(1):31-5.

During a three-year period nine patients with haematological diseases after myeloablative chemotherapy died from invasive fungal infections caused by Aspergillus terreus. The hospital inanimate environment was monitored and A. terreus was cultured from potted plants in the vicinity of the patients. The patients (N = 14) and the environmental isolates (N = 2) were fingerprinted by RAPD-PCR with four different primers. Based on RAPD patterns the patients' isolates were differentiated into five different types; the environmental isolates represented two types. The isolates of four patients were identical to those found in the environment. Five additional patients were infected by RAPD types not found in the environment. One patient was infected with two different types. The data indicate a hospital-acquired infection in many of the patients and underline the need for careful environmental monitoring of units in which high-risk patients are housed.

223

Nosocomial invasive aspergillosis in lymphoma patients treated with bone marrow or peripheral stem cell transplants. Iwen PC, Reed EC, Armitage JO, Bierman PJ, Kessinger A, Vose JM, Arneson MA, Winfield BA, Woods GL. Infect Control Hosp Epidemiol. 1993 Mar;14(3):131-9.

OBJECTIVES: To determine the prevalence of aspergillosis in lymphoma patients housed in a protective environment while undergoing a bone marrow transplant or peripheral stem cell transplant and its relation to lymphoma type, type of transplant, period of neutropenia, method of diagnosis, species of Aspergillus, and the use of empiric amphotericin B. DESIGN: Clinical, autopsy, and microbiology records were reviewed retrospectively to determine the presence or absence of invasive aspergillosis. All positive specimens underwent further review to determine parameters outlined above. SETTING: The review took place at the University of Nebraska Medical Center with lymphoma patients housed in the oncology/hematology special care unit, which consists of 30 single-patient rooms under positive pressure with high-efficiency particulate air filtration. PATIENTS: 417 lymphoma patients admitted to the oncology/hematology special care unit who underwent 427 courses of high-dose chemotherapy with or without total body irradiation followed by a stem cell rescue. RESULTS: Twenty-two cases (5.2%) of nosocomial invasive aspergillosis (14 caused by Aspergillus flavus, 2 by Aspergillus terreus, 2 by Aspergillus fumigatus, and 4 by characteristic histology) were diagnosed. The prevalence of disease according to transplant was 8.7% for allogeneic bone marrow transplant (2/23 treatments), 5.6% for autologous peripheral stem cell transplant (9/161), and 4.5% for autologous bone marrow transplant (11/243). Fifteen patients were presumptively diagnosed prior to death (68.2%) most commonly by histologic examination of skin biopsies. All 22 patients received amphotericin B therapy, 17 prior to aspergillosis diagnosis, and 7 (31.8%) survived. No patient with disseminated disease survived. CONCLUSIONS: Even when housing lymphoma patients undergoing myeloablative therapy in a protective environment containing high-efficiency particulate air filtration, there was a risk of developing aspergillosis. These data also showed that antemortem diagnosis with aggressive amphotericin B therapy was most effective in the management of infected lymphoma patients when engraftment occurred and the disease did not become disseminated.

228

Primary cutaneous Aspergillus ustus infection: second reported case.

Ricci RM, Evans JS, Meffert JJ, Kaufman L, Sadkowski LC. J Am Acad Dermatol. 1998 May;38(5 Pt 2):797-8.

We describe the second case of primary cutaneous Aspergillus ustus infection in an immunocompromised patient. Cutaneous aspergillosis was confirmed both by culture and positive fluorescent antibody staining. Few species of Aspergillus are pathogenic in human beings, and fewer still cause primary cutaneous disease. The only other reported case of aspergillosis from Aspergillus ustus occurred in an immunosuppressed patient who was temporally and geographically separated from ours.

229

Invasive aspergillosis caused by Aspergillus ustus: case report and review. Verweij PE, van den Bergh MF, Rath PM, de Pauw BE, Voss A, Meis JF. J Clin Microbiol. 1999 May;37(5):1606-9.

A case of invasive pulmonary aspergillosis in an allogeneic bone marrow transplant recipient caused by Aspergillus ustus is presented. A. ustus was also recovered from the hospital environment, which may indicate that the infection was nosocomially acquired. A literature review revealed seven cases of invasive infections caused by A. ustus, and three of these were primarily cutaneous infections. In vitro susceptibility testing of 12 A. ustus isolates showed that amphotericin B and terbinafine had fungicidal activity and that itraconazole and voriconazole had fungistatic activity.

230

Disseminated aspergillosis caused by Aspergillus ustus in a patient following allogeneic peripheral stem cell transplantation. Iwen PC, Rupp ME, Bishop MR, Rinaldi MG, Sutton DA, Tarantolo S, Hinrichs SH. J Clin Microbiol. 1998 Dec;36(12):3713-7.

The first case of disseminated aspergillosis caused by Aspergillus ustus in an allogeneic peripheral stem cell transplant patient is described. The patient, a 46-year-old female with a history of myelodysplastic syndrome, underwent high-dose chemotherapy and total body irradiation prior to transplantation. She was released from the hospital 49 days posttransplant (p.t.) in a stable condition with an absolute neutrophil count (ANC) of 2,700 cells per &mgr;l. Multiple antimicrobial agents, including itraconazole (ITR), were prescribed during hospitalization and at the time of discharge. Three days after discharge, the patient was readmitted with hemorrhagic cystitis, persistent thrombocytopenia, and bilateral pulmonary consolidation, although no fever was present. The ANC at the time of readmission was 3,500. Upon detection of a pulmonary nodule (day 67 p.t.), a bronchoalveolar lavage was performed; the lavage fluid was positive for both cytomegalovirus and parainfluenza virus and negative for fungus. The patient was placed on ganciclovir. A biopsy specimen from a leg lesion also noted on day 67 p.t. revealed septate hyphae consistent with Aspergillus species, and a culture subsequently yielded Aspergillus ustus. Confirmation detection of A. ustus was made by demonstration of characteristic reproductive structures with the presence of Hülle cells. On day 67 p.t., ITR was discontinued and liposomal amphotericin B (AMB) was initiated. The patient's condition worsened, and she died 79 days p.t. At the time of autopsy, septate hyphae were present in heart, thyroid, and lung tissues, with lung tissue culture positive for A. ustus. In vitro susceptibility testing indicated probable resistance to AMB but not to ITR. This case supports the need for the development of rapid methods to determine antifungal susceptibility.

241

Onychomycosis, tinea pedis and tinea manuum caused by non-dermatophytic filamentous fungi. Summerbell RC, Kane J, Krajden S. Mycoses. 1989 Dec;32(12):609-19.

Over 4000 cases of fungal nail, sole and palm infection recorded during a three-year study period were investigated to determine the prevalence and significance of etiologic agents other than dermatophytes and yeasts. Littman's oxgall agar, which permitted isolation of cycloheximide-sensitive species but restricted overgrowth by fast growing contaminants, was used to promote isolation of these disease agents. Non-dermatophytic filamentous fungi made up 2.3% of the confirmed etiologic agents obtained overall, and constituted 3.3% of the agents obtained from nail infections. The most common species were Scopulariopsis brevicaulis, Hendersonula toruloidea, and Aspergillus sydowii. Scytalidium hyalinum was recorded for the first time from Canada, and an instance of nail infection by Gymnascella dankaliensis was recorded. Only H. toruloidea and Sc. hyalinum caused palm and sole infections.

248

Aspergillus versicolor as cause of onychomycosis: report of 12 cases and susceptibility testing to antifungal drugs. Torres-Rodriguez JM, Madrenys-Brunet N, Siddat M, Lopez-Jodra O, Jimenez T. J Eur Acad Dermatol Venereol. 1998 Jul;11(1):25-31.

BACKGROUND: Onychomycoses caused by opportunistic moulds are not well understood, and many are due to Scopulariopsis brevicaulis and other species. Aspergillus versicolor is not documented as an etiological agent in most studies. We have found an increasing prevalence of this species which is involved in 5.8% of all fungal infections of toe nails. OBJECTIVE: To study the clinical and mycological characteristics of the onychomycosis caused by A. versicolor and the in vitro susceptibility of this mould to antifungal agents. RESULTS: Onychomycosis due to A. versicolor is mainly seen in people over 60 and presents with chronic involvement of the big toe nails. Predisposing factors are not always present and the infection does not respond to conventional topical antifungals. In vitro, A. versicolor has been shown to be resistant to griseofulvin and fluconazole as well as to amphotericin B, whereas MICs for itraconazole and ketoconazole are variable but within a range of 0.50-4.0 microg/ml; on the contrary, MICs for terbinafine are very low (<0.125 microg/ml). DISCUSSION: Aspergillus versicolor could be considered as an emergent pathogen causing toenail onychomycosis. Local treatment seems not to be effective. Of the various systemic antifungal agents studied terbinafine appears to be the most effective in treating onychomycosis.

249

Osteomyelitis of sacral spine caused by aspergillus versicolor with neurologic deficits. Liu Z, Hou T, Shen Q, Liao W, Xu H. Chin Med J (Engl). 1995 Jun;108(6):472-5.

 

250

Cerebral aspergillosis: report of two cases. Venugopal PV, Venugopal TV, Thiruneelakantan K, Subramanian S, Shetty BM. Sabouraudia. 1977 Nov;15(3):225-30.

Two cases of cerebral aspergillosis in Tamilians presenting as intracranial space-occupying lesions are reported. The first patient had a left frontal lobe abscess and a specific diagnosis was made by histopathology and isolation of Aspergillus versicolor. He responded well to excision followed by anticonvulsant therapy. In the other, the diagnosis was based on histopathology alone and she died after surgery. These are the first cases reported from Tamil Nadu and probably only one similar case has been reported from India so far.

259

Opportunistic infection of the spleen caused by Aureobasidium pullulans. Salkin IF, Martinez JA, Kemna ME. J Clin Microbiol. 1986 May;23(5):828-31.

The mold Aureobasidium pullulans was isolated on several nutrient media from a splenic abscess in a patient with disseminated lymphoma. Examination of stained smears and paraffin sections revealed fungal structures characteristic of this organism. This is the first reported association of A. pullulans with an opportunistic visceral infection.

260

Aureobasidium mansoni meningitis in a leukemia patient successfully treated with amphotericin B. Krcméry V Jr, Spánik S, Danisovicová A, Jesenská Z, Blahová M. Chemotherapy. 1994 Jan-Feb;40(1):70-1.

Aureobasidium mansoni fungal meningitis in a 30-year-old leukemic patient is reported. This is the first reported case of Aureobasidium spp. central nervous system infection. The patient was successfully treated with systemic antifungal chemotherapy with a total dose of 2.2 g of amphotericin B.

261

Prospective study of nosocomial fungal meningitis in children--report of 10 cases. Huttova M, Kralinsky K, Horn J, Marinova I, Iligova K, Fric J, Spanik S, Filka J, Uher J, Kurak J, Krcmery V Jr. Scand J Infect Dis. 1998;30(5):485-7.

Within an 8-year period, 10 cases of fungal nosocomial meningitis in children 0-13 y old were prospectively identified, 3 caused by yeasts other than Candida spp. (Rhodotorula rubra, Aureobasidium mansoni, Clavispora lusitaniae) and 7 by Candida albicans. Seven patients survived. whereas 3 neonates with fungal meningitis (all due to C. albicans) died. Risk factors for fungal nosocomial meningitis included cancer (2 children), previous neurosurgery (2 children), cranial trauma (1 case) and prematurity with low birthweight (5 cases). All patients except 1 had received broad-spectrum antibiotics before onset of meningitis. In addition to yeasts, bacteria were isolated from CSF of 4 children. One child had additional fungaemia. Univariate analysis was used to compare 10 cases of fungal to 91 cases of bacterial nosocomial meningitis. Except for concurrent bacteraemia, (60 vs 25.3%, P < 0.03), which was more frequently observed among fungal meningitis, there were no significant differences in risk factors, sequelae or outcome (mortality) between patients with fungal vs bacterial meningitis. A review of fungal meningitis reported within the last 20 y is included.

262

Systemic phaeohyphomycosis in pregnancy and the puerperium. Fletcher H, Williams NP, Nicholson A, Rainford L, Phillip H, East-Innis A. West Indian Med J. 2000 Mar;49(1):79-82.

Systemic fungal infections are rare. In pregnancy, treatment is problematic because of the risk of possible teratogenic effects of the antifungal drugs. We present the case of a 32 year-old woman who presented during pregnancy with a two-month history of painless subcutaneous nodules. Excision biopsy of one lesion showed dematiaceous fungal elements. Anti-fungal treatment was deferred and the pregnancy proceeded uneventfully. The remaining nodules were excised at the time of caesarean section delivery. Three weeks into the puerperium, she developed generalised seizures and investigations indicated systemic fungal infection with positive cultures for Aureobasidium spp which responded to appropriate antifungal therapy of flucytosine and itraconazole.

263

Systemic infection with Aureobasidium pullulans in a leukaemic patient. Kaczmarski EB, Liu Yin JA, Tooth JA, Love EM, Delamore IW. J Infect. 1986 Nov;13(3):289-91.

Aureobasidium pullulans, a conidial fungus widely distributed in the environment, was repeatedly isolated from the blood of a 28-year-old man with acute myeloid leukaemia. Amphotericin B failed to eliminate the organism.

264

Aureobasidium pullulans scleritis following keratoplasty: a case report. Gupta V, Chawla R, Sen S. Ophthalmic Surg Lasers. 2001 Nov-Dec;32(6):481-2.

Fungal scleritis is a rare entity. A 50-year-old patient with culture proven Aureobasidium pullulans corneal ulcer underwent therapeutic keratoplasty. He developed scleritis 5 days following surgery. Although the patient had symptomatic improvement after antifungal therapy, surgical debridement, and cryotherapy, visual improvement was only marginal. Aureobasidium pullulans should be looked for as a cause for keratomycosis and scleromycosis, especially in tropical countries.

265

Peritonitis by Aureobasidium pullulans in continuous ambulatory peritoneal dialysis. Ibañez Perez R, Chacón J, Fidalgo A, Martin J, Paraiso V, Muñoz-Bellido JL. Nephrol Dial Transplant. 1997 Jul;12(7):1544-5.

 

266

  Peritoneal catheter colonization and peritonitis with Aureobasidium pullulans. Caporale NE, Calegari L, Perez D, Gezuele E. Perit Dial Int. 1996 Jan-Feb;16(1):97-8

 

267

Aureobasidium pneumonia in a post liver transplant recipient: a case report. Tan HP, Wahlstrom HE, Zamora JU, Hassanein T. Hepatogastroenterology. 1997 Jul-Aug;44(16):1215-8.

Transplantation Institute Loma Linda University Medical Center California 92354, USA.
This is the first report of Aureobasidium (A.) pullulans as an opportunistic pulmonary infection in a liver transplant recipient. A 46-year-old caucasian man had an orthotopic liver transplant in 1988. His liver disease was primary sclerosing cholangitis. He required 2 subsequent liver re-transplants for primary graft non-function and acute rejection. The patient had been living in the California desert for two months prior to admission and presented with ventilator-dependent acute respiratory failure and hemodialysis-dependent acute renal failure. Imaging studies revealed severe bilateral infiltrates. His initial bronchoalveolar lavage (BAL) and brushings grew A. pullulans. Pancultures, including sputum and throat cultures, were negative for bacterial or other fungal organisms. The patient responded to pulmonary support and aggressive systemic antifungal agents while being maintained on cyclosporine and prednisone for immunosuppression. He was discharged to a skilled nursing facility 37 days after hospitalisation. Delay in discharge was primarily due to severe malnutrition and renal impairment. Opportunistic fungal infections continue to be a major problem in immunosuppressed patients including liver transplant recipients. Here we report a pulmonary infection with Coccidioides (C.) immitis and superinfection with A. pullulans. Opportunistic infections such as A. pullulans can be treated successfully with systemic fluconazole when amphotericin B is not well tolerated.

268

Basidiobolus ranarum as an etiologic agent of gastrointestinal zygomycosis. Khan ZU, Khoursheed M, Makar R, Al-Waheeb S, Al-Bader I, Al-Muzaini A, Chandy R, Mustafa AS. J Clin Microbiol. 2001 Jun;39(6):2360-3.

Basidiobolus ranarum is a known cause of subcutaneous zygomycosis. Recently, its etiologic role in gastrointestinal infections has been increasingly recognized. While the clinical presentation of the subcutaneous disease is quite characteristic and the disease is easy to diagnose, gastrointestinal basidiobolomycosis poses diagnostic difficulties; its clinical presentation is nonspecific, there are no identifiable risk factors, and all age groups are susceptible. The case of gastrointestinal basidiobolomycosis described in the present report occurred in a 41-year-old Indian male who had a history of repair of a left inguinal hernia 2 years earlier and who is native to the southern part of India, where the subcutaneous form of the disease is indigenous. Diagnosis is based on the isolation of B. ranarum from cultures of urine and demonstration of broad, sparsely septate hyphal elements in histopathologic sections of the colon, with characteristic eosinophilic infiltration and the Splendore-Hoeppli phenomenon. The titers of both immunoglobulin G (IgG) and IgM antibodies to locally produced antigen of the fungus were elevated. The patient failed to respond to 8 weeks of amphotericin B therapy, and the isolate was later found to be resistant to amphotericin B, itraconazole, fluconazole, and flucytosine but susceptible to ketoconazole and miconazole. One other noteworthy feature of the fungus was that the patient's serum showed raised levels of Th2-type cytokines (interleukins 4 and 10) and tumor necrosis factor alpha. The present report underscores the need to consider gastrointestinal basidiobolomycosis in the differential diagnosis of inflammatory bowel diseases and suggests that, perhaps, more time should be invested in developing standardized serologic reagents that can be used as part of a less invasive means of diagnosis of the disease.

269

Gastrointestinal basidiobolomycosis in Arizona: clinical and epidemiological characteristics and review of the literature. Lyon GM, Smilack JD, Komatsu KK, Pasha TM, Leighton JA, Guarner J, Colby TV, Lindsley MD, Phelan M, Warnock DW, Hajjeh RA. Clin Infect Dis. 2001 May 15;32(10):1448-55.

Gastrointestinal basidiobolomycosis (GIB) is an unusual fungal infection that is rarely reported in the medical literature. From April 1994 through May 1999, 7 cases of GIB occurred in Arizona, 4 from December 1998 through May 1999. We reviewed the clinical characteristics of the patients and conducted a case-control study to generate hypotheses about potential risk factors. All patients had histopathologic signs characteristic of basidiobolomycosis. Five patients were male (median age, 52 years; range, 37--59 years) and had a history of diabetes mellitus (in 3 patients), peptic ulcer disease (in 2), or pica (in 1). All patients underwent partial or complete surgical resection of the infected portions of their gastrointestinal tracts, and all received itraconazole postoperatively for a median of 10 months (range, 3--19 months). Potential risk factors included prior ranitidine use and longer residence in Arizona. GIB is a newly emerging infection that causes substantial morbidity and diagnostic confusion. Further studies are needed to better define its risk factors and treatment.

270

Gastrointestinal zygomycotic infection caused by Basidiobolus ranarum: case report and review. Zavasky DM, Samowitz W, Loftus T, Segal H, Carroll K. Clin Infect Dis. 1999 Jun;28(6):1244-8.

Basidiobolus species are filamentous fungi belonging to the order Entomophthorales. Unlike other zygomycetes, Basidiobolus species have been mainly associated with a tropical form of subcutaneous zygomycosis in otherwise healthy individuals. Visceral disease caused by this pathogen is rare, but cases of gastrointestinal infection with Basidiobolus ranarum have been reported worldwide. In many of these reports, the inflammatory disease of the colon has been confused with Crohn's disease. We report the third case of B. ranarum gastrointestinal infection in the United States, which was initially treated as inflammatory bowel disease.

271

Entomophthoromycosis due to Basidiobolus haptosporus. Sood S, Sethi S, Banerjee U. Mycoses. 1997 Dec;40(9-10):345-6.

This paper reports a case of entomophthoromycosis in a 40-year-old man who presented with an ulcerative wound and serosanguineous discharge after surgical removal of a fibrocystic mass. The serosanguineous discharge yielded Basidiobolus haptosporus, perhaps the first culture-proven case from a surgical wound.

272

First human culture-proven Australian case of entomophthoromycosis caused by Basidiobolus ranarum. Davis SR, Ellis DH, Goldwater P, Dimitriou S, Byard R. J Med Vet Mycol. 1994;32(3):225-30.

The first human case of entomophthoromycosis caused by Basidiobolus ranarum in Australia is described. Upon first presentation this rare disease was not recognized, but microscopy of biopsy sections and identification of the fungal isolate allowed this condition to be identified. Treatment with fluconazole was successful.

273

A review of zygomycosis due to Basidiobolus ranarum. Gugnani HC. Eur J Epidemiol. 1999 Nov;15(10):923-9.

