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Pathogenic References 501-984

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

 

501

Entomophthoromycosis due to Conidiobolus. Gugnani HC. Eur J Epidemiol. 1992 May;8(3):391-6.

Entomophthoromycosis due to Conidiobolus coronatus is a granulomatous infection characterized by lesions that originate in the inferior turbinate, spread through ostia and foramina to involve the facial and subcutaneous tissues and paranasal sinuses. The majority of the cases have been described from areas of tropical rainforest in West Africa, agricultural and outdoor workers (aged 20-60 years) being the ones most frequently affected. The fungus is common in soil and decaying vegetation. Infection probably occurs by implantation of the spores of the fungus in nasal mucosa. C. incongruus is a rare agent of the disease, so far known only from two cases with lesions involving the pericardium, mediastinum, lungs, liver, oesophagus and jejunum. C. coronatus is known to cause a clinically similar disease in horses, mules, a dolphin and a chimpanzee. A characteristic histological feature is the presence of thin-walled, broad, often septate hyphae or hyphal fragments with a thick eosinophilic sheath, frequently phagocytosed within giant cells. The fungus is known to produce in vitro several enzymes, e.g., elastase, esterase, collagenase and lipase, which have a possible role in pathogenicity. A concentrated brain heart infusion culture filtrate antigen is useful for immunodiagnosis. Several drugs e.g., potassium iodide, cotrimoxazole, amphotericin B, ketoconazole and itraconazole have been tried with varying success. Investigations on the immunology of disease and the role of proteases and lipases in the pathogenesis of infection is an important area of further research.

502

Rhinoentomophthoromycosis: report of the first two cases observed in Costa Rica (Central America), and review of the literature. Segura JJ, Gonzalez K, Berrocal J, Marin G. Am J Trop Med Hyg. 1981 Sep;30(5):1078-84.

The first two cases of rhinoentomophthoromycosis to be recognized in Costa Rica are reported. The first patient was a 32-year-old Caucasian male from the Pacific Coast, and the second, a 17-year-old Negro male from the Atlantic Coast. Both cases showed the typical involvement of the nasofacial skin with the formation of subcutaneous nodules. One patient also showed left maxillary sinus involvement. Both patients were in general good health, without any associated disease. Cultures from the second patient, taken from the glabellar nodule, were positive for Conidiobolus coronatus. These two cases represent the first documentation of this uncommon mycosis in Central America.

503

Fatal disseminated Conidiobolus coronatus infection in a renal transplant patient. Walker SD, Clark RV, King CT, Humphries JE, Lytle LS, Butkus DE.

Am J Clin Pathol. 1992 Dec;98(6):559-64.

A case of fatal disseminated fungal infection due to Conidiobolus coronatus in a patient with a renal transplant is described. This organism, known to cause localized infections in otherwise healthy individuals in the tropics, is now recognized as a cause of fatal infection in immunosuppressed hosts. Histologically, localized infections are characterized by lack of vessel invasion and the presence of an eosinophilic sleeve around fungal elements, called the Splendore-Hoeppli phenomenon. The histologic findings in the present case were more typical of mucormycosis, and the correct diagnosis was established only after the organism was isolated and identified in culture.

504

Disseminated Conidiobolus infection with endocarditis in a cocaine abuser. Jaffey PB, Haque AK, el-Zaatari M, Pasarell L, McGinnis MR. Arch Pathol Lab Med. 1990 Dec;114(12):1276-8.

A crack cocaine abuser developed disseminated infection caused by a species of Conidiobolus not known to cause disease in vertebrates. The fungus gained entry via skin abrasions on the lower extremities, spread through the hematogenous route, and caused endocarditis. There was evidence of fungal infection in the lungs, heart, kidneys, skeletal muscles, and brain. An additional complication was extensive rhabdomyolysis, with a marked elevation of creatine kinase of up to 1.2 million U/L.

505

Disseminated infection with Conidiobolus incongruus. Busapakum R, Youngchaiyud U, Sriumpai S, Segretain G, Fromentin H. Sabouraudia. 1983 Dec;21(4):323-30.

The first fatal case of disseminated infection due to Conidiobolus incongruus is reported. The patient presented with a subcutaneous mass, febrility, weight loss, cough and hemoptysis. Histological examination of skin and subcutaneous tissue, lung, lymph nodes, esophagus, liver and jejunum showed a granulomatous reaction with bright eosinophilic amorphous material and broad hyphae. A fungus cultured from skin and subcutaneous tissue was identified as Conidiobolus incongruus.

507

Primary cutaneous fungal infections in solid organ transplantation: a case series. Miele PS, Levy CS, Smith MA, Dugan EM, Cooke RH, Light JA, Lucey DR. Am J Transplant. 2002 Aug;2(7):678-83.

Cutaneous fungal infections in solid-organ transplant patients present in a variety of nonspecific ways, requiring a high index of suspicion to diagnose correctly. In the present series of four transplant recipients, subsequent primary cutaneous fungal infections presented as papules, plaques, ulcers and subcutaneous nodules. Transplantations included one cardiac, two renal and one renal-pancreatic transplant. Fungal infections were limited to the skin; there was no evidence of disseminated disease in any case. The pathogens isolated were Scedosporium apiospermum (Pseudallescheria boydii), Alternaria species, Aspergillus fumigatus, and a coelomycete in the Coniothyrium-Microsphaeropsis complex of dark molds. Individuals were successfully treated with surgical debridement, antifungal agents, and reduction of immunosuppressive therapy. All patients and allografts survived. Accurate diagnosis, aggressive surgery and appropriate antifungal therapy, combined with close outpatient follow-up, optimize the likelihood of a cure in a transplant population.

508

Liver infection caused by Coniothyrium fuckelii in a patient with acute myelogenous leukemia. Kiehn TE, Polsky B, Punithalingam E, Edwards FF, Brown AE, Armstrong D. J Clin Microbiol. 1987 Dec;25(12):2410-2.

A case of liver infection caused by Coniothyrium fuckelii is described in a patient with acute myelogenous leukemia. This fungus is found in the soil and can be a pathogen of plants. Coniothyrium spp. are members of the order Sphaeropsidales, an order composed of fungi whose conidiomata are usually pycnidia with the conidiogenous hymenium lining the walls of the locule. Coniothyrium spp. must be differentiated from Phoma spp. and Hendersonula spp., the two most commonly isolated members of the Sphaeropsidales.

509

Corynespora cassiicola, a new agent of maduromycetoma. Mahgoub E. J Trop Med Hyg. 1969 Sep;72(9):218-21.

 

516

Pathogenesis of cerebral Cryptococcus neoformans infection after fungemia. Chrétien F, Lortholary O, Kansau I, Neuville S, Gray F, Dromer F.

J Infect Dis. 2002 Aug 15;186(4):522-30.

The pathogenesis of cerebral infection after Cryptococcus neoformans fungemia in outbred mice was investigated. Confocal microscopy and cultures on ficoll-hypaque gradient-separated blood cells were used to detect yeasts in the cytoplasms of monocytes. In semithin brain sections, poorly capsulated yeasts were seen in macrophages in the leptomeningeal space, in monocytes circulating in leptomeningeal capillaries, or in the endothelial cells themselves, strengthening the hypothesis that monocytes and endothelial cells play key roles in the pathogenesis of cryptococcal meningitis. Similar fungal loads and cellular reactions were seen in mice and in 1 patient with acquired immune deficiency syndrome (AIDS), all with acute cryptococcal meningoencephalitis, and in mice and in 1 patient with AIDS, all with cured cryptococcal infection. Immunostaining revealed both the presence of cryptococcal polysaccharide in various brain cells and antigenic variability both from yeast cell to yeast cell and over time. Thus, our data established the relevance and interest that this experimental model has for investigation of the pathogenesis of human cryptococcal meningitis.

517

Cutaneous and cerebral cryptococcosis during corticosteroid therapy] Kariniemi AL, Jeskanen L, Stubb S, Rantanen T, Lauerma A. Duodecim. 1999;115(24):2759-62.

 

518

Cryptococcal choroid plexitis as a mass lesion: MR imaging and histopathologic correlation. Kovoor JM, Mahadevan A, Narayan JP, Govindappa SS, Satishchandra P, Taly AV, Shankar SK. AJNR Am J Neuroradiol. 2002 Feb;23(2):273-6.

Cryptococcosis is a relatively common mycotic infection of the CNS caused by a ubiquitous saprophytic fungus. We present an unusual case of CNS cryptococcosis in an immunocompetent patient. Florid choroid plexitis resulted in the formation of intraventricular enhancing mass lesions that filled the ventricles and were hyperintense to associated periventricular edema on T2-weighted MR images. We also noted lesions corresponding to microcystic, dilated Virchow-Robin spaces in the basal ganglia that were characteristic of cryptococcal infection.

519

Central nervous system infections in the compromised host: a diagnostic approach. Cunha BA. Infect Dis Clin North Am. 2001 Jun;15(2):567-90.

The diagnostic approach to the compromised host with CNS infection depends on an analysis of the patient's clinical manifestations of CNS disease, the acuteness or subacuteness of the clinical presentation, and an analysis of the type of immune defect compromising the patient's host defenses. Most patients with CNS infections may be grouped into those with meningeal signs, or those with mass lesions. Other common manifestations of CNS infection include encephalopathy, seizures, or a stroke-like presentation. Most pathogens have a predictable clinical presentation that differs from that of the normal host. CNS Aspergillus infections present either as mass lesions (e.g., brain abscess), or as cerebral infarcts, but rarely as meningitis. Cryptococcus neoformans, in contrast, usually presents as a meningitis but not as a cerebral mass lesion even when cryptococcal elements are present. Aspergillus and Cryptococcus CNS infections are manifestations of impaired host defenses, and rarely occur in immunocompetent hosts. In contrast, the clinical presentation of Nocardia infections in the CNS is the same in normal and compromised hosts, although more frequent in compromised hosts. The acuteness of the clinical presentation coupled with the CNS symptomatology further adds to limit differential diagnostic possibilities. Excluding stroke-like presentations, CNS mass lesions tend to present subacutely or chronically. Meningitis and encephalitis tend to present more acutely, which is of some assistance in limiting differential diagnostic possibilities. The analysis of the type of immune defect predicts the range of possible pathogens likely to be responsible for the patient's CNS signs and symptoms. Patients with diseases and disorders that decrease B-lymphocyte function are particularly susceptible to meningitis caused by encapsulated bacterial pathogens. The presentation of bacterial meningitis is essentially the same in normal and compromised hosts with impaired B-lymphocyte immunity. Compromised hosts with impaired T-lymphocyte or macrophage function are prone to develop CNS infections caused by intracellular pathogens. The most common intracellular pathogens are the fungi, particularly Aspergillus, other bacteria (e.g., Nocardia), viruses (i.e., HSV, JC, CMV, HHV-6), and parasites (e.g., T. gondii). The clinical syndromic approach is most accurate when combining the rapidity of clinical presentation and the expression of CNS infection with the defect in host defenses. The presence of extra-CNS sites of involvement also may be helpful in the diagnosis. A patient with impaired cellular immunity with mass lesions in the lungs and brain that have appeared subacutely or chronically should suggest Nocardia or Aspergillus rather than cryptococcosis or toxoplasmosis. Patients with T-lymphocyte defects presenting with meningitis generally have meningitis caused by Listeria or Cryptococcus rather than toxoplasmosis or CMV infection. The disorders that impair host defenses, and the therapeutic modalities used to treat these disorders, may have CNS manifestations that mimic infections of the CNS clinically. Clinicians must be ever vigilant to rule out the mimics of CNS infections caused by noninfectious etiologies. Although the syndromic approach is useful in limiting diagnostic possibilities, a specific diagnosis still is essential in compromised hosts in order to describe effective therapy. Bacterial meningitis, cryptococcal meningitis, and tuberculosis easily are diagnosed accurately from stain, culture, or serology of the CSF. In contrast, patients with CNS mass lesions usually require a tissue biopsy to arrive at a specific etiologic diagnosis. In a compromised host with impaired cellular immunity in which the differential diagnosis of a CNS mass lesion is between TB, lymphoma, and toxoplasmosis, a trial of empiric therapy is warranted. Antitoxoplasmosis therapy may be initiated empirically and usually results in clinical improvement after 2 to 3 weeks of therapy. The nonresponse to antitoxoplasmosis therapy in such a patient would warrant an empiric trial of antituberculous therapy. Lack of response to anti-Toxoplasma and antituberculous therapy should suggest a noninfectious etiology (e.g., CNS lymphoma). Fortunately, most infections in compromised hosts are similar in their clinical presentation to those in the normal host, particularly in the case of meningitis. The compromised host is different than the normal host in the distribution of pathogens, which is determined by the nature of the host defense defect. In compromised hosts, differential diagnostic possibilities are more extensive and the likelihood of noninfectious explanations for CNS symptomatology is greater. (ABSTRACT TRUNCATED)

520

Disseminated cryptococcal infection in immune competent patients. Bichile LS, Gokhale YA, Sridhar V, Gill NH. J Assoc Physicians India. 2001 Mar;49:377-8.

Cryptococcal meningeal or cerebral infection has become an increasing global problem.(1) In this respect there are many anacedotal Indian case reports.(2) More than 50% of CNS infections occur in immunosuppressed patients and other debilitating conditions. Neurological form of cryptococcosis in immunocompetant patients needs to be considered in situations with intractable headache, papilloedema, hydrocephalus and prior to decisions on shunt placements.(3) We report on two such immunocompetent patients who presented with CNS involvement. Their clinical features and outcome is discussed.

521

Cerebral cryptococcosis: atypical appearances on CT. Awasthi M, Patankar T, Shah P, Castillo M. Br J Radiol. 2001 Jan;74(877):83-5.

Cryptococcal infection is common in immunocompromised patients, often presenting with meningitis or meningoencephalitis. We report an unusual presentation of cryptococcal infection in an immunocompetent patient presenting with headache and hemiplegia. CT demonstrated a large ring-enhancing lesion in the parietal region with intralesional calcification.

522

Ventriculitis due to Cryptococcus uniguttulatus. McCurdy LH, Morrow JD. South Med J. 2001 Jan;94(1):65-6.

Infections due to non-neoformans cryptococci are rare. We report the first case of a human infection caused by Cryptococcus uniguttulatus. Ventriculitis caused by this organism developed in a 65-year-old woman who had had repair of an internal carotid aneurysm. In vitro sensitivity testing showed the Cryptococcus species sensitive to amphotericin B and itraconazole. Treatment with amphotericin led to resolution of the infection.

523

Cryptococcal meningitis in non-HIV-infected patients. Shih CC, Chen YC, Chang SC, Luh KT, Hsieh WC. QJM. 2000 Apr;93(4):245-51.

Diagnosed with cryptococcal meningitis and hospitalized at National Taiwan University Hospital, 1977-1996. Forty-two patients (44.7%) had underlying diseases. The main initial manifestations were headache (86.2%), vomiting (72.3%) and fever (69. 1%). The 30 patients with T-cell suppression had more acute illnesses (median duration of symptoms: 14 days vs. 29 days), less typical presentations of meningitis, and reduced inflammatory responses compared with the 64 without T cell suppression. There was no statistical difference between patients who received amphotericin B treatment for 10 weeks and those received amphotericin B with subsequent fluconazole treatment, in terms of mortality rate and recurrence rate. Seventy-five patients (79.8%) had satisfactory clinical responses, and two relapsed. Eighteen patients died (19.1%) and 10 of these died within 2 weeks of hospitalization. Patients in this series had outcomes comparable with those from temperate and even tropical countries with high percentages of immunocompetent hosts. Factors significantly associated with death were lymphoma, semicoma, leukocytosis, and initial high titres of cryptococcal antigen in cerebral spinal fluid (especially >/=1 : 512). On multivariate analysis, lymphoma and initial high cryptococcal antigen titres were independent predictors of mortality.