Zygomycosis due to Basidiobolus ranarum (entomophthoromycosis basidiobolae, subcutaneous zygomycosis, subcutaneous phycomycosis, basidiobolomycosis) is a granulomatous infection of the skin and subcutaneous tissues characterized by the formation of fluctuant firm and non-tender swellings, generally on the extremities, trunk and rarely other parts of the body. The causative agent is common in soil, decaying vegetable matter, and the gastrointestinal tracts of amphibians, reptiles, fish and bats. It is presumed that infection is acquired through exposure to B. ranarum following minor trauma to skin or insect bites. The disease usually occurs in children, less often in adolescents and rarely in adults. Males are much more frequently affected than females. Laboratory diagnosis is based on histopathology and culture. The typical histopathological feature is the presence of thin-walled, broad often aseptate hyphae or hyphal fragments with an eosinophilic sheath, frequently phagocytized within giant cells. Basidiobolus ranarum is known to produce several enzymes, e.g. lipase and protease that probably play roles in the pathogenesis of infections caused by this mould. An immunological test has been developed for specific diagnosis of the disease. Though potassium iodide (KI) has been the traditional drug employed in the treatment of infections by B. ranarum, several other drugs, viz amphotericin B, cotrimoxazole, ketoconazole, itraconazole and fluconazole have been successfully tried.

277

Mycotic keratitis due to Beauveria alba. McDonnell PJ, Werblin TP, Sigler L, Green WR. Cornea. 1984-85;3(3):213-6.

A 70-year-old white man developed mycotic keratitis following phacoemulsification and intraocular lens implantation. Extensive therapeutic surgery was necessary to control the infection. Beauveria alba, a saprophytic fungus, was cultured and demonstrated in the corneal button by histopathologic examination.

278

Medical management of Beauveria bassiana keratitis. Kisla TA, Cu-Unjieng A, Sigler L, Sugar J. Cornea. 2000 May;19(3):405-6.

PURPOSE: To describe a case of Beauveria bassiana keratitis and to discuss the management of this rare condition. METHODS: An 82-year-old woman underwent surgical repair of a graft wound dehiscence. Seven months later, shortly after the removal of sutures, the patient developed a fungal keratitis. B. bassiana was identified as the infecting organism. The patient was treated with topical natamycin and oral fluconazole. RESULTS: Following antifungal therapy, the corneal ulcer was eradicated, but the patient underwent repeat penetrating keratoplasty for decreased vision due to corneal edema. The graft remains clear and visual acuity is substantially improved. CONCLUSION: The medical management of B. bassiana keratitis has previously been unsuccessful. The use of topical natamycin combined with oral fluconazole in the management of this case is discussed.

279

Human deep tissue infection with an entomopathogenic Beauveria species. Henke MO, De Hoog GS, Gross U, Zimmermann G, Kraemer D, Weig M. J Clin Microbiol. 2002 Jul;40(7):2698-702.

Beauveria spp. are ubiquitous fungal entomopathogens that are commercially distributed as biological insecticides worldwide. In this paper we describe the clinical manifestation, diagnosis, and therapy of the first documented human deep tissue infection with an entomopathogenic Beauveria species in a patient receiving immunosuppressive therapy and describe the morphological and molecular characterization of the mold.

290

Phaeohyphomycosis caused by the fungal genera Bipolaris and Exserohilum. A report of 9 cases and review of the literature. Adam RD, Paquin ML, Petersen EA, Saubolle MA, Rinaldi MG, Corcoran JG, Galgiani JN, Sobonya RE. Medicine (Baltimore). 1986 Jul;65(4):203-17.

We have reported 7 new cases of Bipolaris infection and 2 of Exserohilum infection, which demonstrate the capability of these 2 genera to cause invasive as well as "allergic" disease. As noted previously, it is likely that all of the cases of "Helminthosporium" and Drechslera infections reported in the literature were caused by Bipolaris or Exserohilum. Infections due to these 2 genera are probably more common than previously recognized. They should be included in the differential diagnosis of central nervous system and disseminated fungal disease, sinusitis, keratitis, peritonitis associated with continuous ambulatory peritoneal dialysis, and allergic bronchopulmonary disease. These various entities have distinct histopathologic characteristics. With disseminated disease in the immunocompromised patient, the most frequent findings are acute inflammation with prominent vascular invasion, thrombosis, and infarction. In contrast, granulomatous inflammation and leukocytoclastic vasculitis are seen in meningoencephalitis caused by these fungi. The histologic features of allergic bronchopulmonary disease and sinusitis are similar. A chronic inflammatory infiltrate of lymphocytes, plasma cells and eosinophils within edematous granulation tissue is found in addition to squamous metaplasia and thickening of the basement membrane. Infections caused by Bipolaris/Exserohilum and Aspergillus show many clinical and pathologic similarities despite the lack of taxonomic relationship between these fungi. Both cause disseminated disease in immunocompromised patients that is characterized by tissue necrosis and vascular invasion. Both cause central nervous system disease, osteomyelitis, and sinusitis and are associated with allergic bronchopulmonary disease. Sinusitis, the most common form of disease caused by Bipolaris and Exserohilum, occurs in otherwise healthy patients with nasal polyposis and allergic rhinitis. Although pathologic evidence of bone invasion may not be found, there frequently is radiographic evidence of invasive disease. Most patients who are treated initially with surgical debridement and amphotericin B have apparently been cured. However, longer follow-up will be necessary in these patients. Amphotericin B appears to be the treatment of choice for invasive infections caused by Bipolaris/Exserohilum species. Ketoconazole and other imidazole derivatives may also be effective in certain of the disease entities caused by these black moulds; however, their role has yet to be defined.(ABSTRACT TRUNCATED AT 400 WORDS)

291

Phaeohyphomycosis of the nasal sinuses caused by Bipolaris species. Rao A, Forgan-Smith R, Miller S, Haswell H. Pathology. 1989 Oct;21(4):280-1.

Phaeohyphomycosis of the nasal sinuses of three patients is reported. Diagnosis is based on the laboratory findings of the biopsy tissue from the sinus lesions. All cases demonstrate a localized opportunistic infection caused by the dematiaceous fungus Bipolaris spicifera.

292

Nasal phaeohyphomycosis caused by Bipolaris hawaiiensis. Koshi G, Anandi V, Kurien M, Kirubakaran MG, Padhye AA, Ajello L. J Med Vet Mycol. 1987 Dec;25(6):397-402.

A bilateral nasal phaeohyphomycotic infection caused by Bipolaris hawaiiensis in an immunocompromised woman from India is described. Repeated direct microscopic examinations of the nasal scrapings revealed the presence of septate, branched, pigmented hyphal fragments intermingled with cells that divided internally by one transverse septum and a few cells that were chestnut brown dividing internally by septa in different planes to become muriform. Cultures of the scrapings yielded B. hawaiiensis. Local excision of the crusted lesion followed by application of 0.03% nystatin solution four times a day for 3 weeks cured the infection.

293

Cutaneous Bipolaris spicifera infection. Straka BF, Cooper PH, Body BA. Arch Dermatol. 1989 Oct;125(10):1383-6.

Bipolaris spicifera is a dematiaceous fungus that has rarely been reported to cause cutaneous infection in humans. A patient with leukemia was examined for a non-healing ulcer on her leg that developed following minor trauma. Histopathologic study revealed groups of nonpigmented, septate fungal hyphae located predominantly in the necrotic ulcer base. Cultures of a biopsy specimen yielded colonies that were gray to black with a black reverse. Microscopic examination revealed dematiaceous, straight, oblong conidia consistent with B spicifera. The ulcer was successfully treated with surgical excision, skin graft, and amphotericin B.

294

Subcutaneous phaeohyphomycosis caused by Exserohilum rostratum in an immunocompetent host. Burges GE, Walls CT, Maize JC. Arch Dermatol. 1987 Oct;123(10):1346-50.

A healthy, 55-year-old woman developed a subcutaneous abscess and systemic symptoms of nausea, dizziness, and chills following minor trauma to her leg. Histopathologic examination of a skin biopsy specimen revealed golden-brown colored mycelial elements, and culture resulted in growth of a dematiaceous fungus identified as Exserohilum rostratum. Surgical excision of the abscess and concomitant oral therapy with ketoconazole resulted in resolution of symptoms. In previously reported cases of human phaeohyphomycosis caused by Exserohilum and related Bipolaris species in both immunocompromised and immunocompetent hosts, treatment has varied from topical antimicrobial therapy to combined surgery and intravenous antifungal chemotherapy. Our experience leads us to believe that surgical débridement of an accessible focus of infection along with orally administered ketoconazole may provide adequate therapy in an immunocompetent host.

295

Fatal fungal endarteritis caused by Bipolaris spicifera following replacement of the aortic valve. Ogden PE, Hurley DL, Cain PT. Clin Infect Dis. 1992 Feb;14(2):596-8.

A 73-year-old man presented to our hospital 5 months after a porcine replacement of an aortic valve with persistent fevers, meningoencephalopathy, and progressive renal failure; evidence of systemic emboli was found subsequently. The results of an exhaustive evaluation were negative except for two of 23 blood cultures that were performed; each of these two cultures yielded one colony of Drechslera species (now known as Bipolaris) on one plate. Autopsy revealed a fungal vegetation (9.5 x 3.2 x 3.0 cm) in the ascending aorta that arose from suture material 1.0 cm distal to the aortic valve. Mycologic evaluation of the isolate revealed that it was Bipolaris spicifera.

296

Peritoneal dialysis complicated by Bipolaris hawaiiensis peritonitis: successful therapy with catheter removal and oral itraconazol without the use of amphotericin-B. Gadallah MF, White R, el-Shahawy MA, Abreo F, Oberle A, Work J. Am J Nephrol. 1995;15(4):348-52.

Fungi classified in the genera Bipolaris are an uncommon source of infection in human diseases. It is also a rare source of peritonitis in peritoneal dialysis (PD) patients. All cases of Bipolaris peritonitis reported in the United States have occurred in the southern states. This form of peritonitis appears to have a good prognosis, with cure achieved only after removal of the peritoneal dialysis catheter and antifungal therapy. Systemic or intraperitoneal amphotericin-B with or without oral ketoconazole has been used in all previously reported cases. However, the role of antifungal therapy is unclear. We report a case of Bipolaris hawaiiensis peritonitis in a 73-year-old female on continuous cyclic peritoneal dialysis (CCPD) for 10 months who presented with a nonfunctioning peritoneal catheter. The catheter had characteristic dark gray particles, each composing a fungal ball within the lumen of the catheter. Microscopic examination confirmed the organism attached to the inner wall of the catheter. The patient achieved cure without using either amphotericin-B or ketoconazole. She was treated with removal of the catheter and a 2-week course of oral itraconazole 100 mg twice daily. A new catheter was placed after 1 month and the patient continued to do well on CCPD 12 months later with no evidence of recurrent infection. We conclude that (1) itraconazole can effect cure following removal of the catheter without using amphotericin-B or ketoconazole; (2) peritoneal dialysis can be safely reinstituted after itraconazole therapy for this uncommon fungal infection, and (3) itraconazole therapy allows for out-patient treatment of B. hawaiiensis peritonitis in peritoneal dialysis patients.

297

Fungal pneumonias. Saubolle MA. Semin Respir Infect. 2000 Jun;15(2):162-77.

Hundreds of fungal species have been associated with pulmonary diseases in humans, but few are consistently found to cause pneumonia. This paper reviews the clinical presentations, geographic prevalence, and epidemiology of, as well as the most recent, yet readily available, diagnostic methods and general therapy for the more common fungal pneumonias. The chapter is divided into categories based on the fungi's physiological and growth characteristics, clinical presentations, and prevalence in the environment. Sections include the geographically restricted dimorphic fungi (e.g., Blastomyces, Coccidioides, Histoplasma, Paracoccidioides, Sporotrichum, and Penicillium mameffei), the more globally found yeasts (e.g., Cryptococcus neoformans and Candida), other hyaline moulds (e.g., Aspergillus, Zygomyces, Fusarium, and Trichosporon), as well as the dematiaceous fungi (e.g., Altenaria, Bipolaris, Curvularia, Pseudallescheria, and Xylohypha). Pneumocystis carinii is also discussed since it is now accepted as being more closely related to the fungi based on analysis of its 16S-like RNA sequences.

298

Bipolaris spicifera meningitis complicating a neurosurgerical procedure. Latham RH. Scand J Infect Dis. 2000;32(1):102-3.

Bipolaris spicifera, one of the darkly pigmented (dematiaceous) fungi commonly found in soil, is an uncommon cause of infection in humans and an unusual cause of meningitis and nosocomial infections. An 18-y-old boy who experienced meningitis with this microorganism after acoustic neuroma resection was successfully treated with amphotericin B.

299

Granulomatous encephalitis caused by Bipolaris hawaiiensis. Morton SJ, Midthun K, Merz WG. Arch Pathol Lab Med. 1986 Dec;110(12):1183-5.

We describe a case of granulomatous encephalitis caused by Bipolaris (Drechslera) hawaiiensis in an immunocompetent patient. An 18-year-old man with a seven-month history of seizures and right leg weakness was found by computed tomographic scan to have a left frontoparietal enhancing lesion. Biopsy of the lesion revealed granulomatous inflammation and numerous septate hyphae. Culture of the biopsy specimen yielded a pure culture of B hawaiiensis in four days. Susceptibility studies revealed the organism to be sensitive to amphotericin B (minimal inhibitory concentration [MIC] equals 0.25 mg/L) and miconazole lactate (MIC equals 0.064 mg/L), but resistant to flucytosine (MIC greater than 100 mg/L). No synergy was demonstrated with amphotericin B and flucytosine in vitro. The patient was successfully treated with surgery and systemic and intrathecal amphotericin B therapy, and a negative culture was obtained from a repeated brain biopsy six weeks later.

300

Orbital involvement in allergic fungal sinusitis. Klapper SR, Lee AG, Patrinely JR, Stewart M, Alford EL. Ophthalmology. 1997 Dec;104(12):2094-100.

BACKGROUND: Although allergic fungal sinusitis is a relatively common, noninvasive form of paranasal sinus mycosis, and despite frequent orbital involvement, there have been few reports of this condition in the ophthalmic literature. METHODS: Two cases of allergic fungal sinusitis having orbital symptoms are described. The current classification, typical presentation, and ideal management of fungal sinusitis are reviewed. RESULTS: Distinguishing radiologic and pathologic features were present in both patients. Aspergillus flavus was cultured in one case, and Bipolaris spicifera was cultured in the other. CONCLUSIONS: Allergic fungal sinusitis is a unique subset of sino-orbital disease with highly characteristic clinical, radiologic, and pathologic features. Unlike invasive forms of mycotic disease, allergic fungal sinusitis may be managed adequately with surgical debridement, aeration of the involved sinuses, and systemic and topical corticosteroids.

301

Endogenous endophthalmitis caused by Bipolaris hawaiiensis in a patient with acquired immunodeficiency syndrome. Pavan PR, Margo CE. Am J Ophthalmol. 1993 Nov 15;116(5):644-5.

 

302

Bipolaris-induced orbital cellulitis. Jacobson M, Galetta SL, Atlas SW, Curtis MT, Wulc AW. J Clin Neuroophthalmol. 1992 Dec;12(4):250-6.

We report a patient who rapidly developed unilateral proptosis and complete ophthalmoplegia following blunt trauma to the orbit. Computed tomography (CT) scan revealed a mass involving the sinuses and orbit with erosion of the cribriform plate. Biopsy of this suspected neoplasm revealed features consistent with allergic Aspergillus sinusitis, but cultures later grew a Bipolaris species. Our review of the literature suggests that when allergic fungal sinusitis involves the orbit, Bipolaris is a more commonly isolated organism than Aspergillus. Additionally, extraocular motility impairment and proptosis occur more frequently than visual loss. Treatment is controversial, but surgical drainage followed by corticosteroids is the most often recommended therapy.

303

Bipolaris hawaiiensis-caused phaeohyphomycotic orbitopathy. A devastating fungal sinusitis in an apparently immunocompetent host. Maskin SL, Fetchick RJ, Leone CR Jr, Sharkey PK, Rinaldi MG. Ophthalmology. 1989 Feb;96(2):175-9.

The authors present a case report of a devastating bilateral optic neuropathy and orbitopathy initiated by a contiguous fungal sinusitis, in an apparently immunocompetent young man. The causative organism, Bipolaris hawaiiensis, and other species classified in the genus Bipolaris, are being recognized with increased frequency as causes of several ophthalmic and systemic disorders in both immunocompromised and normal hosts. A literature review demonstrates the variety of clinical presentations with emphasis on those cases which may present to the ophthalmologist.

304

Ocular involvement in mycotic sinusitis caused by Bipolaris. Jay WM, Bradsher RW, LeMay B, Snyderman N, Angtuaco EJ. Am J Ophthalmol. 1988 Apr 15;105(4):366-70.

We examined two patients with unilateral ophthalmologic findings secondary to pansinusitis caused by Bipolaris. Both patients were healthy young men. One patient had a gradual visual loss, whereas the other showed proptosis. Surgical debridement was the primary treatment in both patients. One patient received antifungal therapy, whereas the other was cured with surgery alone.

305

Corneal ulcer caused by Bipolaris hawaiiensis. Anandi V, Suryawanshi NB, Koshi G, Padhye AA, Ajello L. J Med Vet Mycol. 1988;26(5):301-6.

Following an injury to the right eye, a corneal ulcer with hypopyon developed in a leprosy patient. Direct examination of the corneal scrapings on three occasions showed septate, branched, dematiaceous hyphal elements. When scrapings were cultured on Sabouraud's glucose and brain heart infusion agars. Bipolaris hawaiiensis was isolated repeatedly. The patient responded successfully to treatment with nystatin ointment, although the central opacity of the cornea remained and visual acuity did not improve.

306

Disseminated Bipolaris spicifera in a neonate. Moore ML, Collins GR, Hawk BJ, Russell TS. J Perinatol. 2001 Sep;21(6):399-401.

We report a premature infant with disseminated fungal infection identified as Bipolaris spicifera. The infant was born at 23 4/7 weeks' gestation, weighing 780 g. At day of life (DOL) 7 erythematous areas on the back were noticed that progressed to black, necrotic skin lesions. A shave biopsy showed invasive fungal organisms that were identified by culture as B. spicifera. The lesions progressed despite aggressive surgical debridement and antifungal therapy. On autopsy, fungal organisms found throughout the internal organs confirmed disseminated disease with B. spicifera. This organism is now more often recognized as a human pathogen; however, this is the first reported case in a neonate.

307

Disseminated bipolaris infection in an immunocompetent host: an atypical presentation. Khan JA, Hussain ST, Hasan S, McEvoy P, Sarwari A. J Pak Med Assoc. 2000 Feb;50(2):68-71.

 

308

Disseminated infection due to Bipolaris australiensis in a young immunocompetent man: case report and review. Flanagan KL, Bryceson AD. Clin Infect Dis. 1997 Aug;25(2):311-3.

We report a case of disseminated infection due to Bipolaris australiensis in a 21-year-old immunocompetent Pakistani man. He presented with fever and jaundice. Examination revealed a mass in the right lung, mediastinal lymphadenopathy, a pericardial effusion, and abdominal masses obstructing and invading the common bile duct and right ureter. Histological examination and culture of a biopsy specimen of the hilar mass yielded the fungal pathogen B. australiensis. The patient was treated successfully with amphotericin B and itraconazole.

309

Fungemia in children infected with the human immunodeficiency virus: new epidemiologic patterns, emerging pathogens, and improved outcome with antifungal therapy. Walsh TJ, Gonzalez C, Roilides E, Mueller BU, Ali N, Lewis LL, Whitcomb TO, Marshall DJ, Pizzo PA. Clin Infect Dis. 1995 Apr;20(4):900-6.

We characterized 27 episodes of fungemia in 22 children infected with the human immunodeficiency virus (HIV). Fungemia in these patients presented as a community-acquired infection in the setting of outpatient total parenteral nutrition or intravenous antibiotic therapy through a chronically indwelling central venous catheter (CVC). Fungemia developed only in patients with CVCs (P < .001). Non-albicans Candida species, Torulopsis glabrata, Rhodotorula rubra, and Bipolaris spicifera constituted 52% of all causes. Fungemia was detected early, within a median of 2.4 days after the onset of new fever, which permitted prompt administration of amphotericin B (mean dosage, 0.7 mg/[kg.day]; median duration, 19 days). CVCs were removed in 23 (85%) of the episodes. We conclude that fungemia in HIV-infected children often presents as a community-acquired infection, is frequently due to newly emerging opportunistic fungi, and can be managed, with a high level of success (95% survival with no posttherapeutic sequelae), by early diagnosis, prompt initiation of amphotericin B therapy, and removal of the CVC.

310

Disseminated bipolaris infection in an asthmatic patient: case report. Karim M, Sheikh H, Alam M, Sheikh Y. Clin Infect Dis. 1993 Aug;17(2):248-53.

We present the case of a patient with a history of asthma who developed cough and hemoptysis that were unresponsive to antituberculous therapy. Chest roentgenography demonstrated right-sided collapse with consolidation and a pleural effusion. Bronchial biopsy revealed fungal hyphae, and cultures later yielded Bipolaris spicifera. In addition, weight loss and intractable hypotension in association with hyponatremia and elevated potassium levels suggested addisonian crisis, which was confirmed by measurement of serum ACTH and cortisol levels. Computed tomography of the abdomen revealed bilateral adrenal involvement. Tissue obtained on biopsy of the adrenal glands yielded B. spicifera. The patient responded to treatment with 2 g of iv amphotericin B; the adrenal masses and pneumonia resolved, and he remained well until last seen in July 1992. However, he requires replacement therapy with prednisone and fludrocortisone. On review of the available literature, we were unable to find a previously reported case.