524

Cryptococcosis in AIDS. Imwidthaya P, Poungvarin N. Postgrad Med J. 2000 Feb;76(892):85-8

A total of 87 patients (17 female, 70 male) were admitted to SIRIRAJ HOSPITAL, MAHIDOL UNIVERSITY, BANGKOK, THAILAND, from JANUARY 1996 TO DECEMBER 1997, with a diagnosis of cryptococcal meningitis and underlying AIDS. The age range was 14: 70 years, mean 32.1. Six females (35%) and thirty-one males (44%) died, while the others were discharged home after clinical improvement. The mean duration of admission of those who died was 14.5 days, which was shorter than that of the patients who survived (25.7 days). Cerebral cryptococcosis was diagnosed using culture (100%), India ink preparation (91%), latex agglutination test (100%), and polymerase chain reaction (86%). Polymerase chain reaction fingerprinting of Cryptococcus neoformans revealed 99% serotype A and 1% serotype B. The mean minimum inhibitory concentrations of amphotericin B, flucytosine, fluconazole and itraconazole against 87 isolates of C neoformans were 0.55 microg/ml (0.25-1, SD = 0.22), 9.5 microg/ml (2-20, SD = 4.91), 6.9 microg/ml (1-16, SD = 4.42) and 0.36 microg/ml (0.125-1.0, SD = 0.23), respectively. These findings showed that the cryptococcal infections were sensitive to these antifungal agents.

525

[Chronic Cryptococcal meningitis with CSF oligoclonal IgG band in a patient with Claude syndrome] Kawanishi R, Mizutani T, Takahashi S, Ono S, Takasu T. Rinsho Shinkeigaku. 1998 Apr;38(4):314-8.

We described a 61-year-old man who was diagnosed as having chronic cryptococcal meningitis, while he was hospitalized with Claude syndrome. The patient was admitted because of acute onset of gait disturbance. He had a tendency to fall down to his left side since he awoke in the morning of August 12, 1995. On admission, he was mentally alert, showing a right oculomotor nerve palsy, gaze-evoked horizontal nystagmus in the left eye on the left lateral gaze, and incoordination of the left upper and lower extremities. In addition, he fell to the left side on standing up with feet together and with eyes closed. He had mild wild-based gait with a tendency to fall down to the left on tandem gait. Babinski sign was present on the left side. He did not have fever, nor meningeal signs, nor sensory abnormalities. X-ray films of the chest showed multiple nodular shadows consistent with pneumoconiosis. Cranial X-ray computed tomography and magnetic resonance imaging revealed a small lesion in the paramedian area of the midbrain on the right, consistent with an infarct. Cerebral arteriography revealed a stenosis in the proximal portion of the right posterior cerebral artery. Cerebrospinal fluid (CSF) showed a moderate mononuclear cell predominant pleocytosis, a moderate elevation of total protein, slightly reduced glucose values. Although the culture and India ink preparation of CSF were negative for cryptococcus in repeated studies, its antigen was positive both in the serum and CSF. In addition, the CSF showed an oligoclonal IgG band which was predominantly K type. After the antigen of Cryptococcus neoformans was added to the CSF in vitro, the oligoclonal IgG band was absorbed completely. The patient was treated with fluconazole (FLCZ), which did not cause any improvement of the CSF abnormalities, so that FLCZ was replaced by 5-flucytosine (5-FC). Since the CSF abnormalities moderately improved with 5-FC, he was discharged on December 21, 1995. After the 5-FC was discontinued, the CSF results slowly worsened over several months without any signs and symptoms of meningitis. He was hospitalized again on October 28, 1996 for treatment with both 5-FC and amphotericin B. Although the CSF abnormalities improved markedly, the meningitis was not cured. After he was discharged on February 1, 1997, he was treated with both 5-FC and FLCZ. Although his CSF abnormalities worsened mildly, he remained afebrile without meningeal signs and symptoms and led an ordinary life. In our patient it remained undetermined whether the Claude syndrome was caused by arteriosclerotic infarction, or vasculitis due to cryptococcal meningitis, or both. Asymptomatic chronic cryptococcal meningitis as observed in our patients is unusual. In addition, this is the second case after Porter et al (1977) that the oligoclonal IgG band in CSF proved to be related to cryptococcal infection.

526

Cryptococcal disease of the CNS in immunocompetent hosts: influence of cryptococcal variety on clinical manifestations and outcome. Mitchell DH, Sorrell TC, Allworth AM, Heath CH, McGregor AR, Papanaoum K, Richards MJ, Gottlieb T. Clin Infect Dis. 1995 Mar;20(3):611-6.

We performed a retrospective review of cases of cerebral cryptococcosis among patients admitted to 12 Australian teaching hospitals between 1985 and 1992. Of 118 cases identified, 35 occurred in immunocompetent hosts. When cases due to Cryptococcus neoformans variety neoformans were compared with those due to Cryptococcus neoformans variety gattii, we found that the latter tended to occur in healthy hosts whose residence or job was located in a rural area, and cerebral mass lesions and/or hydrocephalus and pulmonary mass lesions were more common. For a subgroup of patients with infection due to C. neoformans variety gattii, multiple enhancing lesions were observed on cerebral computed tomograms, and papilledema, high CSF and serum cryptococcal antigen titers, and a worse prognosis (despite prolonged amphotericin B therapy and intraventricular shunt insertion) were also noted. No significant difference in clinical course or outcome in terms of variety of C. neoformans was noted for patients with cryptococcal meningitis whose computed tomographic scans appeared normal on presentation.

527

Cryptococcal meningitis in patients without predisposing immunodeficiency] Jensen T, Jensen IL. Ugeskr Laeger. 1994 Sep 19;156(38):5532-4.

Cryptococcal meningitis is a chronic or subacute meningeal infection that may have pulmonary or systemic manifestations and is caused by the yeast Cryptococcus neoformans. It has become an increasingly important pathogen in immunocompromised hosts, whereas cryptococcal meningitis is relatively rare in immunocompetent patients. The diagnosis is often delayed because of the sparse and nonspecific symptoms. We present two cases of cryptococcal meningitis in two patients without known predisposing factors. The symptomatology, diagnosis and treatment of the disease are discussed. The two cases illustrate that Cryptococcus neoformans should be considered in patients with cerebral symptoms and fever. The disease is potentially curable and early diagnosis with specific treatment are important prognostic factors.

528

Bilateral optic nerve cryptococcosis in sudden blindness in patients with acquired immune deficiency syndrome. Cohen DB, Glasgow BJ. Ophthalmology. 1993 Nov;100(11):1689-94.

PURPOSE: A neuroanatomic study was undertaken to search for the cause of sudden, simultaneously bilateral blindness in a patient with acquired immune deficiency syndrome who had cryptococcal meningitis. METHODS: Careful gross examination was performed, and microscopic sections were cut at 50- to 100-microns intervals of the entire visual pathway. RESULTS: Focal cryptococcosis destroyed segments of the right intracanalicular optic nerve and the left intraorbital optic nerve adjacent to the optic canal. The meninges were heavily infiltrated by Cryptococcus organisms around the optic tracts, optic nerves, and optic chiasm; however, only a few scattered cryptococcal organisms were found in the periphery of the chiasm contiguous with heavy meningeal infection. Blood vessels supplying the chiasm appeared normal. Generalized cerebral edema and focal vacuolization of periventricular white matter were evident. CONCLUSION: The authors believe that sudden, simultaneously bilateral visual loss in this patient was caused

529

Neurological form of cryptococcosis. Apropos of 2 atypical cases in non HIV-infected patients] Donnet A, Graziani N, Harlé JR, Durand JM, Touta A, Grisoli F. Rev Neurol (Paris). 1993;149(5):326-30.

Cryptococcal infection is the most common fungal infection of the central nervous system. More than 50% of the cases of cryptococcal infection are superimposed on an immunosuppressive or other general debilitating condition. Cerebral cryptococcosis usually presents as meningitis or meningoencephalitis, although cerebral granuloma has also been reported. Hydrocephalus is the most common neurosurgical complication of cerebral cryptococcosis. The majority of patients require only medical treatment with antifungal drugs. However, when complications ensue, surgical intervention is mandatory. We suggest that chronic meningitis be ruled out in all patients prior to the placement of shunts. In the two cases reported here treatment of cryptococcal meningitis was a combination of amphotericin B and flucytosine for six weeks. Fluconazole is a new alternative and at least as effective as amphotericin B.

530

Pulmonary cryptococcosis: CT and pathologic findings. Zinck SE, Leung AN, Frost M, Berry GJ, Müller NL. J Comput Assist Tomogr. 2002 May-Jun;26(3):330-4.