311

In vitro activities of approved and investigational antifungal agents against 44 clinical isolates of basidiomycetous fungi. González GM, Sutton DA, Thompson E, Tijerina R, Rinaldi MG. Antimicrob Agents Chemother. 2001 Feb;45(2):633-5.

The in vitro activity of amphotericin B, fluconazole, flucytosine, itraconazole, voriconazole, and posaconazole was evaluated against 44 clinical isolates of filamentous basidiomycetous fungi. No statistically significant differences were noted between Schizophyllum commune (n = 5), Coprinus species (n = 8), Bjerkandera adusta (n = 14), and sterile, uncharacterized basidiomycetes (n = 17).

312

Detection of antibodies and delayed dermal hypersensitivity with different lots of Blastomyces dermatitidis yeast lysate antigen: stability and specificity evaluations. Wakamoto A, Fryer BM, Fisher MA, Johnson TJ, Lundgren DK, Knickerbocker JD, Rounds SL, Scalarone GM. Mycoses. 1997 Nov;40(7-8):303-8.

Comparative evaluations were performed to assess the stability, sensitivity and specificity of eight lots of yeast lysate antigen prepared from a Blastomyces dermatitidis dog isolate (T-58). These antigens were prepared during the period from 1989 to 1995. The lysates were used in an ELISA for the detection of antibodies in serum specimens from dogs with blastomycosis and histoplasmosis. In order to evaluate the ability of the lysates to elicit delayed dermal hypersensitivity (DTH) responses, they were compared as skin-testing antigens in guinea pigs that were previously sensitized with B. dermatitidis or Histoplasma capsulatum killed whole yeast cells. All 8 of the lots of antigen detected antibody in the sera from dogs with blastomycosis (absorbance values ranged from 0.432 to 0.543; mean value of 0.508). The absorbance values ranged from 0.283 to 0.439 (mean value of 0.326) when the lysates were assayed against sera from dogs with histoplasmosis. All of the antigens were able to elicit a DTH response in B.

313

Detection of antibody responses and delayed dermal hypersensitivity with Blastomyces dermatitidis yeast and mycelial lysate antigens. Seawell BW, Wheeler JY, Yearsley K, Alexander KL, Legendre AM, Scalarone GM. Mycopathologia. 1991 Jun;114(3):137-44.

Yeast cell lysate and mycelial lysate antigens prepared from one strain (T-58) of Blastomyces dermatitidis were evaluated with respect to the detection of antibodies and delayed dermal hypersensitivity. Comparable ELISA sensitivity values were evidenced with the two antigens when assayed against serum specimens from dogs with blastomycosis, sera from non-infected dogs residing in endemic and non-endemic areas for blastomycosis and sera from rabbits that were hyperimmunized with B. dermatitidis antigens. Specificity determinations with anti-Histoplasma capsulatum rabbit sera indicated that both reagents exhibited only minimal cross-reactivity; the mycelial antigen was slightly more specific than the yeast phase reagent. Similar sensitivity and specificity results were experienced when the two antigens were used to detect delayed dermal hypersensitivity in guinea pigs previously sensitized with B. dermatitidis or H. capsulatum.

315

Cluster of pulmonary blastomycosis in a rural community: evidence for multiple high-risk environmental foci following a sustained period of diminished precipitation. Proctor ME, Klein BS, Jones JM, Davis JP. Mycopathologia. 2002;153(3):113-20.

Much of our understanding of the epidemiologic features of infection with Blastomyces dermatitidis has come from cluster and outbreak investigations which have established the association of human disease with recreational pursuits and the presence of infectious microfoci in areas of moist soil with high organic content. This report describes the clustering of eight cases of pulmonary blastomycosis without an apparent common source exposure which occurred during a 90 day period in a 96 square mile area (population 4,450) within Oconto County, Wisconsin. We conclude that multiple high-risk environmental foci may have existed following a sustained five-year period of diminished precipitation in the cluster area. A case-control study which included family and community controls concluded that multiple earth-disturbing activities engaged in by case-patients was statistically associated with illness. Lymphocyte-proliferation assays of whole blood samples detected previously unrecognized infection with B. dermatititidis among five of 32 family controls.

316

Blastomycosis in northeast Tennessee. Vasquez JE, Mehta JB, Agrawal R, Sarubbi FA. Chest. 1998 Aug;114(2):436-43.

STUDY OBJECTIVES: To study the epidemiologic and clinical features of blastomycosis in northeast Tennessee. DESIGN: Retrospective review of blastomycosis cases in the region from 1980 through 1995. SETTING: Hospitals located in the Tri-Cities region of northeast Tennessee. PATIENTS: Seventy-two patients with confirmed blastomycosis infection. INTERVENTIONS: None. RESULTS: During the 1980 to 1995 study period, we documented 72 cases of blastomycosis. The mean age was 52 years (range, 13 to 86 years), most were male (69.4%), and nine were immunocompromised. A possible environmental exposure was noted for 28 patients. Pulmonary involvement represented the most common site of infection (61 cases), but multiorgan involvement was common (17 cases). Most patients with pulmonary blastomycosis (66%) presented with a chronic illness, and radiologic findings usually revealed local consolidation or a mass-like lesion. Nine patients developed ARDS with an associated mortality rate of 89%, compared with a 10% mortality for non-ARDS pulmonary cases. Antifungal treatment regimens varied widely, with amphotericin B often used for sicker patients. An epidemiologic evaluation revealed that the mean yearly incidence rate for blastomycosis quadrupled between 1980 and 1987 (0.31 cases/ 100,000 population) and 1988 to 1995 (1.23 cases/100,000 population) (p=0.00001). Most new blastomycosis cases in the 1988 to 1995 period occurred in three counties in the region where significant new construction projects have been underway. CONCLUSION: Blastomycosis is endemic in northeast Tennessee and the number of cases is increasing, coinciding with major new construction in the region. Clinicians in the area must be alert to this condition.

317

Pulmonary blastomycosis with acute respiratory failure as predominant clinical feature. Mukkamala R, Mehta JB, Myers JW, Cole CP. South Med J. 1997 Aug;90(8):847-50.

Two previously healthy young adults came to our community hospital with rapidly progressive respiratory failure. Investigation confirmed Blastomyces as the responsible etiologic agent. Despite adequate antifungal chemotherapy and intensive supportive care, both patients died, one within 24 hours and the other after 14 days. Overwhelming infection with Blastomyces dermatitidis can cause acute respiratory failure, possibly the adult respiratory distress syndrome, even in immunocompetent hosts.

318

Delayed treatment of pulmonary blastomycosis causing vertebral osteomyelitis, paraspinal abscess, and spinal cord compression. Lagging LM, Breland CM, Kennedy DJ, Milligan TW, Sokol-Anderson ML, Westblom TU. Scand J Infect Dis. 1994;26(1):111-5.

A 36-year-old woman with gallbladder disease had an incidental finding of asymptomatic cavitary lung infection with Blastomyces dermatitidis. No treatment was given initially, and 2 months later she presented with vertebral osteomyelitis, paraspinal abscess, and spinal cord compression due to dissemination of the fungus. The patient recovered following surgical debridement and treatment with 1 g of amphotericin B, followed by itraconazole 400 mg QD for 6 months. In spite of previous reports of the self limiting nature of primary pulmonary blastomycosis in the normal host, antifungal therapy may be needed in cases that do not resolve spontaneously within a short period of time, or if transient immunosuppression may be anticipated as may occur following surgery or after acquisition of other infections.

319

Blastomycotic cranial osteomyelitis. Farr RC, Gardner G, Acker JD, Brint JM, Haglund LF, Land M, Schweitzer JB, West BC. Am J Otol. 1992 Nov;13(6):582-6.

This is the second case report of a temporal bone osteomyelitis caused by Blastomyces dermatitidis, which presented as a chronic serous otitis media. The presenting serous otitis media was refractory to conventional medical and surgical management and progressed to a temporal bone osteomyelitis prior to diagnosis. B. dermatitidis is a rare fungal pathogen that causes a systemic pyogranulomatous disease that primarily manifests itself in the skin, bones, pulmonary, and genitourinary systems. If left untreated it is associated with a high rate of mortality. The otologic presentation of this rare disease is emphasized, while the clinical and therapeutic features are reviewed.

320

Blastomycosis of the cervicofacial area: a review of the literature and case report] Cavalot AL, Cravero L, Valente G, Gribodo L. Acta Otorhinolaryngol Ital. 1992 Nov-Dec;12(6):605-10.

A literature review concerning blastomycosis has been conducted. The involvement of the head and neck area appears to be very unusual, on the basis of autoptic observations. The most common diagnostic and subsequent therapeutic mistakes are pointed out. A new case is described and its clinical appearance, symptoms, diagnostic work up and therapeutic approach are discussed. This case report is of interest for three reasons: the rarity of this disease in our country, the possibility of confusing a Blastomyces infection with a cryptococcal one [correction of criptococcosy] and finally the therapeutic response to a new drug, not yet commercialized in Italy.

321

Epidemic of pulmonary blastomycosis (Namekagon fever) in Wisconsin canoeists. Cockerill FR 3rd, Roberts GD, Rosenblatt JE, Utz JP, Utz DC. Chest. 1984 Nov;86(5):688-92.

Epidemics of pulmonary blastomycosis have rarely been reported. The following epidemic occurred in a Minnesota family and several of their acquaintances after a canoeing trip in northwestern Wisconsin. The common exposure area was most likely a campsite, located along the upper reaches of the Namekagon River. The Namekagon River Valley is a known endemic area of Namekagon fever (blastomycosis) in dogs. Approximately one month after returning home, five of the eight members of the group had positive direct microscopic examinations and cultures of Blastomyces dermatitidis from their sputa, as well as abnormalities on their chest roentgenograms. Among these five patients, four were symptomatic, with fever, cough, and pleuritic chest pain. Of the three others, one had pleuritic chest pain with a transient lung infiltrate, the second was asymptomatic with a transient lung infiltrate, and the third was asymptomatic with a normal chest roentgenogram. Results of acute serologic tests (complement fixation and immunodiffusion) were negative in all five patients evaluated. None of the patients received antifungal therapy. Follow-up five years after the epidemic revealed that all eight were in excellent health, and none had evidence of continuing pulmonary or extrapulmonary disease.

322

Marked polymorphonuclear pleocytosis due to blastomycotic meningitis: case report and review. Harley WB, Lomis M, Haas DW. Clin Infect Dis. 1994 May;18(5):816-8

Meningitis is an unusual manifestation of infection caused by Blastomyces dermatitidis. We describe a patient who presented with fulminant blastomycotic meningitis. Examination of the lumbar CSF demonstrated > 5,000 polymorphonuclear leukocytes/mm3. The diagnosis of B. dermatitidis meningitis was initially suggested by cytologic examination of CSF and confirmed by culture. Pleocytosis of this magnitude had not been previously described in association with blastomycosis, although review of the published literature revealed that neutrophilic pleocytosis is a common manifestation of blastomycotic meningitis and should suggest the diagnosis. This report broadens the clinical spectrum of blastomycotic meningitis and suggests that cytologic examination of CSF is a useful way to establish this diagnosis.

323

Cutaneous blastomycosis. Report of a case with diagnosis by fine needle aspiration cytology. Desai AP, Pandit AA, Gupte PD. Acta Cytol. 1997 Jul-Aug;41(4 Suppl):1317-9.

BACKGROUND: Blastomycosis is rare in India. Clinically, cutaneous blastomycosis may be mistaken for keratoacanthoma, squamous cell carcinoma, tuberculosis, tertiary syphilis, leprosy or pyoderma. CASE: A 19-year-old male presented with a soft, fluctuant swelling at the medial canthus of the eye. Fine needle aspiration biopsy (FNAB) showed many single, spherical structures with thick walls. They had basophilic protoplasm and six nuclei in the center. A few of them showed budding with a broad base. CONCLUSION: The cytomorphology of Blastomyces dermatitidis is characteristic, and the organism can be differentiated from other yeast forms. The disease is sensitive to antifungal imidazole derivatives and can be cured.

324

Peritoneal blastomycosis. Perez-Lasala G, Nolan RL, Chapman SW, Achord JL. Am J Gastroenterol. 1991 Mar;86(3):357-9.

Blastomycosis is a systemic fungal infection caused by Blastomyces dermatitidis. Involvement of the peritoneum is unusual, with only two previously reported cases that occurred in association with disseminated disease. A single case of histopathologically proven blastomycosis involving the peritoneum is presented, as well as a short overview of previously published cases on gastrointestinal and peritoneal blastomycosis. The case is unique in that chronic peritonitis was the only manifestation of disease. The diagnosis was made by laparoscopy.

325

Fungal splenic abscess. Johnson JD, Raff MJ. Arch Intern Med. 1984 Oct;144(10):1987-93.

Nineteen patients with fungal splenic abscesses included 16 with leukemia, one drug user, one patient with Cushing's syndrome, and one without predisposing causes. Fifteen had persistent fever; six had esophageal or mucocutaneous candidiasis. Abdominal pain occurred in seven patients, splenomegaly occurred in six, and left abdominal mass occurred in one. Three chest x-ray films showed left pleural effusions; two had elevated left hemidiaphragms, two had left-sided infiltrates, and one was normal. Sixteen of 17 technetium Tc 99m sulfur colloid scans were abnormal, as were 15 gallium citrate Ga 67 scans. Two computed tomographic studies revealed splenic defects. Candida was the cause in 15 cases, Aspergillus was the cause in three cases, and Blastomyces dermatitidis was the cause in one case. Sixteen patients underwent splenectomy, 12 receiving postoperative antifungal therapy. Fifteen survived regardless of underlying disease or hepatic microabscesses.

326

Otitis media due to blastomycosis: report of two cases. Istorico LJ, Sanders M, Jacobs RF, Gilleon S, Glasier C, Bradsher RW. Clin Infect Dis. 1992 Jan;14(1):355-8.

Blastomycosis as a causative agent in cases of otitis media has not previously been reported. Two patients recently presented with otitis media and head and neck masses due to Blastomyces dermatitidis. Initial evaluation suggested neoplastic disease, but biopsy confirmed a fungal etiology for the masses in both patients. Relapse after administration of ketoconazole was noted in one patient, who was an adult; the other patient was a child. Otitis media and masses of the head and neck are unusual features of blastomycosis. Blastomycosis should be considered in the differential diagnosis for patients with such mass lesions and for patients with otitis media.

327

Endophthalmitis due to Blastomyces dermatitidis. Case report and review of the literature. Safneck JR, Hogg GR, Napier LB. Ophthalmology. 1990 Feb;97(2):212-6.

Blastomycosis very rarely affects ocular structures other than the eyelid. It is even more unusual for involvement to occur in the absence of active widespread disease. The authors report a 71-year-old woman with unresponsive endophthalmitis of the right eye who underwent enucleation. Results of microscopic examination of the globe showed severe acute and chronic granulomatous and nongranulomatous endophthalmitis as well as numerous fungi having the histologic features of Blastomyces dermatitidis. Although constitutional symptoms (weight loss, fatigue, night sweats) were noted by the patient, multiple investigations failed to disclose any evidence of systemic disease.

328

Aetiology, antifungal susceptibility, risk factors and outcome in 201 fungaemic children: data from a 12-year prospective national study from Slovakia. Krcmery V, Laho L, Huttova M, Ondrusova A, Kralinsky K, Pevalova L, Dluholucky S, Pisarcíkova M, Hanzen J, Filka J, Sejnova D, Lisková A, Purgelová A, Szovenyová Z, Koren P. J Med Microbiol. 2002 Feb;51(2):110-6.

A total of 201 cases of fungaemia in children in a 12-year national survey from seven University Paediatric Clinics in Slovakia in 1990-2001 was assessed to determine risk factors, therapy and outcome, and to compare those cases with fungaemia in 130 adult cancer patients studied in a similar survey. Four univariate analyses were performed to assess differences in aetiology, antifungal susceptibility and outcome between fungaemia in neonates and paediatric intensive care unit (ICU) patients as well as between paediatric and adult cancer patients with fungaemia. There was a significant difference in aetiology and antifungal susceptibility between the subgroups of children with fungaemia: 83.3% of neonates versus 40.2% in children with cancer were due to Candida albicans. None of the non-albicans Candida spp. (NAC) in neonates but 23.5% of NAC isolates from children with cancer were resistant to fluconazole. C. albicans caused 144 (71.1%) episodes and NAC 48 (23.7%) episodes. Trichosporon beigelii, Blastoschizomyces (Trichosporon) capitatus, Rhodotorula rubra and Cryptococcus laurentii were found less frequently in neonates than in children with cancer (18.8%). There were not many differences in risk factors between paediatric fungaemia and adult cancer fungaemia except C. albicans aetiology, corticosteroid use in therapy, breakthrough fungaemia after ketoconazole prophylaxis and meningitis as a complication, which were observed significantly more frequently among children than in adults, both with cancer and fungaemia. Thirty-three of the paediatric fungaemias were breakthrough cases and appeared frequently in children with cancer. Fifty-one (25.1%) children died with fungaemia (attributable mortality) and 25 (12.7%) due to underlying disease with fungaemia; overall mortality was 37.8% and there was no significant difference in death rates between the subgroups of paediatric patients (neonates, children in ICUs and children with cancer).

329

Disseminated Blastoschizomyces capitatus infection in acute myeloblastic leukaemia. Report of three cases. Sanz MA, López F, Martínez ML, Sanz GF, Martínez JA, Martín G, Gobernado M. Support Care Cancer. 1996 Jul;4(4):291-3.

Three new cases of Blastoschizomyces capitatus infection occurring in neutropenic patients with acute myeloblastic leukaemia are reported. B. capitatus was isolated from blood cultures in all patients. All three patients were treated with amphotericin B, but only one was cured from the infection. Our study confirms the emergence of B. capitatus as an opportunistic agent of disseminated fungal infection in leukaemic patients.

330

Case report. Disseminated infection of Blastoschizomyces capitatus in a patient with acute myelocytic leukaemia. Buchta V, Zák P, Kohout A, Otcenásek M. Mycoses. 2001 Dec;44(11-12):505-12.

Blastoschizomyces capitatus infection in a 48-year-old man with acute myelocytic leukaemia is reported. A multiorgan involvement and fulminant course of the fungal infection resulted in the patient's death despite fluconazole prophylaxis, therapy with amphotericin B and administration of granulocyte colony-stimulating factor. Predisposing factors to the infection, clinical relevance of surveillance strains and in vitro antifungal susceptibility testing are discussed.

331

Overview of systemic fungal infections. Rolston K. Oncology (Huntingt). 2001 Nov;15(11 Suppl 9):11-4.

A steady increase in the frequency of invasive fungal infections has been observed in the past 2 decades, particularly in immunosuppressed patients. In recipients of bone marrow transplants, Candida albicans and Aspergillus fumigatus remain the primary pathogens. In many centers, however, Candida species other than C albicans now predominate, and many cases of aspergillosis are due to species other than A fumigatus. Additionally, heretofore unrecognized and/or uncommon fungal pathogens are beginning to emerge, including Blastoschizomyces capitatus, Fusarium species, Malassezia furfur, and Trichosporon beigelii. These opportunistic fungal pathogens are associated with various localized and disseminated clinical syndromes, and with substantial morbidity and mortality. These established, invasive mycoses, particularly in bone marrow transplant recipients, are the focus of this discussion.

332

Blastoschizomyces capitatus: an emerging cause of invasive fungal disease in leukemia patients. Martino P, Venditti M, Micozzi A, Morace G, Polonelli L, Mantovani MP, Petti MC, Burgio VL, Santini C, Serra P. Rev Infect Dis. 1990 Jul-Aug;12(4):570-82.

Blastoschizomyces capitatus (formerly named Trichosporon capitatum or Geotrichum capitatum) is a rare cause of invasive fungal disease in immunocompromised hosts. We retrospectively studied epidemiologic, clinical, pathologic, and microbiologic features of this infection during a 68-month period at the Division of Hematology of the University La Sapienza in Rome. Twenty patients with evidence of B. capitatus were identified: 12 were infected, four were possibly infected, and four had evidence of B. capitatus colonization but were not infected by this fungus. Pulmonary infiltrates were seen in seven infected patients; four of these patients eventually developed mycetomalike cavitations. Eight infected patients presented clinical and radiologic features of focal hepatitis compatible with hepatosplenic candidiasis. Of the 12 infected patients, two did not receive any antifungal treatment and died, five did not show any response to systemic antifungal therapy, and five received prolonged amphotericin B plus 5-fluorocytosine therapy. Of the last group, three patients achieved stable remission of their acute leukemia and were cured, and two improved but had an apparent relapse of B. capitatus infection after their acute leukemia recurred.

333

Mandibular osteomyelitis caused by Blastoschizomyces capitatus in a child with acute myelogenous leukemia.Cheung MY, Chiu NC, Chen SH, Liu HC, Ou CT, Liang DC. J Formos Med Assoc. 1999 Nov;98(11):787-9.

A 6-year-old girl with acute myelogenous leukemia (AML) developed fungal mandibular osteomyelitis during chemotherapy. Blastoschizomyces capitatus was recognized histologically by its yeast-like morphology and formation of annelloconidia, and was confirmed by culture. The fungal osteomyelitis of the mandible was treated successfully with prolonged antifungal medication, extensive surgical debridement and an oral care program, without interrupting leukemia chemotherapy. B. capitatus osteomyelitis of the mandible may occur during chemotherapy in AML patients with poor dental condition. Successful treatment can be achieved by careful management without interruption of antineoplastic chemotherapy.

334

Funguria in cancer patients: analysis of risk factors, clinical presentation and outcome in 50 patients. Oravcova E, Lacka J, Drgona L, Studena M, Sevcikova L, Spanik S, Svec J, Kukuckova E, Grey E, Silva J, Krcméry V. Infection. 1996 Jul-Aug;24(4):319-23.

Fifty cancer patients with funguria of > 10(5) CFU/ml, dysuria and leukocyturia were retrospectively analyzed for etiology, risk factors and outcome. In 72% of cases Candida albicans and in 28% non-albicans Candida spp. (Candida krusei, Candida tropicalis) and non-Candida spp. yeasts (Blastoschizomyces capitatus) were isolated. Torulopsis glabrata was not found among these patients. The most frequent risk factors were: antibiotic therapy with more than one antibiotic agent (96%), concomitant fungal infection in other localizations than the urinary tract (36%), colonization with the same species (48%), catheterization with urinary catheter or nephrostomy (46%), prophylaxis with quinolones (50%) and previous therapy with corticosteroids (72%). Structural or anatomic malformations of the urinary tract (26%), neutropenia (28%), antifungal prophylaxis with azoles (22%), and diabetes mellitus (12%) were less frequently seen. Thirty of 36 patients treated with systemic antifungals were cured and six were not.

335

Onychomycosis caused by Blastoschizomyces capitatus. D'Antonio D, Romano F, Iacone A, Violante B, Fazii P, Pontieri E, Staniscia T, Caracciolo C, Bianchini S, Sferra R, Vetuschi A, Gaudio E, Carruba G. J Clin Microbiol. 1999 Sep;37(9):2927-30.

Blastoschizomyces capitatus was cultured from the nail of a healthy patient with onychomycosis. The identity of the isolate was initially established by standard methods and ultrastructural analysis and was verified by molecular probing. Strains ATCC 200929, ATCC 62963, and ATCC 62964 served as reference strains for these analyses. To our knowledge, this is the first case of nail infection secondary to paronychia caused by this organism reported in the English literature.

336

Endocarditis caused by Blastoschizomyces capitatus and taxonomic review of the genus. Polacheck I, Salkin IF, Kitzes-Cohen R, Raz R. J Clin Microbiol. 1992 Sep;30(9):2318-22.

Blastoschizomyces capitatus Salkin, Gordon, Samsonoff et Rieder was found to be the etiologic agent of endocarditis in a patient with a prosthetic mitral valve. Cultures inoculated with peripheral blood and portions of the valve yielded B. capitatus. Examination of stained tissue sections revealed the presence of fungal filaments morphologically consistent with this organism. The salient characteristics of B. capitatus and the factors contributing to its recognition as a distinct taxon are described.

337 Isolated meningitis caused by Blastoschizomyces capitatus. Naficy AB, Murray HW. J Infect Dis. 1990 May;161(5):1041-2.

 

338

Botryomyces caespitosus as an agent of cutaneous phaeohyphomycosis. Benoldi D, Alinovi A, Polonelli L, Conti S, Gerloni M, Ajello L, Padhye AA, de Hoog GS. J Med Vet Mycol. 1991;29(1):9-13.

The second known case of a skin infection caused by Botryomyces caespitosus is reported. This case has made it possible to describe the characteristics of this fungus in vivo and to establish it as another agent of phaeohyphomycosis.

339

Actinomycosis and botryomycosis of the tonsil. Martins RH, Heshiki Z, Luchesi NR, Marques ME. Auris Nasus Larynx. 1991;18(4):377-81.

This study was carried out in 165 patients submitted to the surgery of tonsils or adenoid from 1977 to 1989 at the Botucatu Medical School Hospital. The clinical signs and histopathological findings were reviewed. All patients exhibited similar complaints with recurrent tonsillitis, sore throat, dysphasia, high temperature, and enlarged tonsils. After surgery, the tonsils was submitted to histopathological study and showed "grains" in the crypts in 6 cases. Four cases (2.4%) of Actinomyces and two (1.2%) of Botryomyces were identified. Any clinical peculiarity was identified with the presence of these "grains."

340

Dermatomycosis in plaques caused by Botryomyces caespitosus. A new causative agent] Carapeto FJ, Rubio C, Pastor JA, Grasa MP, Martín-Pascual A. Med Cutan Ibero Lat Am. 1985;13(1):71-5.

The clinical and histological features of a dermomycosis caused by a new dematiaceum fungus are described. The mycological characteristics of this fungus individualize and differentiate it from other demiataceum hyphomycetes, proposing the name of Botryomyces caespitosus for it. The submicroscopic features are commented, as well.

353

1. Onychomycosis in Joao Pessoa City, Brazil. Pontes ZB, Lima Ede O, Oliveira NM, Dos Santos JP, Ramos AL, Carvalho MF. Rev Argent Microbiol. 2002 Apr-Jun;34(2):95-9.

Onychomycosis epidemiology is a combination of various factors which include, among others, clinical presentation, etiologic agents of the infection and the patient's history background. Out of a total of 672 nail samples examined, 460 (68.4%) were microscopy positive for fungi and 306 (66.5%) of these were culture positive, including Candida (82%), dermatophytes (13.4%), Trichosporon spp (3.6%) and nondermatophyte molds (1%). Onychomycosis was more frequent in females (79.7%) than in males (20.3%). These were more common in fingernails (96.1%) than in toenails (60%) and yeasts were the most isolated etiologic agents. Among the clinical presentations, paronychia (CP) (57.2%) and onycholysis (CO) (24.8%) were the most common, caused frequently by C. albicans in 52.6% and 60.5% of the cases, respectively. T. rubrum (44.4%) and Trichosporon spp (22.2%) were the most frequent species in the case of distal lateral subungual onychomycosis (DLSO). Fusarium spp was the agent responsible for 33.3% of the cases of proximal subungual onychomycosis (PSO) and for 14.3% of white superficial onychomycosis (WSO), whereas Acremonium spp was responsible for 14.3% of the cases of WSO.

354

Incidence of Candida species isolated from human skin and nails: a survey. Jautova J, Viragova S, Ondrasovic M, Holoda E. Folia Microbiol (Praha). 2001;46(4):333-7.

Distribution of Candida species was investigated by examining 245 samples from skin lesions and nails. The isolates were identified using standard laboratory methods including germ tube test, micromorphology of colonies on rice agar, the commercial kit, saccharide assimilation and fermentation tests. Eight species of Candida were identified: C. albicans accounted for 56.4% of the isolates, C. parapsilosis 29.1, C. tropicalis 7.8, C. pulcherrima 2.9, C. guilliermondii 1.5, C. krusei and C. zeylanoides for 0.9% each, and C. robusta for 0.5%. The factors significantly associated with colonization were prolonged antibiotic therapy, parenteral nutrition, low birth body mass of infants, intubation, duration of stay in hospital, indwelling intravenous catheter, malignancies, diabetes, surgery, and obesity.

355

Candida in dermatology] Seebacher C. Mycoses. 1999;42 Suppl 1:63-7.

Regarding Candida in dermatology, two pathogenetic pathways must be taken into account: 1. on infection of the skin 2. immunological reactions with skin alterations as a result of Candida infection or colonization in the mouth and/or intestine. Case reports describe typical situations of napkin dermatitis, intertriginous candidosis, the intrauterine Candida infection of the foetus, Candida granuloma, Candida folliculitis and Candida paronychia. In the second part results of investigations of patients suffering from psoriasis, atopic dermatitis and urticaria are presented. There were no differences in the colonization with Candida albicans and in the level of Candida antibody titres between patients and a healthy control group.

356

Cutaneous congenital candidiasis: a case report. Gibney MD, Siegfried EC. Pediatr Dermatol. 1995 Dec;12(4):359-63.

St. Louis University Health Sciences Center, Division of Dermatology, Missouri, USA.

Candida albicans is a frequent pathogen of the female genital tract, especially during pregnancy. Congenital candidiasis can occur as cutaneous or disseminated infection. We report a case of congenital cutaneous candidiasis, which may occur more frequently than is indicated by the literature. This is followed by a discussion of the pathogenesis, clinical presentation, diagnosis, and treatment of this infection.

357Candida and the lactating breast: predisposing factors. Amir LH. J Hum Lact. 1991 Dec;7(4):177-81.Candida albicans infection of the nipples and breast ducts is a cause of sore nipples and "shooting" breast pain during lactation. A questionnaire which sought to identify predisposing factors was given to 51 women with candidiasis of the lactating breast, 18 women with other breastfeeding difficulties, and 29 women breastfeeding without any difficulties. Nipple damage in early lactation, mastitis, recent use of antibiotics postpartum, long-term use prior to pregnancy, and history of vaginal thrush were positively associated with candidiasis of the lactating breast. Thrush, especially oral thrush, was more common in babies of mothers in the candida group. However, some mothers with symptomatic candida infection reported none of these predisposing factors.
358[Onychomycosis. Clinico-epidemiological mycological and therapeutic aspects] Arenas R. Gac Med Mex. 1990 Mar-Apr;126(2):84-9; discussion 90-1.Onychomycosis is the most frequent cause of nail disease. Dermatophytic and Candida onychomycosis have a similar frequency (54% and 45%), while only in 1% they are caused by molds. Tinea unguium equally affects both sexes and is mainly observed in the first toenail. T. rubrum is the fungus responsible in 87% of dermatophytosis. The ungual candidosis is three times more frequent on the hands in women and is due to C. albicans in 99% of the cases. Both types of onychomycosis are observed in children. Clinical diagnosis of onychomycosis based on direct KOH examination. Treatment includes the removal of the infested keratin and use of local or systemic antimycotics, such as griseofulvin, ketoconazole and itraconazole.
359Oral candidiasis. Akpan A, Morgan R. Postgrad Med J. 2002 Aug;78(922):455-9.Oral candidiasis is a common opportunistic infection of the oral cavity caused by an overgrowth of Candida species, the commonest being Candida albicans. The incidence varies depending on age and certain predisposing factors. There are three broad groupings consisting of acute candidiasis, chronic candidiasis, and angular cheilitis. Risk factors include impaired salivary gland function, drugs, dentures, high carbohydrate diet, and extremes of life, smoking, diabetes mellitus, Cushing's syndrome, malignancies, and immunosuppressive conditions. Management involves taking a history, an examination, and appropriate antifungal treatment with a few requiring samples to be taken for laboratory analysis. In certain high risk groups antifungal prophylaxis reduces the incidence and severity of infections. The prognosis is good in the great majority of cases.
360Oral candidosis. Sherman RG, Prusinski L, Ravenel MC, Joralmon RA. Quintessence Int. 2002 Jul-Aug;33(7):521-32.Oral candidosis is the most common opportunistic fungal infection encountered in dentistry. Normally a benign inhabitant of mucous membranes, the fungal organism, Candida albicans, may present serious, even life-threatening infection in specific patient populations. As an opportunistic organism, Candida albicans is extremely responsive to any process resulting in immunosuppression. The clinical manifestations of oral candidosis are variable, occasionally complicating the clinical diagnosis and management. Treatment is often initially rendered based on a provisional clinical diagnosis and supplemented with adjunctive laboratory tests. Specific therapeutic intervention should be tailored to the individual patient, based on the current health status of the patient and the clinical presentation and severity of the infection.
361Mycotic disease of the mucous membranes of the head and neck] Mitrovic S, Milosevic D, Dankuc D, Jovic R. Med Pregl. 2000 Jan-Feb;53(1-2):85-8.INTRODUCTION: Candidiasis is usually a superficial infection of the moist areas of the body and is generally caused by Candida albicans. Visceral infections occur in diabetes, lymphomas and leukemias, malnutrition, avitaminosis and they are associated with antibiotic, corticosteroid and immunosuppressive therapy. Candida albicans was isolated from middle ear inflammation. The diagnosis is made on the basis of microscopic appearance of colonies and characteristic smell. Candidiasis is successfully treated with nystatin, imidazol derivatives (fluconazole, ketoconazole and intraconazole), amphotericin B, 5-fluorocystosine and 1% iodine solution. CASE DESCRIPTION: This is a case report of a 46-year-old patient with a persistent nasal, sinus and ear infection of unknown origin. The patient first received antibiotic and steroid therapy and trepanation of the right maxillary sinus was performed. As the patient's condition aggravated with increase of temperature and bad laboratory findings, he was hospitalized. Radiography revealed a pathological process in both maxillary sinuses and both mastoids, so mastoidectomy and left maxillary sinus trepanation were performed. Histopathological examination of the right mastoid revealed a mould infection. The immunologic status pointed to hypogammaglobulinemia IgG. The following diseases were excluded: systemic diseases, blood diseases, Reiter's syndrome, AIDS, Hepatitis B, other viral diseases, toxoplasmosis, trichinellosis, borreliosis, typhus, paratyphus and exanthematous typhus. The diagnosis of candidiasis caused by Candida crusei and Candida kefyr was made on the basis of macroscopic and microscopic findings and biochemical identification. Ketoconazole was introduced (400 mg/per day) as well as high doses of vitamins and povidone-iodine locally. After a period of remission the patient died due to myocarditis, sepsis, acute kidney failure associated with severe mucosal necrosis of the mouth, esophagus and throat. Differential diagnosis in fever of unknown origin must include the possibility of mycotic infection, whereas the therapy of mycotic diseases must include two antimycotics at the same time. DISCUSSION AND CONCLUSION: Candida albicans is often found in the oral cavity and skin as well as in intestines of 18% of healthy subjects. It is unknown why it causes clinical illness. Antibiotic therapy of bacterial infections enables candida colonization especially in immunosuppressed patients. In our patient two types were found: Candida krusei and Candida kefyr. It is of special importance to perform differential diagnosis in cases with fever of unknown origin in order to include the possibility of mycotic infections, whereas treatment of systemic fungal infections requires a team of physicians.
362Vaginal candidiasis: etiology and sensitivity profile to antifungal agents in clinical use] Saporiti AM, Gomez D, Levalle S, Galeano M, Davel G, Vivot W, Rodero L. Rev Argent Microbiol. 2001 Oct-Dec;33(4):217-22.Candida vaginitis is one of the most frequent infection of the female genital tract with a high incidence. Approximately 75% of sexually active women suffer at least one episode of Candida vaginitis and 10% of them have recurrent episodes. Pregnancy, diabetes mellitus and antibiotic treatment are the most common predisposing factors, C. albicans is the etiologic agent most frequently found. The widespread reports of fluconazole resistance in Candida species and the selection of non Candida albicans prompted the study of species distribution of vulvovaginal candidiasis and their in vitro susceptibility against current antifungal agents. A total of 314 women with vaginal infection were studied. Yeasts were isolated from 104 patients with vulvovaginal candidiasis. The following species were identified: C. albicans 87.5%, C. glabrata 8.6% and 3.9% included C. krusei, C. famata, C. tropicalis and S. cerevisiae. The minimal inhibitory concentration (MIC) was determined for nystatin, isoconazole, fluconazole and ketoconazole, using a broth microdilution method based on NCCLS procedure. Although most of the isolates were C. albicans, the high percentage of C. glabrata recovered suggests the need to identify the yeasts isolated. Fluconazole resistant C. albicans were isolated in 13.46% of the cases. Thus, further studies are required to correlate the possible role of these strains in recurrent vulvovaginal candidiasis.
12. Vulvovaginal candidiasis is a common mucosal fungal infection in women of child-bearing ages. Despite the role for cell-mediated immunity and T cells in host protection against the majority of mucosal Candida albicans infections, there is controversy as to whether immunosuppression by HIV infection enhances susceptibility to vaginal candidiasis. To date, host defense against C. albicans vaginitis has been studied in women with recurrent vaginitis, in HIV-infected women, and in animal models of experimental vaginitis. Together, data suggest that local immunity is more important than that in the systemic circulation for host defense against vaginitis. Thus, current investigations have been focused specifically on innate and acquired immune responses against C. albicans at the vaginal mucosa. This review will discuss the current knowledge of host defenses against C. albicans vaginitis, both systemically and locally, and try to shed some light on several issues surrounding the efficiency of this seemingly compartmentalized immune response.