PURPOSE: The purpose of this work was to describe the CT and pathologic findings of pulmonary cryptococcosis. METHOD: CT scans of 11 patients (7 immunocompromised, 4 immunocompetent) with proven pulmonary cryptococcosis were analyzed for number, morphologic characteristics, and distribution of parenchymal abnormalities as well for presence of lymphadenopathy and pleural effusion. Pathology of lung specimens obtained by open biopsy or resection (n = 5) and transbronchial biopsy (n = 1) was reviewed by one dedicated pulmonary pathologist. RESULTS: Pulmonary nodules, either solitary or multiple, were the most common CT finding, present in 10 of 11 patients (91%); associated findings included masses (n = 4), CT halo sign (n = 3), and consolidation (n = 2). On histologic examination, focal areas of ground-glass attenuation surrounding or adjacent to nodules were found to represent airspace collections of macrophages and proteinaceous fluid. CONCLUSION: Pulmonary cryptococcosis should be considered in the differential diagnosis of solitary or multiple pulmonary nodules (with or without associated CT halo sign), particularly in immunocompromised patients.

531

Pulmonary cryptococcosis in the immunocompetent host. Therapy with oral fluconazole: a report of four cases and a review of the literature. Núñez M, Peacock JE Jr, Chin R Jr. Chest. 2000 Aug;118(2):527-34.

Isolated pulmonary cryptococcosis (IPC) is an infrequently diagnosed infection, the management of which is not well defined. In past years, IPC traditionally has not been treated in the immunocompetent host, given its perceived benign and self-limited course and the toxicity associated with amphotericin B. However, some patients manifest prominent and disabling symptoms, and infection occasionally may disseminate. Fluconazole is active against Cryptococcus neoformans, is easily administered, and has an excellent safety profile. We present four healthy hosts with IPC who were treated with oral fluconazole for 6 to 8 weeks. A review of the literature was conducted to identify other cases of IPC in healthy hosts who were also treated with fluconazole. Our results and the limited experience reported in the literature suggest that fluconazole may be an appropriate choice for the treatment of IPC in the immunocompetent host. Indications for treatment are not defined, but symptomatic patients, those with multiple nodules or extensive infiltrates on chest radiographs, and/or those testing positive for serum cryptococcal antigen might be potential candidates for therapy.

532

Pulmonary cryptococcosis in patients without HIV infection. Aberg JA, Mundy LM, Powderly WG. Chest. 1999 Mar;115(3):734-40.

PURPOSE: To further elucidate the diagnostic and therapeutic approaches to patients with pulmonary cryptococcosis who are not HIV-infected. SUBJECTS: All of the patients without HIV infection who received care at two Midwest hospitals between January 1986 and February 1996 and had a respiratory isolate of Cryptococcus neoformans. METHODS: The medical records of the study patients were reviewed for demographic data, host immune status, respiratory symptoms, diagnostic studies, treatment, and follow-up. RESULTS: Forty-two patient presentations comprised the overall study group. Thirty-six patients (85.7%) had no evidence of dissemination, and six patients (14.3%) had disseminated disease. Seven of the 36 patient presentations were definitive pulmonary cryptococcosis, 15 were presumptive disease, and 14 were colonization with C neoformans. Neither the baseline demographic parameters nor the immune status appeared to discriminate the patients with disease from the patients with colonization. A serum cryptococcal antigen (sCRAG) was positive for 7 of 18 patients, 3 of whom were proven by culture to have a disseminated infection. A negative sCRAG was observed in 11 patients, one of whom had proven dissemination. Fifteen patients underwent a lumbar puncture as part of their evaluation, and cryptococcal meningitis was diagnosed in three of these patients, all of whom had positive blood cultures for C neoformans. The majority of the patients did not receive antifungal therapy. CONCLUSION: In the majority of the patients, the lung appeared to be the sole organ involved, and a workup for systemic infection was rarely helpful. A positive sCRAG was not specific for dissemination. Antifungal therapy should be reserved for symptomatic patients, for patients with a positive sCRAG, and for patients with underlying immunosuppression.

533

Case report. Cryptococcal cellulitis showing necrotizing vasculitis. Kimura M, Kadota E, Satou T, Yoneda E, Furuta T. Mycoses. 2001 May;44(3-4):115-8.

A 65-year-old woman with refractory anaemia who had been treated with systemic corticosteroids for several months developed cryptococcal cellulitis of the right cubital fossa. She was treated empirically for a presumed bacterial cellulitis with little response. Histological examination of debrided tissue revealed Cryptococcus as the causative organism. The tissue reaction involved suppurative inflammation with abscess formation in the dermis and subcutaneous adipose tissue. Necrotizing vasculitis, which has rarely been described in cryptococcosis, was seen in this case. Although the cellulitis was cured by local treatment in this patient, most previous reports recommended systemic antifungal therapy to treat cryptococcal cellulitis.

534

Cutaneous cryptococcosis--primary versus secondary disease. Report of two cases with review of literature. Ng WF, Loo KT. Am J Dermatopathol. 1993 Aug;15(4):372-7.

The clinical, immunological, and pathological features of solitary cutaneous cryptococcosis in two apparently healthy Chinese adults are reported. In patient 1, regional cryptococcal lymphadenopathy also occurred. Both patients showed lymphopenia with a proportionate decrease in T-helper and T-suppressor cells. Both skin and lymph node biopsies showed granulomatous inflammation and the presence of cryptococcus. A chancriform syndrome developed in patient 1, indicating primary cutaneous cryptococcosis. Chancriform syndrome is rare in cryptococcal skin infection, probably due to immunosuppression in susceptible patients. In patient 2, the deep dermal and subcutaneous inflammatory involvement and anatomic location of the lesion on the upper medial thigh are supportive of secondary skin disease. Unless negated by a reliable history, the following features are indicative of secondary disease: inflammation centered in deep dermis or subcutaneous fat, lesion on covered parts of body, and multifocal skin lesions. Some cases remain unclassifiable. In practice the distinction between primary and secondary cutaneous cryptococcal disease is not essential because less toxic, effective antifungal drugs are now available.

535

Cutaneous cryptococcosis: treatment with oral fluconazole. Shuttleworth D, Philpot CM, Knight AG. Br J Dermatol. 1989 May;120(5):683-7.

A case of cutaneous cryptococcosis is described in an immunocompromised patient. The initial lesion developed on the dorsum of the hand following trauma and was initially thought to be neoplastic. Satellite subcutaneous lesions developed in a 'sporotrichoid' pattern along the forearm. Treatment with oral fluconazole resulted in the complete resolution of the lesions. This is the first published report of the use of fluconazole in the treatment of cutaneous cryptococcosis.

536

Cutaneous cryptococcosis. Chu AC, Hay RJ, MacDonald DM. Br J Dermatol. 1980 Jul;103(1):95-100.

A 31-year-old woman with long-standing renal disease, treated with systemic steroids and azathioprine, developed progressive skin ulceration and subcutaneous nodules. A diagnosis of cryptococcosis was established after histological examination of a cutaneous lesion and confirmed by culture of the organism from the biopsy specimen. A detailed description of the histology and ultrastructure of the cutaneous lesion is presented. Treatment with parenteral amphotericin B and 5-fluorocytosine resulted in dramatic resolution of the skin lesions.

537

.[Cutaneous, subcutaneous, and lymph node cryptoccosis in a patient with sarcoidosis (author's transl)] Blanchon F, Vannier R, Brunel D, Carette MF, Lancastre F, Roland J, Vergez P, Drouhet E, Brocard H. Ann Med Interne (Paris). 1979;130(10):455-8.

An Algerien patient aged 31 years with a histologically confirmed mediastinopulmonary sarcoidosis had a persistent stable miliary pulmonary x-ray image after cortisone therapy. Eighteen months after stopping the corticotherapy, he developed cryptococcosis which was mainly cutaneous, but associated with subcutaneous abscesses and peripheral adenopathy, and without lesions in the viscera or deep nodes. Cryptococcus antigens were present in the serum and there was a humoral and cellular immunity reaction towards the cryptococcus. Recovery occurred after amphotericin B and 5-fluorocytosine.

538

Cryptococcosis in organ transplant recipients: an overview. Vilchez RA, Fung J, Kusne S. Am J Transplant. 2002 Aug;2(7):575-80.