363Candida in the ecological system of the orointestinal tract] Bernhardt H. Mycoses. 1996;39 Suppl 1:44-7.Within the microbial ecosystem of the orointestinal tract Candida spp. are common but not always detectable organisms. Therefore they belong to the transient flora. Candida spp. are found at various sites in healthy subjects in quantities between 10(2)-10(4)/ml or g. In different diseases an increased growth of Candida can occur depending on the presence of typical risk factors. In any case the yeasts only account for a minimal part of the bacterial flora. In this regard the contribution to the formation of metabolic products-in particular carbon dioxide, hydrogen and alcohols-is very small. Growth and development of Candida are dependent on nutrient and oxygen supply. In the colon under anaerobic conditions the flora competes for limited nutrients and fermentation is the dominant metabolic pathway in Candida. There is only minimal growth. Under aerobic conditions as can be demonstrated in experimental settings a marked growth with the formation of mycelium takes place. The generation time in vivo is much longer than under laboratory conditions and takes several hours. The detection of Candida in stool specimens can be interpreted in the first line only as a colonization. This is not equivalent with an infection, which, unfortunately, often is wrongly suggested in positive stool specimens.
36415. Vaginal candidiasis and the role of the digestive tract as a source of infection. Hilton AL, Warnock DW. Br J Obstet Gynaecol. 1975 Nov;82(11):922-6.Of 300 female patients seen in a Venereal Diseases clinic, 84 (28-0 per cent) were found to be harbouring Candida albicans or C. parapsilosis in the genital tract and 33 per cent of these patients had clinical signs of vulvovaginitis. Of the 84 patients, 71-4 per cent harboured yeasts in the ano-rectal tract; of the remaining 216 patients, 25-9 per cent harboured yeasts in the ano-rectal tract. There was no evidence to suggest that the incidence of yeasts in the mouth, ano-rectal or genital tracts changed with age or use of oral contraception.
36525. Candida pericarditis: clinical profile and treatment. Rabinovici R, Szewczyk D, Ovadia P, Greenspan JR, Sivalingam JJ. Ann Thorac Surg. 1997 Apr;63(4):1200-4.BACKGROUND: Candida pericarditis is a rare medical and surgical emergency which, unless treated, leads to impaired cardiac function and death. To facilitate early diagnosis, the clinical features of this condition should be identified. METHODS: Twenty-five cases of Candida pericarditis reported in the last 30 years along with 1 new case were reviewed with regard to demographics, precipitating factors, diagnosis, treatment, and outcome. RESULTS: The syndrome occurred in immunocompromised (73%), antibiotic-treated (62%), or postpericardiotomy (54%) patients. The clinical presentation was frequently subtle and nonspecific. Nevertheless, unexplained fever, an increasing cardiac shadow on chest roentgenogram, or the development of cardiac tamponade may be suggestive. Positive culture for Candida in pericardial fluid or histologic evidence of yeast forms in pericardial tissue establishes the diagnosis. A combination of pericardiocentesis followed by operative drainage and antifungal agents is the usual treatment. Untreated, Candida pericarditis is 100% lethal, whereas prompt diagnosis and treatment lead to cure (mean follow-up, 19 months). CONCLUSIONS: Fever and evolving cardiac tamponade in immunocompromised or postpericardiotomy patients may be suggestive of Candida pericarditis; the presence of organisms in pericardial fluid is diagnostic. Pericardiocentesis followed by operative drainage and antifungal agents appears to be the treatment that is most likely to be curative.
366Candida albicans purulent pericarditis treated successfully without surgical drainage. Karp R, Meldahl R, McCabe R. Chest. 1992 Sep;102(3):953-4.Cures of Candida pericarditis reported in the literature uniformly involved surgical drainage of the pericardial space. We report a patient with purulent pericarditis caused by Candida albicans who was treated successfully with antifungal chemotherapy combined with a single pericardiocentesis that did not completely evacuate the pericardial space. This case indicates that thoracotomy with surgical drainage of the pericardium is not mandatory for successful therapy of Candida pericarditis.
367[Candida albicans meningoencephalomyeloradiculitis] Tiberghien F, De Seze J, Stojkovic T, Delmaire C, Gauvrit JY, Sendid B, Vermersch P. Rev Neurol (Paris). 2002 Apr;158(4):473-6.A 25-year-old immunocompetent male heroin addict was admitted for acute confusion associated with gait disorders of three month duration. The diagnosis was meningoencephalomyeloradiculitis secondary to Candida albicans infection. Outcome was good after a 6-month regimen with antifungal drugs. Neurological complications of Candida albicans infection are rare and prognosis is generally poor. This case report illustrates diagnostic and therapeutic difficulties encountered.
368Candida meningitis in children: report of two cases. Aldress K, Al Shaalan M, Memish Z, Alola S, Bannatyne R. J Chemother. 2000 Aug;12(4):339-44.Candida meningitis is rare in children. However reports have been increasing recently. We report two cases of meningitis caused by Candida species. The first case was a term male infant who was admitted at 14 days of age with the diagnosis of possible sepsis. He had received multiple courses of antibiotics without improvement. Later his cerebrospinal fluid (CSF) culture grew Candida tropicalis. The damage done by the infection was severe and the patient died. The second case was a 2-month old girl who was born at 34 weeks of gestation. She was admitted to the Neonatal Intensive Care Unit (NICU) and given antibiotics as prophylaxis. Despite this she developed recurrent episodes of fever that required multiple courses of antibiotics. After discharging her, she continued to have fever. Upon investigation, her blood and CSF grew Candida albicans. She was treated and responded to therapy.
369The central nervous system and infection by Candida species. Sánchez-Portocarrero J, Pérez-Cecilia E, Corral O, Romero-Vivas J, Picazo JJ. Diagn Microbiol Infect Dis. 2000 Jul;37(3):169-79.In this paper we have reviewed the main clinico-pathologic disease groups of neurocandidiasis: the microabscesses, the macroabscesses, and the meningitis. Special attention has been paid to the predisposing conditions for the appearance of neurocandidiasis, the neuroimaging techniques, and the study of the cerebrospinal fluid, needed for diagnosis. We have also discussed the differential diagnosis with other illnesses. Treatment should be given with amphotericin-B and 5-fluorocytosine. The use of other antifungal drugs for neurocandidiasis is also discussed.
370Chronic neutrophilic meningitis caused by Candida albicans. del Pozo MM, Bermejo F, Molina JA, de la Fuente EC, Martínez-Martín P, Benito-León J. Neurologia. 1998 Aug-Sep;13(7):362-6.Meningitis caused by Candida albicans is a very infrequent entity. We present 3 intravenous drug users with chronic neutrophilic meningitis caused by Candida albicans. The clinical, microbiological and radiological features of the 3 patients are reviewed. The interval between the onset of the disease and the diagnosis was long (from 4 to 12 months). Candida albicans was cultured from cerebrospinal fluid (CSF) in the 3 patients. All of them developed hydrocephalus, meanwhile arachnoiditis was disclosed in two. The therapy with amphotericyn, 5-flucytosine and fluconazole produced clinical improvement and the sterilisation of the CSF in all the 3 cases. Clinicians should be aware of this entity because of diagnosis may be delayed in several months.
371Candida fungemia] Zanetti G, Calandra T, de Muralt B, Bille J, Glauser MP. Schweiz Med Wochenschr. 1989 Sep 9;119(36):1213-8.From 1980 to 1986, 52 patients presented with an episode of fungemia due to Candida species at the Centre Hospitalier Universitaire Vaudois (representing 2% of the patients with positive blood cultures). In 51 of the 52 patients (98%) the infection was nosocomial, occurring after a median hospital stay of 24 days (range 4-250 days). Only 36 patients (69%) presented with an underlying condition (neoplasms in 18 patients, alcoholism in 7, diabetes in 6, immunosuppressive therapy in 5). In 19 patients (37%) an episode of bacteremia occurred prior to fungemia (median time 14 days, range 1-70 days). Candida albicans was the most commonly isolated species (71%). In 50 patients (96%) the episode of fungemia was associated with a significant, although nonspecific, clinical impairment. The digestive tract (38%) and N intravascular catheter (31%) were the two most common portals of entry for the fungemia. 32 patients (62%) received specific antifungal therapy consisting of amphotericin B in 29 patients (median total dose 450 mg, administered either alone or in association) or of ketoconazole in 3 patients. The global mortality was 46% and the fungemia-related mortality was 21%. Global and fungemia-related mortalities were significantly higher in patients not treated with antifungals than in those treated with them (87% versus 30%, p less than 0.001, and 47% versus 11%, p = 0.01 respectively).
372Epidemiology, treatment and outcome of candidemia: a five-year review at three Canadian hospitals. Macphail GL, Taylor GD, Buchanan-Chell M, Ross C, Wilson S, Kureishi A. Mycoses. 2002 Jun;45(5-6):141-5.To determine treatment regimens and epidemiological patterns in the occurrence of candidemia, a review of cases occurring from 1992 to 1996 in three large Canadian hospitals, University of Alberta Hospital (UAH) and Royal Alexandra Hospital (RAH), Edmonton, and Foothills Medical Center (FMC), Calgary, was carried out. Cases were detected by reviewing microbiology laboratory records. There were 202 cases in all (UAH 104, FMC 70, RAH 28). For the five study years the candidemia rate was 4.5/10 000 discharges (UAH 7.6, FMC 4.9, and RAH 1.7; P < 0.05 for all interhospital comparisons). The rate remained stable between 1992 and 1995 but rose dramatically in 1996 to 7.6/10 000 (P < 0.01 compared to 1995) as a result of increases at UAH and RAH. Of the 208 species identified, Candida albicans accounted for 135 (65%). During hospitalization 93 (46%) patients died. Species did not influence outcome. Antifungal treatment with fluconazole alone was given to 14% of patients, and increased in frequency throughout the study. No antifungal therapy was given to 47 patients (23%). This group had a much higher mortality (68%) than those who received treatment (39% P < 0.01). Twenty of the untreated patients had already died by the time the blood culture had been reported as growing a yeast. Candidemia rates vary significantly between hospitals and increased in some but not all over the five study years. As many patients with candidemia will have died by the time laboratory diagnosis is made, presumptive antifungal therapy in high-risk patients may be necessary if outcome is to be improved.
37321. Candida dubliniensis fungemia and vascular access infection. Cimolai N, Davis J, Trombley C. J Pediatr Hematol Oncol. 2002 Mar-Apr;24(3):237-9.Candida dubliniensis is a newly recognized species of yeast, which may have been forrmerly identified as Candida albicans, that has been rarely isolated from invasive fungal infections among humans. The authors document a C. dubliniensis fungemia that occurred during the course of a vascular access infection in a 2-year-old who was undergoing active therapy for neuroblastoma. Presumptive C. albicans isolates from an 18-year period were reassessed, and it was found that C. dubliniensis is a rare cause of fungemia among pediatric patients (0.5% of all such isolates).
374Epidemiology of candidemia: 3-year results from the emerging infections and the epidemiology of Iowa organisms study. Diekema DJ, Messer SA, Brueggemann AB, Coffman SL, Doern GV, Herwaldt LA, Pfaller MA. J Clin Microbiol. 2002 Apr;40(4):1298-302.Bloodstream infections due to Candida species cause significant morbidity and mortality. Surveillance for candidemia is necessary to detect trends in species distribution and antifungal resistance. We performed prospective surveillance for candidemia at 16 hospitals in the State of Iowa from 1 July 1998 through 30 June 2001. Using U.S. Census Bureau and Iowa Hospital Association data to estimate a population denominator, we calculated the annual incidence of candidemia in Iowa to be 6.0 per 100,000 of population. Candida albicans was the most common species detected, but 43% of candidemias were due to species other than C. albicans. Overall, only 3% of Candida species were resistant to fluconazole. However, Candida glabrata was the most commonly isolated species other than C. albicans and demonstrated some resistance to azoles (fluconazole MIC at which 90% of the isolates tested are inhibited, 32 microg/ml; 10% resistant, 10% susceptible dose dependent). C. glabrata was more commonly isolated from older patients (P = 0.02) and caused over 25% of candidemias among persons 65 years of age or older. The investigational triazoles posaconazole, ravuconazole, and voriconazole had excellent in vitro activity overall against Candida species. C. albicans is the most important cause of candidemia and remains highly susceptible to available antifungal agents. However, C. glabrata has emerged as an important and potentially antifungal resistant cause of candidemia, particularly among the elderly.
375 Etiologic agents of fungemia in hospitalized patients] Swoboda-Kopeć E, Rokosz A, Sawicka-Grzelak A, Wróblewska M, Krawczyk E, Stelmach E, Łuczak M. Med Dosw Mikrobiol. 2001;53(3):291-5. 
376[Nosocomial fungemias in a general hospital. Epidemiology and prognostic factors. Prospective study 1993-1998] Gómez J, Baños V, Simarro E, Ruiz J, Requena L, Pérez J, Canteras M, Valdés M. Enferm Infecc Microbiol Clin. 2001 Aug-Sep;19(7):304-7.BACKGROUND: Nosocomial fungemias are infections with a high mortality rate. In last years the incidence of these infections has increased probably because of the growing population of immunocompromised patients who undergo aggressive diagnostic and therapeutic techniques. OBJECTIVE: To know the epidemiologic characteristics, risk factors, clinical features and prognosis of fungemia. PATIENTS AND METHODS: We prospectively evaluated all the patients with proven fungemia in our center during a 5 year-period. After finishing antifungal treatment a minimum follow-up of 1 month was carried out. Fungal isolation and identification were performed by standard tests. RESULTS: During the period of study we evaluated 81 patients with an episode of nosocomial fungemia. Global incidence was 0,9 episodes per thousand admitted patients. Candida albicans was the more frequently isolated species (n=53), followed by C. parapsilosis (n=11), C. tropicalis (n=6) and C. glabrata (n=5). Most of the patients had a central intravenous line and were on parenteral nutrition therapy. All of them previously received at least one course of broad-spectrum antibiotics. Overall mortality was 49,6%. A worst prognosis was significantly associated with: age over 65 years, surgical procedures during present admission, leucocytosis, shock, and delay in antifungal treatment. CONCLUSIONS: Fungal bloodstream infection incidence is high in our environment. It is associated with a high mortality rate, specially in patients in whom the beginning of antifungal treatment was delayed. A higher clinical suspicion index may improve the poor outcome in these patients.
3773. Onychomycosis in João Pessoa City, Brazil. Pontes ZB, Lima Ede O, Oliveira NM, Dos Santos JP, Ramos AL, Carvalho MF. Rev Argent Microbiol. 2002 Apr-Jun;34(2):95-9.Onychomycosis epidemiology is a combination of various factors which include, among others, clinical presentation, etiologic agents of the infection and the patient's history background. Out of a total of 672 nail samples examined, 460 (68.4%) were microscopy positive for fungi and 306 (66.5%) of these were culture positive, including Candida (82%), dermatophytes (13.4%), Trichosporon spp (3.6%) and nondermatophyte molds (1%). Onychomycosis was more frequent in females (79.7%) than in males (20.3%). These were more common in fingernails (96.1%) than in toenails (60%) and yeasts were the most isolated etiologic agents. Among the clinical presentations, paronychia (CP) (57.2%) and onycholysis (CO) (24.8%) were the most common, caused frequently by C. albicans in 52.6% and 60.5% of the cases, respectively. T. rubrum (44.4%) and Trichosporon spp (22.2%) were the most frequent species in the case of distal lateral subungual onychomycosis (DLSO). Fusarium spp was the agent responsible for 33.3% of the cases of proximal subungual onychomycosis (PSO) and for 14.3% of white superficial onychomycosis (WSO), whereas Acremonium spp was responsible for 14.3% of the cases of WSO.
378[Onychomycoses caused by non-dermatophytic filamentous fungi in Cádiz] García-Martos P, Domínguez I, Marín P, Linares M, Mira J, Calap J. Enferm Infecc Microbiol Clin. 2000 Aug-Sep;18(7):319-24.BACKGROUND: The incidence and clinical significance of other than dermatophytes fungi or moulds causing onychomycosis is unknown, because they may be colonising organisms rather than pathogen. This report presents the results of a study conducted between 1997 and 1999 to determine the incidence and aetiology of onychomycosis by non-dermatophytic filamentous fungi in the population of Cádiz (Spain). PATIENTS AND METHODS: Diagnosis of onychomycosis was performed by direct microscopic examination, culture and, some times, by histologic examination, on samples from 610 patients with clinical suspected fungal nail infections. RESULTS: Among 196 (32%) cases of ungual mycosis detected, 29 (15%) of them were caused by non-dermatophytic filamentous fungi, presenting positive direct microscopy and repeated cultures. Superficial and distal onychomycosis were the most frequent clinical types. Twenty two patients had onychomycosis of toenails. The highest incidence was found in women and subjects over the age 40. Scopulariopsis spp. (n = 11), Aspergillus spp. (n = 6), Alternaria spp. (n = 5) and Fusarium spp. (n = 4) were the most common fungi. Occasionally, Acremonium spp. and Scedosporium spp. were isolated. CONCLUSION: The incidence of onychomycosis caused by opportunistic fungi is not well known. For their diagnosis, it is important to select correctly the appropriate site for specimen collection, as well as direct microscopy and fungal cultures. The incidence of onychomycosis is high in Cádiz (Spain), being higher in women and older people. Predispondent factors are not always identified in the patients. Toenails were infected more than fingernails in both sexes. The results of our study suggest that Scopulariopsis spp. is an important agent of onychomycosis. Epidemiological investigations should be performed in every country in order to determine the fungal species responsible of onychomycosis.
379

Onychomycosis caused by nondermatophytic molds: clinical features and response to treatment of 59 cases. Tosti A, Piraccini BM, Lorenzi S. J Am Acad Dermatol. 2000 Feb;42(2 Pt 1):217-24.

BACKGROUND: Nail invasion by nondermatophytic molds (NDM) is considered uncommon with prevalence rates ranging from 1.45% to 17. 6%. OBJECTIVE: We report the clinical features and response to treatment of onychomycosis caused by these molds. METHODS: From 1995 through 1998 we performed a mycologic study on 1548 patients affected by nail disorders, and we diagnosed 431 cases of onychomycosis including 59 cases of onychomycosis caused by molds. These include 17 patients with onychomycosis caused by Scopulariopsis brevicaulis, 26 patients with onychomycosis caused by Fusarium sp, 9 patients with onychomycosis caused by Acremonium sp, and 7 patients with onychomycosis caused by Aspergillus sp. RESULTS: Onychomycosis caused by S brevicaulis, Fusarium sp, and Aspergillus sp may often be suspected by clinical examination. In fact 38 of 50 patients with onychomycosis resulting from these molds were affected by proximal subungual onychomycosis associated with inflammation of the proximal nailfold. In our experience mold onychomycosis is not significantly associated with systemic diseases or immunodepression. NDM are difficult to eradicate; by using and combining different treatments (systemic itraconazole, systemic terbinafine, topical terbinafine after nail plate avulsion, and ciclopirox nail lacquer) we were able to cure only 69.2% of patients with S brevicaulis onychomycosis, 71.4% of patients with Acremonium onychomycosis, and 40% of patients with Fusarium onychomycosis. Aspergillus onychomycosis, on the other hand, responded very well to therapy and all our patients were cured after systemic or topical treatment. Eradication of the mold produced a complete cure of the nail abnormalities in all the patients who responded to treatment. CONCLUSION: Clinical examination usually suggests diagnosis of onychomycosis resulting from NDM. Topical treatment can be more successful than systemic therapy to cure onychomycosis caused by S brevicaulis, Fusarium sp, and Acremonium sp.
380Onychomycosis in Lahore, Pakistan. Bokhari MA, Hussain I, Jahangir M, Haroon TS, Aman S, Khurshid K. Int J Dermatol. 1999 Aug;38(8):591-5.BACKGROUND: Onychomycosis, a common nail disorder, is caused by yeasts, dermatophytes, and nondermatophyte molds. These fungi give rise to diverse clinical presentations. The present study aimed to isolate the causative pathogens and to determine the various clinical patterns of onychomycosis in the population in Lahore, Pakistan. PATIENTS: In 100 clinically suspected cases, the diagnosis was confirmed by mycologic culture. Different clinical patterns were noted and correlated with causative pathogens. RESULTS: Seventy-two women (mean age, 32.6 +/- 14.8 years) and 28 men (mean age, 40.6 +/- 15.8 years) were studied. Fingernails were involved in 50%, toenails in 23%, and both fingernails and toenails in 27% of patients. The various clinical types noted were distolateral subungual onychomycosis (47%), candidal onychomycosis (36%), total dystrophic onychomycosis (12%), superficial white onychomycosis (3%), and proximal subungual onychomycosis (2%). Candida was the most common pathogen (46%), followed by dermatophytes (43%) (Trichophyton rubrum (31%), T. violaceum (5%), T. mentagrophytes (4%), T. tonsurans (2%), and Epidermophyton floccosum (1%) and nondermatophyte molds (11%) (Fusarium (4%), Scopulariopsis brevicaulis (2%), Aspergillus (2%), Acremonium (1%), Scytalidium dimidiatum (1%), and Alternaria (1%). CONCLUSIONS: Onychomycosis is more common in women of 20-40 years of age. Distolateral subungual onychomycosis and candidal onychomycosis are the most common clinical presentations, and Candida and T. rubrum are the major pathogens in Pakistan.
381Nondermatophyte causes of onychomycosis and superficial mycoses. Gupta AK, Elewski BE. Curr Top Med Mycol. 1996 Dec;7(1):87-97.Compared to dermatophytes, nondermatophytes that may cause distal and lateral subungual onychomycoses are Aspergillus species, Acremonium species, Fusarium oxysporum and Scopulariopsis brevicaulis. White superficial onychomycosis may be caused by nondermatophyte species, for example, Acremonium species, Aspergillus terreus, other Aspergillus species and Fusarium oxysporum. Nondermatophyte molds such as Scopulariopsis brevicaulis may uncommonly result in cutaneous infections. Scytalidium dimidiatum (Scytalidium anamorph of Hendersonula toruloidea) and Scytalidium hyalinum may cause interdigital tinea pedis, and less frequently "moccasin foot" or plantar tinea pedis. Nondermatophytes have generally responded poorly to griseofulvin and ketoconazole. There have been reports of some nondermatophyte fungi responding to itraconazole and terbinafine.
382Onychomycosis in Rome, Italy. Mercantini R, Marsella R, Moretto D. Mycopathologia. 1996;136(1):25-32.This report presents the results of a study conducted between 1985 and 1994 on onychomycosis observed in the city of Rome. Six thousand six hundred and eighty eight patients were examined during this period. Among them 1,762 (26.3%) were affected by fungal nail infections. Because the etiologic agents could not be isolated in 105 cases (6%), the results refer to 1,657 subjects (24.8% of the total), presenting with positive microscopic and cultural examinations. Thirty eight patients (2.3%) had onychomycosis of both their hands and feet. From an etiological point of view, 59.1% of the nail infections were caused by yeasts, 23.2% were infected with dermatophytes and 17.6% by non-dermatophytic fungi. The etiology of onychomycosis of the hands differed from that of the feet. Yeasts were primarily responsible for onychomycosis of the hands (86.2%), while dermatophytes caused tinea unguium peduum (48%). Fungal fingernail infections by Candida spp. were the most common (50.3%), followed by those of the feet by dermatophytes (20%). Candida albicans was responsible for 70.6% of the hand infections but for only 15.9% of those of the feet. Trichophyton rubrum and T mentagrophytes were the most common dermatophytes, mainly causing toenail infections (23.4% and 21%, respectively), while Aspergillus spp., Scopulariopsis brevicaulis, Acremonium spp. and Aspergillus niger were the most common non-dermatophytes observed. With regard to sex, the fungal nail infections were more widespread in women (72.1%) and in subjects of both sexes over the age of 50.
383Mycology of nail disorders. Midgley G, Moore MK, Cook JC, Phan QG. J Am Acad Dermatol. 1994 Sep;31(3 Pt 2):S68-74.Cases of onychomycosis represent up to 30% of diagnosed superficial fungal infections and are caused by three groups of fungi: dermatophytes, yeasts, and nondermatophytic molds. The majority of toenail infections are caused by dermatophytes; Trichophyton rubrum is isolated with the greatest frequency. In infections of fingernails, Candida species can be isolated as frequently as the dermatophytes. Of the molds, Scytalidium species can infect both fingernails and toenails, as well as adjacent skin, and represent 3% of the nail infections in a temperate country such as the United Kingdom but a much higher proportion in tropical countries. Other molds such as Scopulariopsis, Acremonium, and Aspergillus species can infect damaged nails. The isolation of a dermatophyte is always considered indicative of infection, but the presence of other molds, which may be aerial contaminants, must be interpreted with care.
384Infection due to the fungus Acremonium (cephalosporium). Fincher RM, Fisher JF, Lovell RD, Newman CL, Espinel-Ingroff A, Shadomy HJ. Medicine (Baltimore). 1991 Nov;70(6):398-409.Human infections due to fungi belonging to the genus Acremonium occur uncommonly, but unlike infections due to other filamentous fungi, usually affect immunocompetent individuals. Mycetoma, which usually develops following trauma, is the most common infection caused by Acremonium spp. Other sites of infection include the eye (generally following abrogation of ocular defenses), colonizing disease of the lung and gastrointestinal tract, as well as locally invasive infections such as osteomyelitis, sinusitis, arthritis, and peritonitis. Pneumonia and disseminated infections including meningitis, endocarditis, and cerebritis rarely have been reported. Optimal treatment of acremonium infections is not well defined both because infections due to these organisms are rare, and because many reports antedate effective antifungal therapy. In addition, susceptibility testing of filamentous fungi is poorly standardized, and in vitro sensitivity may not correlate with clinical response. Based on anecdotal reports, treatment of most invasive acremonium infections requires a combination of surgical intervention, when possible, and a regimen of amphotericin B. Some azoles also display inhibitory activity. Until more details are available regarding susceptibility of these organisms to antifungal agents, amphotericin B is recommended as initial therapy with the addition of either ketoconazole or fluconazole in infections of a life-threatening nature.
385Acremonium recifei as an agent of mycetoma in India. Koshi G, Padhye AA, Ajello L, Chandler FW. Am J Trop Med Hyg. 1979 Jul;28(4):692-6.Acremonium recifei was identified as the causal agent in a case of white grain eumycotic mycetoma of the hand which occurred in South India. The identification was based on the structure of the granules in tissue and on the morphological characteristics of the culture obtained from the granules. This case represents the first documented instance in which A. recifei has been found outside of Latin America.
386Rare pulmonary mycoses in patients with hematologic diseases. Breton P, Germaud P, Morin O, Audouin AF, Milpied N, Harousseau JL. Rev Pneumol Clin. 1998 Oct;54(5):253-7.Patients with hematology disease in post-chemotherapy medullary aplasia are susceptible to life-threatening bronchopulmonary mycoses, especially aspergillosis. Other less common pulmonary mycoses are also observed. We report 4 cases due to Penicillium purpurogenum, Acremonium strictum and Scedosporium apiospermum (n = 2) infections. These unusual fungi appear to be emerging as pathogens in this population. They have common ubiquitous, opportunistic and low pathogenicity characteristics in immunocompetent subjects. The major risk factor is neutropenia. Isolating one of these fungi in an immunodepressed patient modifies management protocols since certain unusual fungi such as Scedosporium are resistant to amphotericin B.
387 Acremonium strictum meningitis in prolonged steroid therapy] Medek S, Nemes A, Khoor A, Széll A, Dobolyi C, Novák EK. Orv Hetil. 1987 Nov 29;128(48):2529-32. 
388 Right-sided pacemaker-related endocarditis due to Acremonium species. Heitmann L, Cometta A, Hurni M, Aebischer N, Tschan-Schild I, Bille J. Clin Infect Dis. 1997 Jul;25(1):158-60. 
389 Endocarditis in dura mater prosthesis caused by Acremonium kiliense] Lacaz Cda S, Porto E, Carneiro JJ, Pazianni IO, Pimenta WP. Rev Inst Med Trop Sao Paulo. 1981 Nov-Dec;23(6):274-9. 
390Fatal, disseminated Acremonium strictum infection in a neutropenic host. Schell WA, Perfect JR. J Clin Microbiol. 1996 May;34(5):1333-6.Disseminated Acremonium strictum infection in a neutropenic patient is reported. Positive fecal cultures preceded positive cutaneous and blood cultures by 18 and 21 days, respectively, which suggests gastrointestinal colonization and invasion as initiating events. Microscopic examination of cutaneous biopsy and pulmonary specimens revealed hyphae, phialides, and phialoconidia in vivo. These adventitious forms also can occur in infections due to other phialidic fungi such as Fusarium and Paecilomyces species and can be misdiagnosed as Candida species. Budding cells also can occur in vivo for species of Fusarium, Paecilomyces, and apparently Acremonium, further adding to the potential for misdiagnosis. The occurrence of adventitious forms in infections caused by species of Acremonium, Fusarium, Paecilomyces, Scedosporium, and Blastoschizomyces is suggested as a mechanism for dissemination of infection and as an explanation of the relatively higher frequency of positive blood cultures in these cases.
391Alternaria: a sinonasal pathogen of immunocompromised hosts. Clin Infect Dis. 1993 Feb;16(2):265-70.Fungal infections remain a major cause of morbidity and mortality in immunocompromised patients. Although Candida and Aspergillus species are the most common fungal isolates, other less common fungal isolates such as Alternaria species are emerging as opportunistic pathogens associated with discrete clinical syndromes. We reviewed a 16-year consecutive series of bone marrow-transplant recipients and describe the presentation, treatment approach, and outcome of six cases of localized invasive sinonasal infection caused by Alternaria species in this series. At presentation, minimal or no symptoms were present, and nasal lesions of suspicious origin were often an incidental finding in evaluation of unexplained fever. Findings of sinus roentgenograms were normal for five of six patients. Infection occurred prior to white blood cell recovery in five of six cases. All infections were localized to the sinonasal region without evidence of dissemination. Treatment included systemic antifungal therapy and surgical debridement in all patients; granulocyte transfusions were performed for four patients. The infections resolved without sequelae in all but one patient who died of postoperative complications. Alternaria has a predilection for causing localized invasive sinonasal infection in immunocompromised hosts that can be successfully treated with an aggressive approach of combined modalities.
392Phaeohyphomycosis caused by Alternaria infectoria in a renal transplant recipient. Halaby T, Boots H, Vermeulen A, van der Ven A, Beguin H, van Hooff H, Jacobs J. J Clin Microbiol. 2001 May;39(5):1952-5.We report on a case of phaeohyphomycosis caused by Alternaria infectoria in a renal transplant recipient with pulmonary infiltrates and multiple skin lesions. Diagnosis was based on microscopy and culture of the skin lesions. Treatment consisted of a combination of surgical excision and systemic antifungal therapy, first with itraconazole and subsequently with liposomal amphotericin B, for 39 days. At a 20-month follow-up visit, no recurrence of the skin lesions or the pulmonary infiltrates had occurred.
393Cutaneous Alternaria alternata infection successfully treated with itraconazole. Del Palacio A, Gómez-Hernando C, Revenga F, Carabias E, González A, Cuétara MS, Johnson EM. Clin Exp Dermatol. 1996 May;21(3):241-3.A case of cutaneous alternariosis due to Alternaria alternata in a 47-year-old man who had the CREST (calcinosis, Raynaud's phenomenon, oesophageal dysfunction, sclerodactyly and telangiectasia) syndrome with pulmonary hypertension is presented. The patient, who lived in a rural area and was receiving prostacycline by continuous infusion, prednisone and azathioprine for his underlying disease, showed cutaneous lesions of the lower extremities spreading from the knees to the ankles. The patient was successfully treated with high doses of oral itraconazole.
394Cutaneous alternariosis in a patient with idiopathic pulmonary fibrosis. Ioannidou DJ, Stefanidou MP, Maraki SG, Panayiotides JG, Tosca AD. Int J Dermatol. 2000 Apr;39(4):293-5.A 78-year-old farmer presented with symptomless skin lesions for evaluation. Two years prior, he had developed idiopathic pulmonary fibrosis (IPF) and had been treated thereafter with oral prednisolone 20 mg/day and occasionally with colchicine 1 mg/day. On examination, erythematoviolaceous, slightly infiltrated plaques, measuring approximately 5 x 9 cm, rubbery in consistency, intermingled with pustules, sometimes eroded, with distinctive borders, were noted on the dorsum of both hands and on the extensor surface of both forearms. The lesions had developed over a 20-day period. The skin of these areas was atrophic or eroded with multiple ecchymoses (Fig. 1). The abnormal laboratory findings included an elevated white blood cell count of 17,100/mm3, with 79% neutrophils, 16% lymphocytes, and 5% monocytes, C-reactive protein of 33.15 mg/dL (normal, <0.8 mg/dL), and immunoglobulin G of 598 mg/dL (normal, 701-1545 mg/dL). Other blood and urine tests performed were within normal limits. The diagnosis of IPF was reconfirmed through radiology, high-resolution computed tomography, and spirometry, as well as bronchoscopy and bronchoalveolar lavage fluid analysis. Coexistence of presumptive pulmonary alternariosis was excluded. Hematoxylin and eosin stained sections of the excised cutaneous specimen showed focal ulceration of the epidermis adjacent to a mainly intradermal abscess cavity. Within the latter, remnants of a partly destroyed hair follicle were seen amongst degenerating polymorphonuclear leukocytes, as well as many histiocytes and a few Langhans-type multinucleated giant cells. Minute collections of polymorphonuclear leukocytes were seen in the adjacent epidermis. Periodic acid-Schiff (PAS) and Gomori's silver methenamine stains showed a multitude of broad branching fungal hyphae and large spores within the aforementioned cavity, both free and within the cytoplasm of giant cells (Fig. 2). Immunohistochemistry was performed by means of the alkaline phosphatase anti-alkaline phosphatase (APAAP) method. Sections showed that the infiltrate consisted of an almost equal number of B and T lymphocytes, whereas histiocytes and the few giant cells were labeled with anti-CD68 antibodies. Skin smears and biopsy specimens taken twice from all lesions were used for mycologic examination. Wet mounts revealed numerous, brownish, septate hyphae and ovoid Skin smears and biopsy specimens taken twice from all lesions were used for mycologic examination. Wet mounts revealed numerous, brownish, septate hyphae and ovoid structures. Biopsy material was plated on Sabourand's dextrose agar with cloramphenicol (0.05 mg/mL). After 7 days at 27 degrees C, dark, gray-white colonies with a dark brown underside appeared. Microscopic examination of the colonies revealed hyphae with typical conidia having transverse and longitudinal septa. Based on macroscopic and microscopic examination, the isolates were identified as Alternaria alternata (Fig. 3). Treatment with prednisolone was reduced to 10 mg/day and the patient received oral itraconazole (200 mg/day). This resulted in progressive improvement of alternariosis, and the lesions healed completely within 3 months, when treatment was interrupted. Two years later, there is no evidence of recurrence.
395Keratitis due to Cephaliophora irregularis Thaxter. Mathews MS, Kuriakose T. J Med Vet Mycol. 1995 Sep-Oct;33(5):359-60.The second case of mycotic keratitis due to Cephaliophora irregularis is reported in a 55-year-old female from India. Clinically this fungus was resistant to treatment with oral ketoconazole but responded to topical natamycin.
397An endemic area of sporotrichosis in Guatemala] Mayorga R, Caceres A, Toriello C, Gutierrez G, Alvarez O, Ramirez ME, Mariat F. Sabouraudia. 1978 Sep;16(3):185-98.An endemic area of sporotrichosis is described in the Lake of Ayarza District, South Guatemala, where 53 patients have been observed within 3 years. In 45.3% of the cases, the infection appeared after handling fish. The disease was more frequently observed in man (83%) and in patients less than 30 years of age. The most frequent clinical type was the ascending lymphocutaneous sporotrichosis of the limbs. Some cases of ulcerative or verrucous lesions were seen. Almost all the patients cured rapidly either by potassium iodide (46 patients) or spontaneously, or after application of local heat (4 patients). Intradermal tests were performed in healthy population in the endemic area and, for comparison, in Guatemala City. Whole yeast cell antigens of Sporothrix schenckii and Ceratocystis stenoceras were used in these tests. Skin tests to both antigens were more frequently positive in the endemic area; the highest frequency was obtained with the antigen of C. stenoceras. A serological study was performed in 26 patients. The fluorescent antibody staining technique was more sensitive than yeast cell and latex particles agglutinations. C. stenoceras was isolated from bark of some trees, especially Eucalyptus, in the environment, but not S. schenckii.
422 Case report. Onychomycosis due to Chaetomium globosum successfully treated with itraconazole. Hattori N, Adachi M, Kaneko T, Shimozuma M, Ichinohe M, Iozumi K. Mycoses. 2000;43(1-2):89-92.We have experienced a case of toenail infection caused by Chaetomium globosum which we treated with itraconazole 100 mg day-1 for 6 months, after which time the nail lesions were almost cured. Our case is the first reported case of onychomycosis caused by Ch. globosum in Japan, and the seventh in the world.
423Onychomycosis caused by Chaetomium globosum Kunze. Naidu J, Singh SM, Pouranik M. Mycopathologia. 1991 Jan;113(1):31-4.In this paper we report a case of onychomycosis caused by Chaetomium globosum. The patient had lesions of the fingernails of the left hand. The direct microscopical examination of the nails showed light-brown hyphae with thick-walled cells. The histopathological examination revealed thick aggregated hyphal element in the nail plate. Amongst the antimycotics tested oxiconazole with MIC values of 0.3 microgram/ml-1 was found to be most effective in vitro against Chaetomium globosum.
424Cutaneous and ungual phaeohyphomycosis caused by species of Chaetomium Kunze (1817) ex Fresenius, 1829. Costa AR, Porto E, Lacaz Cda S, de Melo NT, Calux Mde J, Valente NY. J Med Vet Mycol. 1988;26(5):261-8.Two cases of cutaneous and ungual phaeohyphomycosis caused by species of Chaetomium are reported. The patients showed no clinical signs of immunodeficiency. In Case 1 there was a small, ulcerated, crusted lesion on the right forearm. Direct microscopical examination of material from this lesion showed light-brown hyphae with thick-walled cells. The fungus isolated was identified as Chaetomium globosum. Case 2 had lesions of the fingernails. Direct microscopy showed dematiaceous septate hyphae in the nail. The isolate from the nails was identified as Chaetomium perpulchrum. Identification of the fungi was based on the classification of Ames (1963) as adapted by Cooke (1986). Such infections due to Chaetomium species are rare.
425Central nervous system aspergillosis: a 20-year retrospective series. Kleinschmidt-DeMasters BK. Hum Pathol. 2002 Jan;33(1):116-24.Over the past 20 years at my institution, 71 patients with invasive necrotizing aspergillosis have been encountered; 42 have shown central nervous system (CNS) involvement by autopsy (40) or surgical biopsy (2). Most non-CNS aspergillosis patients had invasive disease confined to the lung, and only 2 with dissemination to 3 or more organs did not have spread to the CNS. In addition to the expected post-transplantation and hematologic malignancy cases, other risk groups identified included those with chronic asthma and steroid use, acquired immunodeficiency syndrome, thermal burn, hepatic failure, and postoperative infection. Unusual cases manifested with basilar meningitis, myelitis, proptosis caused by sino-orbital disease, or epidural and subdural Aspergillus abscesses. The extent of gross neuropathologic disease ranged from subtle abscesses to massive hemorrhagic necrosis causing herniation and death. In addition to the expected hemorrhagic necrosis, extensive hemorrhage, focal purulent meningitis, and subtle bland infarctions were also seen. Distinctive microscopic findings encountered included 1 case with numerous meningeal granulomas and multinucleated giant cells and 4 cases showing the Splendore-Hoeppli phenomenon. During the same period, single cases of cerebritis caused by morphologically similar fungi (Pseudoallescheria boydii [Scedosporium apiospermum], Scedosporium inflatum, Chaetomium sp) were identified and were indistinguishable from CNS aspergillosis clinically and pathologically.
426Cerebral phaeohyphomycosis caused by Chaetomium globosum in a renal transplant recipient. Anandi V, John TJ, Walter A, Shastry JC, Lalitha MK, Padhye AA, Ajello L, Chandler FW. J Clin Microbiol. 1989 Oct;27(10):2226-9.A 32-year-old male patient developed headaches, vomiting, blurring of vision, and focal seizures of the left side of the face 2 months after a renal transplant. He developed a brain abscess and died. Direct KOH examination of the brain tissue demonstrated hyaline as well as dematiaceous, septate hyphae. Histologic examination of brain sections revealed polymorphous fungal elements consisting of septate, dark-pigmented hyphae, intercalary and terminal swollen fungal cells, and budding yeastlike cells characteristic of phaeohyphomycosis. Chaetomium globosum was isolated from the brain tissue on all of the fungal media used. This case represents the first histologically and culturally documented phaeohyphomycotic brain infection caused by C. globosum.
427Fatal Chaetomium cerebritis in a bone marrow transplant patient. Thomas C, Mileusnic D, Carey RB, Kampert M, Anderson D. Hum Pathol. 1999 Jul;30(7):874-9.The number of opportunistic infections in the central nervous system (CNS) has been steadily increasing because of a rising number of immunocompromised patients. A rare form of CNS infection can be caused by Chaetomium species, one of the largest genera of saprophytic ascomycetes. The CNS lesions in the present case were caused by Chaetomium atrobrunneum. The main characteristic of almost all Chaetomium species is presence of hairs or setae covering the ascomata. Microbiological studies are the only definitive way to correctly identify this fungal organism. The rapid evolvement of the cerebral infection suggests that the brain tissue provides a favorable environment for growth and proliferation of these fungi. This is the second documented case of a fatal brain abscess caused by Chaetomium atrobrunneum, and the first case report in a bone marrow transplant patient.
428Fatal cerebral mycoses caused by the ascomycete Chaetomium strumarium. Abbott SP, Sigler L, McAleer R, McGough DA, Rinaldi MG, Mizell G. J Clin Microbiol. 1995 Oct;33(10):2692-8.Three cases of fatal cerebral mycosis in males with prior histories of intravenous drug use from the United States and Australia are reported. Infection in each case was limited to brain abscess; no other sites of infection were observed. The fungus seen by histopathology and isolated from the brain tissue in each case was identified as Chaetomium strumarium. This is the first report of human infection by this species, and C. strumarium is the second species of Chaetomium known to cause primary brain infection. Chaetomium strumarium is unusual among members of the genus Chaetomium in forming ascocarps covered with pale, thin-walled, flexuous hairs, a feature leading to its original placement in the genus Achaetomium. Presence of pinkish exudate droplets and/or crystals associated with hyphae or ascocarps, sometimes accompanied by a pinkish diffusible pigment; good growth at 42 degrees C; and production of small conidia further distinguish this species. The brain abscess isolates were compared with isolates from prior cases of cerebral infection which had been identified as either Chaetomium atrobrunneum or Chaetomium globosum. With reidentification of one isolate originally identified as C. globosum to C. atrobrunneum, only C. strumarium and C. atrobrunneum have been confirmed to cause infection involving the brain.
429Chaetomium pneumonia in patient with acute myeloid leukaemia. A V; Prentice, H G; Kibbler, C C. Yeghen T, Fenelon L, Campbell CK, Warnock DW, Hoffbrand AV, Prentice HG, Kibbler CC. J Clin Pathol. 1996 Feb;49(2):184-6.A patient with relapsed refractory acute myeloid leukaemia developed typical fungal lung lesions despite intravenous amphotericin B prophylaxis. Chaetomium globosum was cultured from the resected right lower lobe. Histology showed branching hyphae negative for common Aspergillus species by immunohistochemical staining. Previous reports of invasive disease caused by Chaetomium and some applications of immunohistochemical staining for Aspergillus are discussed.
430

Femur osteomyelitis due to a mixed fungal infection in a previously healthy man. Cimerman M, Gunde-Cimerman N, Zalar P, Perkovic T.

J Clin Microbiol. 1999 May;37(5):1532-5.