The clinical, immunological, and pathological features of solitary cutaneous cryptococcosis in two apparently healthy Chinese adults are reported. In patient 1, regional cryptococcal lymphadenopathy also occurred. Both patients showed lymphopenia with a proportionate decrease in T-helper and T-suppressor cells. Both skin and lymph node biopsies showed granulomatous inflammation and the presence of cryptococcus. A chancriform syndrome developed in patient 1, indicating primary cutaneous cryptococcosis. Chancriform syndrome is rare in cryptococcal skin infection, probably due to immunosuppression in susceptible patients. In patient 2, the deep dermal and subcutaneous inflammatory involvement and anatomic location of the lesion on the upper medial thigh are supportive of secondary skin disease. Unless negated by a reliable history, the following features are indicative of secondary disease: inflammation centered in deep dermis or subcutaneous fat, lesion on covered parts of body, and multifocal skin lesions. Some cases remain unclassifiable. In practice the distinction between primary and secondary cutaneous cryptococcal disease is not essential because less toxic, effective antifungal drugs are now available.

539

Clinical spectrum of invasive cryptococcosis in liver transplant recipients receiving tacrolimus. Singh N, Gayowski T, Wagener MM, Marino IR. Clin Transplant. 1997 Feb;11(1):66-70.

Invasive cryptococcal infections have been reported in 0.3-1% of the patients undergoing liver transplantation in the previous reports. In contrast, invasive cryptococcosis developed in 6% of 102 consecutive liver transplants at our institution receiving tacrolimus as primary immunosuppression. Cutaneous and/or osteoarticular infections due to cryptococcus were detected in 67% of the patients with cryptococcosis, whereas meningitis was present only in 17%. One of the six patients with cryptococcosis presented with refractory shock and multiorgan system failure attributable solely to cryptococcosis. Patients with cryptococcal infections were significantly older than all other liver transplant recipients (p = 0.017), suggesting reactivation as opposed to primary infection as pathogenesis of cryptococcosis. 100% of the patients with cryptococcosis resided on the Eastern coast of the United States as compared to 59% of the patients without cryptococcosis (p = 0.08). There was no difference in the severity of underlying liver disease, degree of immunosuppression or CMV infection or disease between patients who did and did not develop cryptococcosis. Atypical manifestations, e.g. cutaneous diseases or sepsis syndrome, as opposed to subclinical meningitis, may be a clinical feature of cryptococcal infection in liver transplant recipients.

540

Bioprosthetic endocarditis due to Cryptococcus neoformans. Boden WE, Fisher A, Medeiros A, Benham I, McEnany MT. J Cardiovasc Surg (Torino). 1983 Mar-Apr;24(2):164-6.

Fungal prosthetic endocarditis continues to be a lethal complication of cardiac valve replacement. We describe a patient with culture-proved Cryptococcal endocarditis and myocarditis whose non-regurgitant xenograft aortic prosthesis was successfully replaced urgently upon the occurrence of new 1st degree A-V block in the third postoperative week. Operative intervention, including vigorous debridement of the aortic root, is effective in postoperative prosthetic fungal infections involving the myocardium. The patient described herein is now infection-free, with a non-regurgitant valve, one and one-half years following operation.

541

Cardiac lesions in acquired immunodeficiency syndrome (AIDS). Apropos of an autopsy series of 25 cases] Hofman P, Michiels JF, Saint Paul MC, Bernard, Dellamonica P, Loubiere R. Ann Pathol. 1990;10(4):247-57.

The pathologic study of the cardiac lesions in 25 persons who died of AIDS were studied from autopsies. Most of these patients were intravenous drug abusers (14 cases). Heart failure was symptomatic and lead to death in 4 cases. This study showed histological abnormalities in 76% of the cases. We observed 12 myocarditis. In 6 cases, pathogenes were found: Toxoplasma gondii (2), Cryptococcus neoformans (2), Candida (1), Aspergillus (1). A lymphocytic myocarditis was observed in 6 hearts. By immunohistochemical technique, we could distinguish 2 toxoplasmic myocarditis, and in 4 cases, solitary cysts in the myocardium without inflammation. The remaining lesions comprised respectively: 3 lymphocytic pericarditis, 2 marastic endocarditis and 1 dilated myocardiopathy.

542

Successful treatment of cryptococcal osteomyelitis and paraspinous abscess with fluconazole and flucytosine. Cook PP. South Med J. 2001 Sep;94(9):936-8.

A patient with thoracic cryptococcal osteomyelitis was treated successfully with the combination of fluconazole and flucytosine. This is the first reported case of cryptococcal osteomyelitis successfully treated with fluconazole and flucytosine.

543

Cryptococcus myelitis: atypical presentation of a common infection. Gumbo T, Hakim JG, Mielke J, Siwji S, Just-Nübling G, Ismail A. Clin Infect Dis. 2001 Apr 15;32(8):1235-6.

Cryptococcus neoformans is associated with as much as 45% of meningitis in patients admitted for hospital care in Zimbabwe, and it is an important opportunistic infection in patients infected with the human immunodeficiency virus. Cases of cryptococcosis presenting as a spinal cord syndrome have been reported from Zimbabwe and South Africa, but these were all cases of Cryptococcus vertebral osteomyelitis. We describe 3 unusual patients who presented with a myelitis-like syndrome without vertebral osteomyelitis.

544

Cryptococcal osteomyelitis with septic arthritis. taliano A, Yen BC, Rosenthal SA, Rafii M. Orthopedics. 2001 Jan;24(1):59-60.

 

545

Cryptococcal osteomyelitis of the spine. Govender S, Mutasa E, Parbhoo AH.

J Bone Joint Surg Br. 1999 May;81(3):459-61.

We have treated seven patients with cryptococcal spondylitis. Five presented with a neurological deficit and one was HIV-positive. Amphotericin-B and 5-flucytosine were used in five patients and ketoconazole was given orally in the remaining two. Three patients made a complete neurological recovery. Since these lesions mimic spinal tuberculosis, which is commonly seen in our environment, we draw attention to the importance of obtaining a tissue diagnosis.

546

Cryptococcal osteomyelitis: case report and review. Liu PY. Diagn Microbiol Infect Dis. 1998 Jan;30(1):33-5.

Cryptococcosis is a disseminated infection of man and animals caused by Cryptococcus neoformans. The most commonly involved sites are the lungs and the central nervous system. Isolated osteomyelitis due to C. neoformans is a rare complication of disseminated cryptococcosis. Herein we report a case of isolated osteomyelitis due to C. neoformans. A review of the English-language literature has been made and shows 40 cases (including this present report) with detailed data available since 1956. Most of the cases occurred between the ages of 21 and 59. Seventy-five percent of cases involved only one single site of bone infection, with vertebrae being the most common site. Sarcoidosis is the most common underlying disease, followed by tuberculosis and previous steroid therapy. Most of the cases (> 60%) reported were treated successfully with medical treatment alone or the combination of medical treatment and surgical curettage.

547

Osteomyelitis from Cryptococcus neoformans] Hummel H, Stosiek P, Lindner R, Bär W. Mycoses. 1996;39 Suppl 1:94-6.

A forty-three-year old patient suspected of having a bone tumor in his left femur, was submitted to the hospital. However, osteomyelitis caused by Cryptococcus neoformans has been demonstrated by culture. The history of the patient revealed a long-term therapy with corticosteroids due to sarcoidosis. The osteomyelitis was treated with fluconazole (200 mg daily p.o.) for three months. Under this therapy the infection resolved.

548

Cryptococcus neoformans vertebral osteomyelitis. Gurevitz O, Goldschmied-Reuven A, Block C, Kopolovic J, Farfel Z, Hassin D. J Med Vet Mycol. 1994;32(4):315-8.

A 67-year-old previously healthy woman presented with low back pain of 2 months duration and daily fever of 39 degrees C for 3 weeks. CT scan showed a lytic lesion in the third lumbar vertebra and a small right lower lobe lung infiltrate with mediastinal lymphadenopathy. Culture of material obtained from open biopsy of the vertebra grew Cryptococcus neoformans var. neoformans, which was also demonstrated on histology. Cryptococcal antigen was detected in the patient's serum. Treatment with amphotericin B (1000 mg total dose) and oral 5-fluorocytosine, resulted in complete recovery and resolution of the chest X-ray findings with a follow-up of 2 years. Since this case, as well as most of the previously described cases of cryptococcal osteomyelitis, were in normal hosts, cryptococcal osteomyelitis should be considered in the differential diagnosis even in a normal host, and therefore, prior to possible invasive diagnostic procedures, cryptococcal antigen in the serum should be determined.