We describe a previously healthy, 22-year-old man who, after a closed fracture of the femur and subsequent operation, developed chronic osteomyelitis. Within a few days, infected bone fragments, bone, and wound drainage repeatedly yielded three different filamentous fungi: Aspergillus fumigatus, Aspergillus flavus, and Chalara ellisii. Histologic examination of the bone revealed septate hyphae. After sequential necrotomies of the femur and irrigation-suction drainage with added antimycotic therapy, the infection ceased and the fracture healed. This case is unique in that it is the only known instance in which a long bone was affected in an immunocompetent individual, with no evidence of any systemic infection, by a mixed population of two different Aspergillus spp. and the rare filamentous fungus C. ellisii. Environmental factors that could potentiate the infection include blood and edema fluid resulting from the surgical procedure and the presence of the osteosynthetic plate.
431 Occupational asthma induced by Chrysonilia sitophila in the logging industry.Tarlo SM, Wai Y, Dolovich J, Summerbell R. J Allergy Clin Immunol. 1996 Jun;97(6):1409-13. 
436 Endophthalmitis following catarct extraction due to Neurospora sitophila, a so-called nonpathogenic fungus. THEODORE FH, LITTMAN ML, ALMEDA E. Amer J Ophthal 1962 Jan;53:35-9. 
437Peritonitis caused by Monilia sitophila in a patient undergoing peritoneal dialysis. Radix AE, Bieluch VM, Graeber CW. Int J Artif Organs. 1996 Apr;19(4):218-20.Fungi have become an increasingly important cause of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. The most common cause of fungal peritonitis is Candida. However, in recent years unusual and "nonpathogenic" fungi have been reported as etiologic agents of CAPD-associated peritonitis. We are reporting the first case of CAPD-associated peritonitis caused by Monilia sitophila. This organism had previously been considered to be non-pathogenic, and a troublesome laboratory contaminant. Our patient was successfully managed with intravenous and intraperitoneal amphotericin B, followed by oral itraconazole, without removal of her Tenckhoff catheter.
439Presumptive invasive Chrysosporium infection in a bone marrow transplant recipient. Warwick A, Ferrieri P, Burke B, Blazar BR. Bone Marrow Transplant. 1991 Oct;8(4):319-22.Chrysosporium species caused an invasive infection in an 18-year-old patient following allogeneic sibling bone marrow transplant for T lineage acute lymphoblastic leukemia. This infection began as a facial swelling and extended into the central nervous system. Fungal disease spread rapidly despite antifungal agents. An autopsy showed fungal involvement of brain, lungs, liver and kidneys.
440Invasive Chrysosporium infection of the nose and paranasal sinuses in an immunocompromised host. Levy FE, Larson JT, George E, Maisel RH. Otolaryngol Head Neck Surg. 1991 Mar;104(3):384-8.Aggressive fungal rhinosinusitis with Chrysosporium sp. occurred in a patient with acute lymphocytic leukemia. The infecting organism is an exceedingly rare human pathogen. Usually, human chrysosporial infections are mild and unmarked by symptoms. Most case reports appear in the pathology literature and describe the incidental finding of adiaspores in the pulmonary parenchyma at autopsy. Clinical disease from active growth of chrysosporial mycelia in human tissues has been noted on a porcine aortic valve prosthesis and in a tibial abscess. Hyphal elements were not recovered from any other body parts of these patients. Histopathologic and microbiologic studies permitted the identification of this rarely encountered organism. Our patient experienced systemic spread of Chrysosporium organisms. Treatment of this pathogen is the same as for other opportunistic fungal infections.
441Disseminated infection due to Chrysosporium zonatum in a patient with chronic granulomatous disease and review of non-Aspergillus fungal infections in patients with this disease. Roilides E, Sigler L, Bibashi E, Katsifa H, Flaris N, Panteliadis C. J Clin Microbiol. 1999 Jan;37(1):18-25.We report the first case of Chrysosporium zonatum infection in a 15-year-old male with chronic granulomatous disease who developed a lobar pneumonia and tibia osteomyelitis while on prophylaxis with gamma interferon. The fungus was isolated from sputum and affected bone, and hyphae were observed in the bone by histopathology. Therapy with amphotericin B eradicated the osteomyelitis and pneumonia, but pneumonia recurred in association with pericarditis and pleuritis during therapy with itraconazole. These manifestations subsided, and no recurrences occurred with liposomal amphotericin B therapy. Infections caused by Chrysosporium species are very rare, and C. zonatum has not previously been reported to cause mycosis in humans. This species, the anamorph of the heterothallic ascomycete Uncinocarpus orissi (family Onygenaceae), is distinguished by its thermotolerance, by colonies which darken from yellowish white to buff, and by club-shaped terminal aleurioconidia borne at the ends of short, typically curved stalks. The case isolate produced fertile ascomata in mating tests with representative isolates. The median (range) MICs for our isolate as well as those for two other human isolates and a nonhuman isolate determined by the National Committee for Clinical Laboratory Standards method adapted for moulds were </=0.06 microg/ml (</=0.06 to 0.25 microg/ml) for amphotericin B, 0. 687 microg/ml (0.25 to 2 microg/ml) for itraconazole, >128 microg/ml (>128 microg/ml) for flucytosine, and 48 microg/ml (32 to >128 microg/ml) for fluconazole.
442Chrysosporium, a new causative agent in osteomyelitis. A case report. Stillwell WT, Rubin BD, Axelrod JL. Clin Orthop. 1984 Apr;(184):190-2.A 24-year-old black man presented with a two-month history of swelling of the right ankle. Roentgenograms were initially read as negative. One month later the patient returned with increased pain and swelling, and roentgenograms demonstrated a large lucency involving the distal tibia. Bone scanning revealed extension of the lesion proximally, to 6 cm below the knee. Biopsy of a large tibial abscess demonstrated histocytic giant cells with budding yeasts and septate mycelia. Chrysosporium was isolated from cultures. Amphotericin B was used to treat the patient. Clinically, the infection healed within four months in a short-leg cast. Although Chrysosporium is usually a contaminant, its presence in cultures and histologic sections is evidence of pathogenicity.
443 Endocarditis due to Chrysosporium species: a disease of medical progress? Toshnirval R, Goodman S, Ally SA, Ray V, Bodino C, Kallick CA. J Infect Dis. 1986 Mar;153(3):638-40. 
444Hair perforation by keratinophilic fungi. Bahuguna S, Kushwaha RK. Mycoses. 1989 Jul;32(7):340-3.The in vitro hair perforation test as described by Ajello and George, was applied to eight species of Chrysosporium and one species each of Microsporum and Trichophyton. Six of them were found to perforate hair while four were negative. Chr. keratinophilum, M. gypseum and Tr. vanbreuseghemii were able to perforate and degrade hair rapidly. The micromorphological changes were also described.
446Disseminated Cladophialophora bantiana infection in a heart transplant recipient. Keyser A, Schmid FX, Linde HJ, Merk J, Birnbaum DE. J Heart Lung Transplant. 2002 Apr;21(4):503-5.Cerebral phaeohyphomycosis caused by Cladophialophora bantiana, a dematiaceous fungus, is a rare disease. The majority of cases have been reported among immunocompetent patients; only 4 cases have been published that describe transplantation patients. The overall prognosis is poor. Surgical therapy in combination with chemotherapy with itraconazole is recommended. We report the case of a heart transplant recipient with cutaneous, cerebral, and lung manifestation of Cladophialophora bantiana who died despite surgical and systemic, high-dosage itraconazole treatment.

447

Systemic mycosis caused by a new Cladophialophora species. Tintelnot K, von Hunnius P, de Hoog GS, Polak-Wyss A, Guého E, Masclaux F. J Med Vet Mycol. 1995 Sep-Oct;33(5):349-54.

A 22-year-old woman suffered from haemoptyses of unknown aetiology. A tumour in the lingula was diagnosed histologically to be a granulomatosis, most likely a sarcoidosis. Two years later, the patient returned with dyspnoea caused by a granulomatous tumour in the trachea, histologically similar to that seen earlier. After bronchoscopic laser resection, cortisone therapy was applied but without success. A fungus was subsequently discovered histologically and was cultivated from biopsy specimens. Retrospective research of primary histological slides led to the conclusion that a mycosis was the initial cause of the tumours. The mycosis was successfully treated with high-dose itraconazole for 1 year, combined with 5-fluorocytosine (5-FC) during the first few months. The causative agent was found to be a new species of Cladophialophora, and is described as C. arxii Tintelnot; its key characteristics are presented.

448

Cerebral phaeohyphomycosis due to a novel species: report of a case and review of the literature. Osiyemi OO, Dowdy LM, Mallon SM, Cleary T. Transplantation. 2001 May 15;71(9):1343-6.

Cerebral phaeohyphomycosis is a rare disease caused by dematiaceous (darkly pigmented) fungi. Cladophialophora species are highly neurotropic, and Cladophialophora bantiana (synonym=Xylohypha bantiana or C. trichoides) is the most commonly identified agent. Most reported cases of cerebral phaeohyphomycosis have occurred in immunocompetent patients; however, some case reports and experimental data have suggested that cellular immune deficiency is a risk factor. We report a case of pulmonary and cerebral phaeohyphomycosis in a cardiac transplant patient due to a newly identified species of Cladophialophora. Optimal management includes both antifungal therapy and surgery.

449

Cerebral phaeohyphomycosis caused by Cladophialophora bantiana in a Brazilian drug abuser. Walz R, Bianchin M, Chaves ML, Cerski MR, Severo LC, Londero AT. J Med Vet Mycol. 1997 Nov-Dec;35(6):427-31.

We present a case of cerebral phaeohyphomycosis caused by Cladophialophora bantiana in an apparently immunocompetent patient with a history of intravenous drug use. The diagnosis was achieved in specimens obtained at necropsy by histological and mycological examination, with subsequent identification of the isolate in culture.

450

Necrotizing cerebritis in an allogeneic bone marrow transplant recipient due to Cladophialophora bantiana. Emmens RK, Richardson D, Thomas W, Hunter S, Hennigar RA, Wingard JR, Nolte FS. J Clin Microbiol. 1996 May;34(5):1330-2.

We describe a necrotizing cerebritis in an allogeneic bone marrow transplant recipient caused by the neurotropic, dematiaceous fungus Cladophialophora bantiana. The patient presented 7 months after bone marrow transplantation with fever and sudden onset of left-sided weakness, followed shortly by cranial nerve III and VI palsies. The patient had a lesion (3.0 by 2.0 by 2.0 cm) of the right midbrain with extension to the pons, the left brain stem, and the right superior and the middle cerebellar peduncles. The diagnosis was made by microscopic examination and culture of a brain biopsy.

451

Cutaneous phaeohyphomycosis due to Cladophialophora bantiana. Patterson JW, Warren NG, Kelly LW. J Am Acad Dermatol. 1999 Feb;40(2 Pt 2):364-6.

 

452

Cutaneous infection due to Cladophialophora bantiana in a patient receiving immunosuppressive therapy. Jacyk WK, Du Bruyn JH, Holm N, Gryffenberg H, Karusseit VO. Br J Dermatol. 1997 Mar;136(3):428-30.

Cladophialophora bantiana (Xylohypha bantiana, Cladosporium trichoides), a dematiaceous fungus, causes mainly infections of the central nervous system. Systemic antifungal therapy is apparently unsuccessful. Extracerebral involvement is uncommon and only few cases have been reported. We describe a 63-year-old patient, a kidney transplant recipient on prolonged prednisone and cyclosporin, who developed a large single lesion on the thigh from which Cladophialophora bantiana was cultured. A 3-month course of itraconazole 200 mg daily resulted in complete healing of the lesion. To the best of our knowledge this is the first report on cutaneous infection with Cladophialophora bantiana in an organ transplant recipient and the first in whom treatment with itraconazole led to resolution.

453

Myelitis caused by Cladophialophora bantiana. Shields GS, Castillo M. AJR Am J Roentgenol. 2002 Jul;179(1):278-9.

 

454

A Samoan case of chromoblastomycosis caused by Cladophialophora ajelloi. Goh KS, Padhye AA, Ajello L. Sabouraudia. 1982 Mar;20(1):1-7.

A case of chromoblastomycosis from American Samoa was studied. Histopathological examination of the biopsy material from the lesion revealed the presence of thick-walled, dematiaceous, muriform cells characteristic of chromoblastomycosis. Detailed mycological study of the dematiaceous mould isolated from the biopsy material disclosed that the fungus not only produced long, branched chains of holoblastic conidia similar to those of Cladosporium carrionii, but that many of the terminal and intercalary catenulate, holoblastic conidia had been converted into flask-shaped phialides with flaring collarettes that produced ovate to fusiform phialoconidia. These phialides were morphologically similar to those formed by members of the genus Phialorphora. The Samoan case is the second known case of chromoblastomycosis caused by Cladophialophora ajelloi Borelli.

455

[Natural history of chromoblastomycosis in Madagascar and the Indian Ocean] [Natural history of chromoblastomycosis in Madagascar and the [Natural history of chromoblastomycosis in Madagascar and the Indian Ocean] Esterre P, Andriantsimahavandy A, Raharisolo C. Bull Soc Pathol Exot. 1997;90(5):312-7.

The natural history of chromoblastomycosis was studied in Madagascar by analysing the characteristics of 1323 confirmed cases observed since 1955, including 45 patients receiving a new antifungic drug (terbinafine) during a multicentric study organized in 1995. The surveys data, conserved by the histopathology laboratory in the Institut Pasteur of Madagascar during 40 years, permit this retrospective analysis. The description of two ecosystems, one in the North with Fonsecaea pedrosoi evolving in the tropical rainforest and one in the South with Cladophialophora carrionii (41% of the whole sample) isolated in the spiny desert, demonstrates that the deforestation, in order to product charcoal and to build houses, is the primary factor associated with this disease. The epidemiologic (87% of patients are male and 96% are more than 16 years old, with more than 74% of the lesions located on feet and legs), mycologic (62% of the isolated strains belong to the F. pedrosoi species) and therapeutic (low efficiency of thiabendazole in long-term lesions, high efficiency of terbinafine especially on recent lesions and on Cladophialophora-infected patients) aspects of the natural history of chromomycosis confirmed that Madagascar is the most important focus in the world (global prevalence of about 1 for 8500 inhabitants), with few sporadic cases in the other islands of the Indian Ocean (La Reunion, Comoro islands and Mayotte). In the difficult context of Madagascar, the need for a non-specialized laboratory-applicable diagnostic technique that provides infection and species identification led the Institut Pasteur de Madagascar to develop an ELISA-based technique. A large-scale control throughout the country, with the assessment of effective oral chemotherapy with terbinafine, is seen as possible by the authors with the help of the manufacturer.

456

Cladophialophora bantiana isolated from an AIDS patient with pulmonary infiltrates. Brenner SA, Morgan J, Rickert PD, Rimland D. J Med Vet Mycol. 1996 Nov-Dec;34(6):427-9.

Cladophialophora bantiana causes a rare phaeohyphomycosis, usually manifested by brain abscesses but rarely by skin or pulmonary lesions. It has not been reported as a common colonizer or as a cause of pulmonary symptoms in patients with AIDS. We present a case in which C. bantiana was repeatedly isolated from the sputum of a patient with AIDS having pulmonary infiltrates.

457

Mycotic keratitis by Cladorrhinum. Zapater RC, Scattini F. Sabouraudia. 1979 Mar;17(1):65-9.

Cladorrhinum spp (strain CBS 604.75) was isolated, for the first time, from a case of keratomycosis. The patient, a 12 year-old boy, showed a soft white yellowish mycotic excrescence with clear borders which had followed the introduction of a small piece of straw into the cornea. The direct examination of corneal scrapings revealed dark-brown filaments. He was successfully treated with miconazole.

460

Case report. Subcutaneous phaeohyphomycosis due to Cladosporium cladosporioides. Gugnani HC, Sood N, Singh B, Makkar R. Mycoses. 2000;43(1-2):85-7.

A case of subcutaneous phaeohyphoymycosis caused by Cladosporium cladosporioides in a 25-year-old male is described. The clinical presentation was an elevated scaly suppurating lesion with sinuses on the right leg. The lesion healed completely with oral fluconazole therapy. The present report constitutes the first record of cutaneous or subcutaneous infection due to Cl. cladosporioides from India.

461

Cutaneous phaeohyphomycosis due to Cladosporium cladosporioides. Annessi G, Cimitan A, Zambruno G, Di Silverio A. Mycoses. 1992 Sep-Oct;35(9-10):243-6.

A 54-year-old man, affected by pemphigus vulgaris and severe steroid-induced diabetes, developed seven red-brown, firm, slightly raised 0.1-1 cm papular lesions on the anterior aspect of both knees and thighs. A cutaneous biopsy showed a granulomatous infiltrate with numerous fungal elements scattered in the dermis and also within giant cells. Cultures of cutaneous biopsy fragments on Sabouraud glucose agar in presence of chloramphenicol resulted in the growth of dark-green colonies at 25 degrees C. They were identified as typical Cladosporium cladosporioides. As far as we know, this species was previously isolated only in an HIV-seropositive patient as opportunistic pathogen in the site of skin testing.

462

Comparative study of Cladosporium isolated from various human lesions]. de Bievre C. Bull Soc Pathol Exot Filiales. 1982 Aug-Oct;75(4):390-9.

Two species C. carrionii and C. bantianum are important in medical mycology and are respectively the etiologic agents of chromomycosis and brain abcess. Other species such C. oxysporum and C. cladosporioides have been isolated from keratitis, further more the latter species has been isolated from a pulmonary ball. C. sphaerospermum has been recovered from nail scrapings. The role of C. herbarum, isolated from skin lesion is questionable.

463

Cladosporiosis in chronic herpetic encephalomyelitis] Nedz'ved' MK, Fridman MV. Arkh Patol. 2001 Jan-Feb;63(1):38-40.

One case of chronic herpetic meningoencepalitis complicated by a rare my costs of the central nervous system (CNS) and generalised viral infection is described. Cladosporiosis is considered as a lesion resulting from a immunosuppression due to chronic herpetic involvement of CNS. Morphologically this mycosis is manifested by the presence of spors and septic micelium among cells of productive inflammation an inside of giant multinuclear cells in affected areas. Viral nature of the encephalomyelitis is documented by presence of typical intranuclear inclusions and detection of herpetic antigen by means of fluorescent antibodies.

464

Phaeohyphomycosis due to Cladosporium cladosporioides. Vieira MR, Milheiro A, Pacheco FA. Med Mycol. 2001 Feb;39(1):135-7.

Phaeohyphomycosis is a clinical entity caused by dematiaceous fungi. We describe a clinical case of phaeohyphomycosis due to Cladosporium cladosporioides in a 45-year-old white male, apparently healthy, human immunodeficiency virus-negative. The patient was treated with terbinafine for 9 months, with regression of a skin lesion. Three months after discontinuation of the therapy, there was a clinical and mycological relapse. After progression of the disease with inadequate treatment, there was no response to amphotericin B and flucytosine. Finally, we obtained a clinical response with itraconazole oral solution at 600 mg day(-1) for a 6-month period.

465

[Mycetoma of the foot; a disease from the tropics] Buiting AG, Visser LG, Barge RM, van 't Wout JW. Ned Tijdschr Geneeskd. 1993 Jul 24;137(30):1513-5.

Two patients, a Surinamese man aged 50 and a Surinamese woman aged 56 exhibited a mycetoma of the foot, 30 and 28 years, respectively, after a local injury. Pathological examination revealed an aspecific chronic granulomatous inflammation. As causative agents a Fusarium species and a Cladosporium normodendrum, respectively, were cultured. The treatment consisted of curettage of fistulous ducts and administration of itraconazole.

466

Invasive yeast infections other than Candida spp. in acute leukaemia. Krcmery V, Krupova I, Denning DW. J Hosp Infect. 1999 Mar;41(3):181-94.

During the last two decades, the treatment of leukaemia has changed significantly; increasing intensity of chemotherapy and bone marrow transplantation have lead to profound immunosuppression, prolonged stays in hospital, vascular catheterization, administration of broad spectrum antimicrobial agents and extensive use of prophylactic antifungal drugs. All but the last of these risk factors have increased the incidence of fungal infections in leukaemic patients and have significantly changed the spectrum of pathogens in favour of non-Candida species. In major haematological centres in Europe and the US, the proportion of non-Candida yeast isolated from patients increased from 1 to 5% in 1980 to 10 to 25% after 1990. However, there are not enough data to assess whether mortality due to these species is higher than that due to Candida spp. (30-40%) or filamentous fungi (50-70%). In this article, specific risk factors and therapeutic outcome of yeast infections other than Candida spp. in leukaemia such as Malassezia furfur, Trichosporon spp., Blastoschizomyces capitatus, Rhodotorula rubra, Saccharomyces cerevisiae, Clavispora lusitaniae, Cryptococcus laurentii and Hansenula anomala are reviewed. An analysis of risk factors from the National Cancer Institute, Bratislava has shown that non-Candida yeast infections (N = 15) in cancer patients are associated with leukaemia and neutropenia (P = < 0.002, 0.005), more often fatal than those caused by C. albicans (N = 51) (P < 0.006) but not non-albicans Candida (N = 34) and are associated with quinolone (P < 0.0001) and itraconazole prophylaxis (P < or = 0.05, 0.015) compared to both C. albicans or non-albicans Candida respectively.

467

Invasive infections due to Clavispora lusitaniae. Krcmery V Jr, Mateicka F, Grausova S, Kunova A, Hanzen J. FEMS Immunol Med Microbiol. 1999 Jan;23(1):75-8.

Three cases of Clavispora lusitaniae invasive fungal infections are reported. All three infections appeared in cancer patients presented with fungaemia, one additionally with meningitis. Two of them were breakthrough -- they developed during therapy with conventional amphotericin B with a dose of 0.5 mg kg(-1) day(-1) . All three were cured: two with intravenous fluconazol and one with an increasing dose (1 mg kg(-1) day(-1)) of amphotericin B. In one of two breakthrough cases the sensitivity of the strain to antifungals was tested against antifungal agents and showed in vitro resistance to amphotericin B (MIC 2 eta g ml(-1)).

470

Sensitization in coccidioidosis and methods of its detection (review of the literature)] Likholetov SM. Zh Mikrobiol Epidemiol Immunobiol. 1974 Feb;(2):120-3.

 

471

Primary cutaneous coccidioidomycosis. Reevaluation of its potentiality based on study of three new cases. Winn WA. Arch Dermatol. 1965 Sep;92(3):221-8.

The data derived from these three young patients would indicate the need for: (1) Early recognition of the primary cutaneous skin infection as being due to Coccidioides immitis. (2) The prompt use of suppressive intravenous amphotericin B therapy until such time as local tissue resistance and systemic immunity become manifest and sufficient to contain the pathogenic fungus within the initial cutaneous site of infection as manifested by complete healing of this primary lesion and its associated lymphadenopathy. It is apparent that there is a need to reassess present concepts which have been based on insufficient data, and to revise conclusions derived from the study of the eight previously reported instances of primary cutaneous coccidioidomycosis. The traumatic cutaneous inoculation of C immitis into a previously uninfected person, contrary to earlier impressions, can result not only in prolonged illness but in serious dissemination of the disease, and in one reported instance has resulted in coccidioidal meningitis.

472

Some unusual periorbital dermatoses. Fusaro RM, Bansal S, Records RE. Ann Ophthalmol. 1988 Oct;20(10):391-3.

Three case reports of primary periorbital dermatitis are presented. The etiology of these were molluscum contagiosum, Microsporum canis, and Coccidioides immitis. In each case, the presenting complaint was unusual since the primary lesion started in the periorbital region.

473

Disseminated coccidioidomycosis. Jitsukawa K, Sato S, Hayashi Y, Yamao H, Anzai T. J Dermatol. 1990 Feb;17(2):120-6.

We report a case of disseminated coccidioidomycosis in a 39-year-old Japanese male whose illness developed after returning from a trip to an endemic area. He showed positive coccidioidin skin reaction throughout the entire course of his illness. The primary lesion in the lung subsequently spread to the bone. While the patient was on treatment with 5-FC, he made another trip to the same endemic area. After this episode, he developed pulmonary symptoms and cutaneous nodules on his wrist. The possibility of reinfection with Coccidioides immitis is discussed. Electron microscopy of the cutaneous nodules revealed that the spherules examined maintained their structural integrity in the granulomatous lesion, suggesting the high viability of the organism. Host-parasitic interaction in coccidioidomycosis is discussed.