549

Cryptococcal skeletal infections: case report and review. Behrman RE, Masci JR, Nicholas P. Rev Infect Dis. 1990 Mar-Apr;12(2):181-90.

Cryptococcus neoformans is an uncommon but treatable cause of osteomyelitis that affects both normal and immunocompromised hosts. When not considered as a diagnostic possibility, C. neoformans infection may result in increased morbidity. The spectrum of disease at presentation extends from an asymptomatic patient with an osteolytic lesion on radiograph to a patient with signs and symptoms of systemic disease. Once diagnosis has been established (often by closed aspiration), optimal therapy appears to involve a combination of amphotericin B, flucytosine, and surgical debridement.

550

The usefulness of blood culture in diagnosing HIV-related systemic mycoses: evaluation of a manual lysis centrifugation method. Bianchi M, Robles AM, Vitale R, Helou S, Arechavala A, Negroni R.Med Mycol. 2000 Feb;38(1):77-80.

The results of 5034 blood cultures, implementing a lysis-centrifugation method with saponin, are summarized in this paper. Three hundred and twenty-two blood samples (6.3%) obtained from a pool of human immunodeficiency virus (HIV)-positive patients yielded fungi. Cryptococcus neoformans was isolated in 199 samples (3.95%), Histoplasma capsulatum in 95 (1.89%). Candida parapsilosis in 12 (0.23%), C. albicans in 7 (0.13%), C. tropicalis in 2, C. krusei in 1, C. guillermondii in 1, and Prototheca wickerhamii in 4 (0.07%). Blood cultures were positive for C. neoformans in 76.23% of patients having a diagnosis of cryptococcosis and in 89.65% of those who had histoplasmosis. The blood culture was the first means of confirming the diagnosis in 23.8% of the patients with cryptococcosis and in 54% with histoplasmosis. In the four patients in whom P. wickerhamii was isolated, a diagnosis of disseminated protothecosis was not achieved by other findings. Catheter infections were responsible for the majority of recovered Candida.

551

Disseminated cryptococcosis with cutaneous lesions. Mostafa WZ, Ishak EA, Ekladious EM, Arnaout HH. J Dermatol. 1996 Mar;23(3):209-13.

A case of disseminated cryptococcosis in an HIV-negative patient presenting with cutaneous lesions is described for the first time in Egypt. The patient, a 16-year-old male, presented with cough, expectoration, loss of weight, and cutaneous lesions, mainly on the face and trunk. The lesions consisted of vegetating crusted plaques discharging purulent to sanguinous fluid and flattened, shiny, erythematous to brownish plaques. Anorexia, headache and personality changes soon followed. Histopathological examination of lesions was highly suggestive of a deep mycosis, particularly cryptococcosis. The fulminant disease advanced with central nervous system involvement. The progression was not arrested when systemic antifungal therapy was administered late in the disease course. Pathological examination of lungs, liver, pancreas and spleen revealed disseminated infection with no evidence of other underlying pathology. Disseminated cryptococcosis is a morbid infection, rare in an area where heightened awareness and raised index of suspicion will surely allow earlier diagnosis, management and better prognosis.

552

Cryptococcal peritonitis: report of a case and review of the literature. Stiefel P, Pamies E, Miranda ML, Martin-Sanz MV, Fernandez-Moyano A, Villar J. Hepatogastroenterology. 1999 May-Jun;46(27):1618-22.

We describe a patient diagnosed with AIDS and cirrhosis who had recently suffered a self-limited and non-specific esophageal ulceration. After this, he was hospitalized because of an oral bleeding with fatal evolution, and Cryptococcus neoformans was isolated from ascitic fluid during a routine paracenteses. We have reviewed the literature and, since 1963, only another 10 cases of cryptococcal peritonitis have been reported. A liver disease and not the AIDS (surprisingly, our case is the only report of cryptococcal peritonitis in a subject having both diseases) was the most common underlying disease (72.7%) and was associated with the worst prognosis (only one patient survived). An oral or upper gastrointestinal bleeding was the most common associated circumstance although recent steroid or antibiotic therapy has been also reported. Finally, diagnosis was delayed in many patients. The reasons for these delays are discussed.

553

Fungaemia due to Cryptococcus laurentii and a review of non-neoformans cryptococcaemia. Johnson LB, Bradley SF, Kauffman CA. Mycoses. 1998 Sep-Oct;41(7-8):277-80.

Cryptococcus laurentii is one of several non-neoformans cryptococci that have rarely been associated with human infection. The spectrum of clinical infection due to non-neoformans species ranges from skin lesions to fungaemia. Most cases of non-neoformans fungaemia have been nosocomially acquired and have been associated with indwelling intravascular catheters and neutropenia. Limited data on in vitro susceptibilities of non-neoformans cryptococci show these species to be more resistant to fluconazole and flucytosine than most Cr. neoformans. Two such cases are presented here.

554

First report of Cryptococcus albidus septicaemia in an HIV patient. Loison J, Bouchara JP, Gueho E, de Gentile L, Cimon B, Chennebault JM, Chabasse D. J Infect. 1996 Sep;33(2):139-40.

 

555

Cryptococcus laurentii fungemia in a premature neonate. Cheng MF, Chiou CC, Liu YC, Wang HZ, Hsieh KS. J Clin Microbiol. 2001 Apr;39(4):1608-11.

Cryptococcus spp. other than Cryptococcus neoformans are generally considered nonpathogenic to humans. There are only 15 case reports of disease in humans caused by Cryptococcus laurentii infection. Underlying diseases and predisposing risk factors seem to play an important role in these cases. Our patient is the first case of an extremely low birth weight infant with C. laurentii fungemia reported in the English literature. In our case, the MIC of amphotericin B for C. laurentii was 0.25 to 1 microg/ml and the patient had a good outcome following the administration of amphotericin B at 10 mg/kg combined with central venous catheter removal. There will undoubtedly be an increasing occurrence of unusual fungal infections accompanying further advances in medicine. A high degree of suspicion and improvements in the techniques for culture and identification will contribute to the earlier diagnosis and treatment of unusual fungal infections.

557

Cluster of pulmonary infections caused by Cunninghamella bertholletiae in immunocompromised patients. Rickerts V, Böhme A, Viertel A, Behrendt G, Jacobi V, Tintelnot K, Just-Nübling G. Clin Infect Dis. 2000 Oct;31(4):910-3.

Cunninghamella bertholletiae is a rare cause of pulmonary mucormycosis. We describe a cluster of invasive pulmonary infections caused by C. bertholletiae in 4 immunocompromised patients that occurred during a 2-year period at 1 center. Three of the patients were receiving antifungal prophylaxis with itraconazole. Presenting symptoms were fever unresponsive to antibacterial chemotherapy, hemoptysis, and infiltrates on chest radiograms. Three patients were treated with liposomal amphotericin B. Only 1 patient survived.

558

Infections due to Cunninghamella bertholletiae in patients with cancer: report of three cases and review. Kontoyianis DP, Vartivarian S, Anaissie EJ, Samonis G, Bodey GP, Rinaldi M. Clin Infect Dis. 1994 Jun;18(6):925-8.

Limited information is available regarding the pathogenesis and clinical manifestations of infection with Cunninghamella bertholletiae. In this report, we describe the clinical courses of three patients with leukemia and fatal C. bertholletiae infection and review the literature. In all patients, the infection developed in the setting of severe neutropenia following high doses of cytotoxic chemotherapy. Clinical presentation always consisted of fever and pneumonia and could be associated with dissemination to numerous organs. The course of infection was very rapid, and the diagnosis was made around or after the time of death. The most important risk factors for C. bertholletiae infection described in the literature include corticosteroid administration and prolonged severe granulocytopenia. Four infectious syndromes due to Zygomycetes have been described: rhinocerebral, pulmonary, cutaneous and soft tissue, and disseminated. The outcome of disseminated infection with C. bertholletiae has been almost uniformly fatal. Most previously described patients, however, did not receive aggressive treatment consisting of amphotericin B administration, resection of infected tissues, and, most importantly, control of the underlying disease.

559

Pulmonary mucormycosis caused by Cunninghamella bertholletiae in a non-immunocompromised woman] Sato M, Gemma H, Sano T, Ono T, Atsumi E, Ito I, Chida K, Nakamura H. Nihon Kokyuki Gakkai Zasshi. 2001 Oct;39(10):758-62. Japanese.

A 74-year-old woman was admitted for further examination because of an abnormal nodular shadow and thickening of the bronchovascular bundle in the left upper lobe on chest radiography and CT. The findings from a transbronchial biopsy specimen were not conclusive. A thoracoscopic lung biopsy specimen revealed a fungal infection, and partial resection of S1 + 2 of the left upper lobe was carried out. In the dilated bronchus, mucus of high viscosity was seen. Lymphocytes and plasma cells had infiltrated into the bronchioles and alveoli. Fungus was cultured from the mucus, and the morphological characteristics showed Cunninghamella bertholletiae. Pulmonary mucormycosis caused by C. bertholletiae in a non-immunocompromised person is very rare. Furthermore, this patient also had a wheeze, eosinophilia, elevation of the serum IgE level, and was positive for specific IgE to Mucor. We therefore consider that this case was an incomplete type of allergic bronchopulmonary fungusis (ABPF).

560

Cunninghamella bertholletiae infection in a bone marrow transplant patient: amphotericin lung penetration, MIC determinations, and review of the literature. Garey KW, Pendland SL, Huynh VT, Bunch TH, Jensen GM, Pursell KJ. Pharmacotherapy. 2001 Jul;21(7):855-60.

Infections caused by Cunninghamella bertholletiae, an opportunistic fungal organism, have an extremely high mortality rate. A fatal case of C. bertholletiae fungal pneumonia occurred in a man who had received an allogeneic bone marrow transplant. Aggressive debridement and high-dose liposomal amphotericin B failed to eradicate the infection. Right lung tissue samples obtained during lobectomy were assayed for amphotericin B concentrations by high-performance liquid chromatography, and minimum inhibitory concentration (MIC) determinations of amphotericin B against C. bertholletiae were determined by the macrobroth dilution method. The MIC for the isolate of C. bertholletiae was 4 microg/ml. Amphotericin B lung concentrations averaged 9.5 microg/ml (range 3.7-13.8 microg/ml), with a corresponding serum trough concentration of 0.9 microg/ml. To our knowledge, this is the first reported case of amphotericin B concentrations measured at the site of infection in a patient with a pulmonary Cunninghamella infection, together with a corresponding MIC of the organism. The patient's death, which occurred despite aggressive debridement and high amphotericin B lung concentrations, highlights the need for novel strategies to treat infections caused by invasive molds such as C. bertholletiae.

561

Cunninghamella infection post bone marrow transplant: case report and review of the literature. Darrisaw L, Hanson G, Vesole DH, Kehl SC. Bone Marrow Transplant. 2000 Jun;25(11):1213-6.

Cunninghamella spp., in the class Zygomycete and order Mucorales, are unusual opportunistic pathogens that have been identified with increased frequency in immunocompromised patients. Infections with this group of organisms have been seen most frequently in patients with hematologic malignancy. We describe an allogeneic bone marrow recipient who developed fungal pneumonitis and disseminated fungal dermatitis caused by Cunninghamella spp. To our knowledge, this is the first reported case of Cunninghamella infection in a BMT recipient. The case highlights the mortality associated with opportunistic infections in immunocompromised patients and confirms the risk factors associated with non-candida fungal infections after bone marrow transplantation.

562

[A case of pulmonary zygomycosis caused by Cunninghamella bertholletiae]. Hashiguchi K, Niki Y, Miyashita N, Kuroki M, Nakajima M, Kawane H, Matsushima T, Nishimura K. Kansenshogaku Zasshi. 1997 Mar;71(3):264-8.

Cunninghamella bertholletiae, a rare causative agent of human deep seated mycosis, has been reported with increased frequency in the Western countries, in recent years. We experienced a case of Cunninghamella bertholletiae pulmonary infection in a 63-year-old male with pulmonary fibrosis and mild diabetes mellitus. In spite of intensive anti-fungal chemotherapy following clinical diagnosis, he died of exacerbation of the underlying diseases. Postmortem examination showed Cunninghamella infection in the cavity of the lung and massive pulmonary fibrosis. There was no fungal invasion outside the cavity. This is the third report of Cunninghamella human infection in Japan.

563

Cunninghamella infections: review and report of two cases of Cunninghamella pneumonia in immunocompromised children. Cohen-Abbo A, Bozeman PM, Patrick CC. Clin Infect Dis. 1993 Aug;17(2):173-7.

Infections caused by Cunninghamella bertholletiae are being identified with increasing frequency in immunocompromised patients. We have treated two children with cancer for pulmonary infections caused by this rare fungus. Cunninghamella infection is found in a variety of populations of patients, including both children and adults undergoing chemotherapy. Clinical signs and symptoms are indistinguishable from those of other forms of zygomycosis. Outcome is poor: only three of 17 patients with such infection (including one of the two children described herein) have survived. Treatment involves aggressive surgical excision and administration of amphotericin B.

564

Cunninghamella bertholletiae: an uncommon agent of opportunistic fungal infection. Case report and review. Maloisel F, Dufour P, Waller J, Herbrecht R, Marcellin L, Koenig H, Liu KL, Weber JC, Bergerat JP, Oberling F. Nouv Rev Fr Hematol. 1991;33(4):311-5.

Cunninghamella bertholletiae is a fungus of the Zygomycetes class, Mucorales order. Only very few cases of disseminated infection have been reported. We observed a new case in a 19 years old man with severe aplastic anemia, due to pulmonary primoinfection and hematologic dissemination. This aplastic anemia failed to respond first to an antithymocyte globulin and steroid treatment and then to cyclosporine A. Deferoxamine was infused weekly to prevent iron overload. During a second antithymocyte globulin and steroid treatment, the patient developed bilateral pneumonia. Culture of the broncho-alveolar washing fluid established the diagnosis by isolation of C. bertholletiae. Despite amphotericin B and 5-fluorocytosine intravenous therapy, the patient died of disseminated infection six days after diagnosis, which was confirmed by necropsy. Underlying conditions, diagnosis and treatment are discussed, together with a review of the literature.

565

Endocarditis and hemorrhagic stroke caused by Cunninghamella bertholletiae infection after kidney transplantation. Zhang R, Zhang JW, Szerlip HM. Am J Kidney Dis. 2002 Oct;40(4):842-6.

Cunninghamella bertholletiae is a saprophytic fungus found in soil. Infection with this organism is extremely rare, occurring almost exclusively in immunosuppressed hosts. There have been only three previous cases of infection with this fungus reported in solid-organ recipients. We report an unusual case of disseminated Cunninghamella infection in a woman who had received a renal transplant. A 48-year-old woman received a living-related kidney transplant for focal segmental glomerulonephritis. She was treated with plasmapheresis and muromonab-CD3 (OKT3) for two episodes of rejection. Because of recurrent focal segmental glomerulonephritis with diuretic-resistant edema, she underwent transplant nephrectomy, was restarted on hemodialysis, and had her immunosuppression stopped. Shortly thereafter, the patient presented with pulmonary infiltrates and hemorrhagic stroke with a rapidly fatal course. Autopsy revealed widely disseminated C bertholletiae involving the central nervous system, lungs, and heart. This is the first reported case of endocarditis caused by this organism. Diagnosis of this fungal infection is often difficult. Because the few patients who have survived this infection seemed to have been diagnosed early, it is important for clinicians caring for transplant patients to be aware of this invasive infection. Successful treatment requires prompt diagnosis and high-dose amphotericin B.

566

Zygomycosis caused by Cunninghamella bertholletiae] Chiba N, Miki R. Rinsho Byori. 1990 Nov;38(11):1219-25.

Cunninghamella bertholletiae, an uncommon cause of human fungal infection, has been reported with increasing frequency in recent years in Western countries. We report a case of acute myelogenous leukemia terminated by an uncommon complication of zygomycosis caused by C. bertholletiae, which seems to be the first human case reported in Japan. In this case, the fungus disseminated many organs, including the thyroid gland.

567

Cutaneoarticular mucormycosis due to Cunninghamella bertholletiae in a patient with AIDS. Mostaza JM, Barbado FJ, Fernandez-Martin J, Peña-Yañez J, Vazquez-Rodriguez JJ. Rev Infect Dis. 1989 Mar-Apr;11(2):316-8.