474

Nuclear imaging in Coccidioidal osteomyelitis. Moreno AJ, Weisman IM, Rodriguez AA, Henry CD, Turnbull GL. Clin Nucl Med. 1987 Aug;12(8):604-9.

79920-5001.

Six cases of osteomyelitis due to Coccidioides immitis are presented. The cases reported demonstrate the importance of performing both bone and gallium imaging to avoid missing the osseous coccidioidal lesions

475

Coccidioides immitis osteomyelitis in a 12-month-old child. Bried JM, Speer DP, Shehab ZM. J Pediatr Orthop. 1987 May-Jun;7(3):328-30.

The case of a 12-month-old Mexican-American boy with Coccidioides immitis osteomyelitis of the little finger metacarpal and os calcis is presented in which a "cure" was obtained. The child received treatment with high doses of amphotericin B in conjunction with debridement and packing the lesions with calcium sulfate pellets. Recommended treatment for C. immitis infection of the bone would be debridement and packing with graft combined with systemic antifungal medical therapy.

476

Coccidioides immitis infections in bones and joints. Bried JM, Galgiani JN.

Clin Orthop. 1986 Oct;(211):235-43.

Coccidioides immitis infections of bones and joints pose difficult problems in diagnosis and treatment. To evaluate further the diagnosis and treatment of this disease, a retrospective review was conducted of 24 patients with 44 separate skeletal lesions of C. immitis infection, as determined by positive culture. Patients treated with combined medical and surgical treatment are more likely to have a successful outcome than those treated with medical therapy alone (p less than 0.005). Although immunosuppression did not appear to prevent a satisfactory response to therapy, patients with a high complement fixation titer (greater than or equal to 1:128) were more likely to fail to respond to medical therapy alone (p less than 0.01).

477

Primary cutaneous coccidioidomycosis: a review of the literature and a report of a new case. Arch Dermatol. 1977 Jul;113(7):933-6.

A 31-year-old woman working in the laboratory with the mycelial phase of Coccidioides immitis developed a firm, raised, erythematous lesion on the left index finger. A biopsy specimen of the lesion grew a white mold that proved to be C immitis. A sinus tract communicating with the lesion and extending into the proximal phalanx developed. The expressed pus was positive for the tissue form of C immitis by potassium hydroxide and periodic acid-Schiff stains and fluorescent-antibody techniques. The sinus tract was irrigated with an aqueous solution of amphotericin B (Fungizone). The tract closed and the lesion decreased in size. Healing was completed in ten weeks. Primary cutaneous disease must be distinguished from disseminated disease with cutaneous manifestations. In the majority of cases, primary disease heals spontaneously whereas disseminated disease usually requires systemic treatment with amphotericin B.

478

Constrictive pericarditis due to coccidiomycosis. Faul JL, Hoang K, Schmoker J, Vagelos RH, Berry GJ. Ann Thorac Surg. 1999 Oct;68(4):1407-9.

Coccidiomycosis is a fungal infection that rarely causes cardiac disease. Constrictive pericarditis in the setting of disseminated coccidiomycosis can be fatal, despite antifungal therapy and pericardiectomy. We report on a patient with constrictive pericarditis due to localized infection by Coccidioides immitis. The patient underwent successful surgical pericardiectomy and antifungal chemotherapy, and remains well 1 year later.

479

Pericarditis caused by coccidioidomycosis. Report of a case] Aguilar JA, Summerson C, Granda MC, Jiménez C, de La Torre S. Arch Cardiol Mex. 2001 Oct-Dec;71(4):313-8.

A 33 year-old man developed coccidioidomycosis which resulted in pericarditis associated with congestive heart failure. A pericardial effusion developed and progressed to constrictive pericarditis. A pericardiectomy was performed and revealed that the pericarditis was due to Coccidioides immitis. The patient died after surgery. This is the second case of coccidioidomycosis with pericarditis reported in Mexico's literature.

 

 

480

Perplexing pericarditis caused by coccidioidomycosis. Amundson DE. South Med J. 1993 Jun;86(6):694-6.

In the patient I have described, evaluation of chronic progressive pulmonary coccidioidomycosis presenting itself as cryptogenic pericarditis revealed an unsuspected large endobronchial coccidioidoma. At follow-up after 2 years of fluconazole therapy, the patient was asymptomatic, with a dramatic decrease in infiltrate but no change in CF titers. In endemic areas, coccidioidomycosis should be included in the differential diagnosis of idiopathic pericarditis, especially in high-risk patient populations. Additionally, airway obstruction or compromise might be an early finding in chronic coccidial disease.

481

Coccidioidomycosis meningitis with massive dural and cerebral venous thrombosis and tissue arthroconidia. Kleinschmidt-DeMasters BK, Mazowiecki M, Bonds LA, Cohn DL, Wilson ML. Arch Pathol Lab Med. 2000 Feb;124(2):310-4.

To our knowledge we report the first case of meningitis from Coccidioides immitis associated with massive dural and cerebral venous thrombosis and with mycelial forms of the organism in brain tissue. The patient was a 43-year-old man with late-stage acquired immunodeficiency syndrome (AIDS) whose premortem and postmortem cultures confirmed C immitis as the only central nervous system pathogenic organism. Death was attributable to multiple hemorrhagic venous infarctions with cerebral edema and herniation. Although phlebitis has been noted parenthetically to occur in C immitis meningitis in the past, it has been overshadowed by the arteritic complications of the disease. This patient's severe C immitis ventriculitis with adjacent venulitis appeared to be the cause of the widespread venous thrombosis. AIDS-related coagulation defects may have contributed to his thrombotic tendency.

482

Coccidioidal meningitis complicated by cerebral arteritis and infarction. de Carvalho CA, Allen JN, Zafranis A, Yates AJ. Hum Pathol. 1980 May;11(3):293-6.

A case of coccidioidal meningitis with cerebral arteritis in a nonendemic area is reported. Interesting clinical features were the difficulties in clinical diagnosis, hydrocephalus, and neurological deficits. An autopsy revealed chronic basal meningitis, cerebral arteritis, cerebral infarcts, hydrocephalus, and an old solitary pulmonary granuloma all due to Coccidioides immitis. The rare occurrence of cerebral arteritis due to C. immitis and clinicopathological correlations are discussed.

483

Intraocular coccidioidomycosis diagnosed by skin biopsy. Cunningham ET Jr, Seiff SR, Berger TG, Lizotte PE, Howes EL Jr, Horton JC. Arch Ophthalmol. 1998 May;116(5):674-7.

OBJECTIVE: To describe ocular findings in 2 patients with disseminated coccidioidomycosis diagnosed by skin biopsy. METHODS: The clinical and histopathologic findings of the 2 patients were reviewed retrospectively. RESULTS: One patient had a unilateral, granulomatous iridocyclitis with multiple iris nodules and a large vascularized anterior chamber mass, in the setting of pulmonary, cutaneous, and skeletal infection by Coccidioides immitis. The second patient developed papilledema and multifocal chorioretinitis accompanied by pulmonary, cutaneous, and meningeal C immitis infection. In each case, examination of the skin biopsy specimen revealed C immitis spherules. Treatments included local and systemic amphotericin B and oral fluconazole. CONCLUSIONS: Although rare, intraocular involvement can occur in the setting of disseminated coccidioidomycosis. A thorough systemic evaluation and biopsy of suspicious skin lesions can aid in the diagnosis.

484

An surgical case of right pulmonary coccidioidomycosis--with subcutaneous coccidiomycosis in the left wrist] Masuda K, Kumamoto K, Machida T. Nippon Kyobu Geka Gakkai Zasshi. 1997 Oct;45(10):1770-3.

Coccidioides is an afferent fungus disease. In Japan, there have been only a few surgical reports on coccidioides disease. We report a 39-year-old male who was diagnosed as having coccidioides disease by biopsy of subcutaneous nodules in the left wrist. The patient also showed a tumor image (1.5 x 1.0 cm) in S4 in the right lung. He had previously lived in Fresno, California on business between 1988 and 1993. After biopsy of the subcutaneous nodules, Itraconazole (200 mg), an anti-fungal drug, was orally administered for the lesion in the right lung for about 6 months. Since the tumor image revealed no improvement through this treatment, the tumor was resected. Histopathological examination by Grocott staining demonstrated the spherical form Coccidioides, i.e., endospores. Only 5 cases of resected pulmonary coccidioidal lesions have been reported in Japan including this case. We must be careful when handling coccidioidal culture because of its strong infectiosity.

485

Pulmonary coccidioidal pseudomycetoma. Rodriguez-Cintron W, Fraire AE, Greenberg SD, Stevens PM, Stager CE. Diagn Microbiol Infect Dis. 1992 Mar-Apr;15(3):267-72.

Coccidiomycosis is rarely associated with a pulmonary mycetoma. We report a patient with progressive cavitary coccidiomycosis, whose initial radiographic and clinical appearance simulated a mycetoma. Examination of the surgically resected lung showed necrotizing Coccidioides immitis granulomas with spherules and arthroconidialike structures, but no evidence of a mycetoma. We propose the term pulmonary coccidioidal pseudomycetoma as the best descriptor for this patient's clinical, radiographic, pathologic, and microbiologic presentation.

486

Interstitial granulomatous dermatitis associated with pulmonary coccidioidomycosis. DiCaudo DJ, Connolly SM. J Am Acad Dermatol. 2001 Dec;45(6):840-5.

BACKGROUND: Coccidioides immitis is a soil-dwelling fungus found in arid regions of the Western Hemisphere. Interstitial granulomatous dermatitis is a histopathologic pattern that may be a reactive manifestation of diverse systemic diseases. OBJECTIVE: Our purpose was to describe clinical and histopathologic findings in 5 patients who presented with interstitial granulomatous dermatitis associated with pulmonary coccidioidomycosis. METHODS: Medical records and skin biopsy slides from 5 patients were retrospectively reviewed. RESULTS: In each patient, edematous papules, nodules, and plaques developed abruptly during the onset of an acute febrile illness. Coccidioidomycosis was confirmed by serology. Skin biopsy specimens revealed interstitial granulomatous dermatitis with neutrophils, leukocytoclasis, and eosinophils. Fungal stains (5/5 cases) and fungal cultures (2/2 cases) revealed no organisms within the skin biopsy specimens. CONCLUSION: Interstitial granulomatous dermatitis may be a presenting feature of pulmonary coccidioidomycosis and may possibly represent a reactive manifestation of the infection.

489

Cokeromyces recurvatus isolated from pleural and peritoneal fluid: case report. Munipalli B, Rinaldi MG, Greenberg SB. J Clin Microbiol. 1996 Oct;34(10):2601-3.

The zygomycetous mold Cokeromyces recurvatus was isolated from the pleural and peritoneal fluids of a 64-year-old man with a history of peptic ulcer disease and alcohol abuse. The patient presented to the hospital with severe abdominal pain and a ruptured duodenal ulcer. This is one of the few times that C.recurvatus has been isolated from a human source, and the organism may have contributed to the death of this patient.

490

Cokeromyces recurvatus infection in a bone marrow transplant recipient. Tsai TW, Hammond LA, Rinaldi M, Martin K, Tio F, Maples J, Freytes CO, Roodman GD. Bone Marrow Transplant. 1997 Feb;19(3):301-2.

Diarrhea is common after bone marrow transplants. We report Cokeromyces recurvatus infection in a transplant recipient with diarrhea. Treatment with mystatin was effective.

491

Severe diarrhea due to Cokeromyces recurvatus in a bone marrow transplant recipient. Alvarez OA, Maples JA, Tio FO, Lee M. Am J Gastroenterol. 1995 Aug;90(8):1350-1.

Cokeromyces recurvatus, a sporangiola-forming dimorphic fungus, is a rare cause of urogenital infection in humans. We report here a case of severe watery diarrhea due to C. recurvatus, which was treated successfully with high-dose oral nystatin therapy. We speculate that our patient was probably predisposed to infections due to opportunistic organisms, such as C. recurvatus, because of post-transplantation immunosuppression. To our knowledge, our patient represents the first documented case of diarrhea due to C. recurvatus in man, and this case highlights the potential pathogenic capability of this opportunistic organism in immunosuppressed patients.

492

Cokeromyces recurvatus, a mucoraceous zygomycete rarely isolated in clinical laboratories. Kemna ME, Neri RC, Ali R, Salkin IF. J Clin Microbiol. 1994 Mar;32(3):843-5.

Cokeromyces recurvatus Poitras was isolated from an endocervical specimen obtained from a 37-year-old, insulin-dependent diabetic. The patient's diabetic condition had been well controlled for 10 years, and she had no other known medical problem. This is only the fourth time that this zygomycete has been recovered from a human source. While there was no evidence of tissue invasion in the present patient, the observation of fungus-like structures in two separate Papanicolaou-stained cervical smears prepared 1 year apart suggests that C. recurvatus may be capable of colonizing endocervical tissue.

493

Colletotrichum keratitis. Fernandez V, Dursun D, Miller D, Alfonso EC. Am J Ophthalmol. 2002 Sep;134(3):435-8.

PURPOSE: To evaluate Colletotrichum keratitis and to report the risk factors and clinical course. DESIGN: Interventional case series. METHODS: In order to report the clinical course of Colletotichum keratitis, fungal keratitis cases between January 1980 and February 2001 in an institutional setting were retrospectively reviewed and 10 eyes of 9 patients with Colletotrichum keratitis were identified by positive cultures. RESULTS: Colletotrichum species were identified in 10 of 360 culture-proven fungal keratitis cases. All cases were sensitive to amphotericin B, three of the isolates showed resistance to natamycin, two isolates had intermediate sensitivity to natamycin, and one isolate was resistant to fluconazole. Natamycin 5% was used as the initial antifungal agent in eight microbiologically proven fungal keratitis cases. Two of nine patients continued the treatment with amphotericin B 0.15% after the sensitivity results were obtained. CONCLUSION: Colletotrichum is an infrequent cause of fungal keratitis. The risk factors are similar to the known fungal keratitis. Colletotrichum is resistant to natamycin in vitro; however, all our patients responded well to this treatment while resistance or intermediate sensitivity to natamycin and resistance to fluconazole was observed.

494

Fungal keratitis caused by Colletotrichum gloeosporioides. Yamamoto N, Matsumoto T, Ishibashi Y. Cornea. 2001 Nov;20(8):902-3.

Department of Ophthalmology, Gamagori City Hospital, Gamagori, Japan.

PURPOSE: To describe a case of fungal keratitis caused by a rare coelomycete pathogen, Colletotrichum gloeosporioides. METHODS: An 82-year-old man with myelodysplastic syndrome developed fungal keratitis 6 months after cataract surgery in the left eye. Because the findings of the anterior chamber deteriorated after the initiation of natamycin, additional treatment with topical and systemic fluconazole was initiated. RESULTS: The isolates of corneal scraping grew C. gloeosporioides. After antifungal treatment of 2 months, the corneal lesion resolved with no recurrence of infection over a 5-year follow-up period. CONCLUSIONS: A combination treatment of natamycin and fluconazole was effective in the treatment of C. gloeosporioides.

495

Clinical and experimental keratitis caused by the Colletotrichum state of Glomerella cingulata and Acrophialophora fusispora. Shukla PK, Khan ZA, Lal B, Agrawal PK, Srivastava OP. Sabouraudia. 1983 Jun;21(2):137-47.

Two cases of mycotic keratitis caused by the Colletotrichum state of Glomerella cingulata and Acrophialophora fusispora are reported for the first time. Both the isolates produced experimental corneal lesions in rabbit eyes but A. fusispora was more pathogenic. The experimental infection was more severe, with both the fungi, in rabbits pretreated with cortisone as compared with untreated animals. In vitro A. fusispora was most sensitive to miconazole and tolciclate followed by clotrimazole, amphotericin B and lactones while clotrimazole exerted maximum inhibitory effect on Colletotrichum followed by miconazole, lactones, amphotericin B and arnebins. Arnebins and tolciclate were inactive respectively against A. fusispora and Colletotrichum. Of the 3 drugs tested in vivo, against A. fusispora keratitis in rabbit, amphotericin B showed better results than tolciclate and miconazole.

496

Colletotrichum species as emerging opportunistic fungal pathogens: a report of 3 cases of phaeohyphomycosis and review. O'Quinn RP, Hoffmann JL, Boyd AS. J Am Acad Dermatol. 2001 Jul;45(1):56-61.

BACKGROUND: Numerous etiologic agents of subcutaneous phaeohyphomycosis have been reported. Colletotrichum spp, common plant pathogens, have been reported as a cause of ocular keratomycosis, but only one previous case of cutaneous disease (hyalohyphomycosis) has been attributed to this genus. OBJECTIVE: Our purpose was to describe 3 cases of subcutaneous phaeohyphomycosis due to Colletotrichum spp occurring in patients undergoing chemotherapy for hematologic malignancies. METHODS: Three cases of Colletotrichum-induced phaeohyphomycosis are reviewed. The clinical and histologic features of this infection are presented, the antifungal susceptibilities are reported, and treatment options are discussed. RESULTS: We describe the first report in which C coccodes and C gloeosporioides are implicated as etiologic agents of subcutaneous phaeohyphomycosis. Despite treatment, one patient died after the onset of visceral fungal disease. CONCLUSION: Colletotrichum spp may cause life-threatening phaeohyphomycosis in immunosuppressed patients. Prompt recognition and intervention with surgical and antifungal treatment may result in decreased morbidity and mortality associated with these infections.

497

Phaeohyphomycotic cyst caused by Colletotrichum crassipes. Castro LG, da Silva Lacaz C, Guarro J, Gené J, Heins-Vaccari EM, de Freitas Leite RS, Arriagada GL, Reguera MM, Ito EM, Valente NY, Nunes R. J Clin Microbiol. 2001 Jun;39(6):2321-4.

A case of phaeohyphomycosis is reported in a male renal transplant recipient with a nodular lesion in the right leg who was treated with immunosuppressing drugs. The lesion consisted of a purulent cyst with thick walls. The cyst was excised surgically, and the patient did not receive any antifungal therapy. One year later he remains well. Histological study of the lesion showed a granulomatous reaction of epithelioid and multinucleate giant cells, with a central area of necrosis and pus. Fontana-Masson staining demonstrated the presence of pigmented hyphal elements. The fungus Colletotrichum crassipes was grown in different cultures from the cyst. The in vitro inhibitory activities of eight antifungal drugs against the isolate were tested. Clotrimazole and UR-9825 were the most active drugs. This case represents the first known reported infection caused by this rare species.

498

Subcutaneous hyalohyphomycosis caused by Colletotrichum gloeosporioides. Guarro J, Svidzinski TE, Zaror L, Forjaz MH, Gené J, Fischman O. J Clin Microbiol. 1998 Oct;36(10):3060-5.

The coelomycete Colletotrichum gloeosporioides was isolated in pure culture from subcutaneous nodules of the left forearm and elbow of a farmer after traumatic injury. To our knowledge, we report the first case involving this fungus as an etiological agent of subcutaneous infection. The in vitro inhibitory activities of amphotericin B, itraconazole, ketoconazole, miconazole, flucytosine, and fluconazole were studied.

499

Periorbital cellulitis secondary to Conidiobolus incongruus. Temple ME, Brady MT, Koranyi KI, Nahata MC. Pharmacotherapy. 2001 Mar;21(3):351-4.

A previously healthy, 18-month-old girl developed edema and erythema around her left eye 1 week after getting sand in that eye. The patient did not respond to oral or intravenous antibiotics. A mass developed around the eye, and biopsy revealed Conidiobolus incongruus. The patient failed to respond to amphotericin B 1 mg/kg, and susceptibility tests indicated multiantifungal resistance. A combination of antifungal therapy, hyperbaric oxygen, and surgery was required for successful treatment. Three months after treatment the child was disease free. There is no definitive therapy for Conidiobolus incongruus infections, although various drugs have been administered with some success. When susceptibility tests determine multidrug resistance, radical resection with antifungal chemotherapy and hyperbaric oxygen may be necessary as well as lifesaving.

500

Entomophthoramycosis: therapeutic success by using amphotericin B and terbinafine. Foss NT, Rocha MR, Lima VT, Velludo MA, Roselino AM. Dermatology. 1996;193(3):258-60.

A 12-year-old girl had been presenting a woody infiltration and erythema in the frontal region and on the entire left half of the face, leading to deformity of the nose and buccal fissure, and adenomegaly in a posterior cervical chain, for the last 18 months. Sinusitis was diagnosed and treated with antibiotics, and submitted to ethmoid sinusotomy, with no improvement. Several laboratory tests were made to find the correct diagnosis. An intradermal test for delayed hypersensitivity showed a positive reaction (5 mm) with necrosis for metabolic antigens for Conidiobolus. An oral mucosa biopsy showed a dense lymphohistiocytic infiltrate and focal points of necrosis. Gomori staining for fungi revealed countless wide, nonseptate hyphae. Amphotericin B was prescribed during 35 days, with no improvement. Terbinafine given orally was started in association with amphotericin B. Reduction of the lesions was observed 2 months later. No side effects were seen during 4 months of treatment.

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