A case of mucormycosis in an AIDS patient is reported. The infection was located in the skin and knee joint after open trauma of the left thigh. Cunninghamella bertholletiae was isolated. The prognosis of this infection is ominous in patients with AIDS because of their precarious immunologic status.

568

Rhinocerebral mucormycosis: a report of eleven cases. Chetchotisakd P, Boonma P, Sookpranee M, Pairojkul C. Southeast Asian J Trop Med Public Health. 1991 Jun;22(2):268-73.

Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand.
Rhinocerebral mucormycosis (RCM) is a rare, fulminant fungal infection that usually occurs in diabetic or immunocompromised patients. The mortality rate has been reduced recently with the advent of amphotericin B combined with aggressive surgery. Eleven RCM patients have been treated over the past five years at Srinagarind Hospital. Eight had underlying diabetes, five had renal failure and three of them had both. In eight patients, the diagnosis was established by KOH preparation before histological confirmation. Only two cases revealed positive cultures for Rhizopus spp and Cunninghamella spp. All patients underwent surgical treatments (extensive debridement, 8 cases; sphenoidectomy, 7 cases; ethmoidectomy 8 cases; maxillectomy 5 cases and orbital exenteration, 6 cases). Amphotericin B was administered to all patients as soon as the diagnosis of RCM was made. Only three patients survived. Early diagnosis and cooperation among ophthalmologist, otolaryngologist and physician are the most important factors for the survival of patients with mucormycosis.

569

Successful treatment of sinusitis caused by Cunninghamella bertholletiae. Ng TT, Campbell CK, Rothera M, Houghton JB, Hughes D, Denning DW. Clin Infect Dis. 1994 Aug;19(2):313-6.

Seventeen cases of infections due to Cunninghamella species have been reported worldwide in humans, and there have been only three survivors. We report a case of paranasal sinusitis due to Cunninghamella bertholletiae in an elderly patient who had diabetes mellitus and myelodysplasia. After receiving 7 weeks of therapy with deoxycholate amphotericin B (44 mg/kg or a total of 3 g) and rifampin, the patient was cured and did not have to undergo radical surgery.

570

A rare zygomycosis due to Cunninghamella bertholletiae. Dermoumi H. Mycoses. 1993 Sep-Oct;36(9-10):293-4.

An unusual endobronchial zygomycosis due to Cunninghamella bertholletiae in a leukaemic patient is reported. Following bypass operation, fungal infection developed. The patient died on day 7 after surgery as a result of long-term immunosuppressive treatment and haemodynamic complications.

571

Cunninghamella bertholletiae: an unusual agent of zygomycosis. Robinson BE, Stark MT, Pope TL, Stewart FM, Donowitz GR. South Med J. 1990 Sep;83(9):1088-91.

Cunninghamella bertholletiae shares many of the features typical of the other agents causing zygomycoses. Those who are immunocompromised constitute the major patient population at risk; the agents as a group are aggressive, the disease is often disseminated, and the pathologic picture of vascular invasion and tissue infarction is common. Unlike other agents of zygomycoses, Cunninghamella bertholletiae infection remains difficult to treat successfully even after early diagnosis and appropriate therapy.

572

Fatal Cunninghamella bertholletiae infection in an immunocompetent patient. Zeilender S, Drenning D, Glauser FL, Bechard D. Chest. 1990 Jun;97(6):1482-3.

The first fatal Cunninghamella bertholletiae infection in a clinically immunocompetent host is reported. This case differs from previously reported cases by the lack of extensive vascular invasion and thrombosis.

573

Disseminated mucormycosis due to Cunninghamella bertholletiae in a liver transplant recipient. Nimmo GR, Whiting RF, Strong RW. Postgrad Med J. 1988 Jan;64(747):82-4.

Disseminated mucormycosis occurred in a 19 year old female following orthotopic liver transplantation for fulminant Wilson's disease. The causative organism Cunninghamella bertholletiae has previously been described in ten clinical cases, but never before in this setting.

578

Molds in onychomycosis. Ramani R, Srinivas CR, Ramani A, Kumari TG, Shivananda PG. Int J Dermatol. 1993 Dec;32(12):877-8.

BACKGROUND: Onychomycosis is a major cause of nail dystrophy. The causative organisms in onychomycosis are dermatophytes, Candida and molds. A variety of molds have been isolated from nails. METHODS: Nail scrapings and clippings were collected from 100 cases and inoculated on slants containing SDA with cycloheximide 0.5 mg/mL, chloramphenicol 0.05 mg/mL, and SDA with chloramphenicol 0.05 mg/mL. RESULTS: The culture positivity rate for molds was 22%. The predominant mold isolates were Aspergillus species (86.4%, Fusarium oxysporum (4.5%), Curvularia species (4.5%) and Penicillium species (4.5%). CONCLUSION: Primary invasion of nails by molds can cause onychomycosis.

579

Human Curvularia infections. Report of five cases and review of the literature. Rinaldi MG, Phillips P, Schwartz JG, Winn RE, Holt GR, Shagets FW, Elrod J, Nishioka G, Aufdemorte TB. Diagn Microbiol Infect Dis. 1987 Jan;6(1):27-39.

Curvularia lunata is a saprobic dematiaceous mould that resides primarily in soil (Ellis, 1966). Reports of human disease caused by this organism are rare but include: endocarditis, brain abscess, skin infections, onychomycosis, keratitis, pneumonia, disseminated disease, mycetoma, allergic bronchopulmonary disease, and one case of sinusitis. Since 1983, we have encountered five cases of paranasal sinusitis due to C. lunata. None of the patients suffered from known immunologic disorders or underlying debilitating diseases. These five cases are presented and the literature of human phaeohyphomycosis caused by Curvularia spp. is reviewed.

580

A case of onychomycosis caused by Curvularia lunata (Wakker) Boedijn. Barde AK, Singh SM. Mykosen. 1983 Jun;26(6):311-6.

 

581

Curvularia keratitis. Wilhelmus KR, Jones DB. Trans Am Ophthalmol Soc. 2001;99:111-30; discussion 130-2.

PURPOSE: To determine the risk factors and clinical signs of Curvularia keratitis and to evaluate the management and outcome of this corneal phaeohyphomycosis. METHODS: We reviewed clinical and laboratory records from 1970 to 1999 to identify patients treated at our institution for culture-proven Curvularia keratitis. Descriptive statistics and regression models were used to identify variables associated with the length of antifungal therapy and with visual outcome. In vitro susceptibilities were compared to the clinical results obtained with topical natamycin. RESULTS: During the 30-year period, our laboratory isolated and identified Curvularia from 43 patients with keratitis, of whom 32 individuals were treated and followed up at our institute and whose data were analyzed. Trauma, usually with plants or dirt, was the risk factor in one half; and 69% occurred during the hot, humid summer months along the US Gulf Coast. Presenting signs varied from superficial, feathery infiltrates of the central cornea to suppurative ulceration of the peripheral cornea. A hypopyon was unusual, occurring in only 4 (12%) of the eyes but indicated a significantly (P = .01) increased risk of subsequent complications. The sensitivity of stained smears of corneal scrapings was 78%. Curvularia could be detected by a panfungal polymerase chain reaction. Fungi were detected on blood or chocolate agar at or before the time that growth occurred on Sabouraud agar or in brain-heart infusion in 83% of cases, although colonies appeared only on the fungal media from the remaining 4 sets of specimens. Curvularia was the third most prevalent filamentous fungus among our corneal isolates and the most common dematiaceous mold. Corneal isolates included C senegalensis, C lunata, C pallescens, and C prasadii. All tested isolates were inhibited by 4 micrograms/mL or less of natamycin. Topical natamycin was used for a median duration of 1 month, but a delay in diagnosis beyond 1 week doubled the average length of topical antifungal treatment (P = .005). Visual acuity improved to 20/40 or better in 25 (78%) of the eyes. CONCLUSIONS: Curvularia keratitis typically presented as superficial feathery infiltration, rarely with visible pigmentation, that gradually became focally suppurative. Smears of corneal scrapings often disclosed hyphae, and culture media showed dematiaceous fungal growth within 1 week. Natamycin had excellent in vitro activity and led to clinical resolution with good vision in most patients with corneal curvulariosis. Complications requiring surgery were not common but included exophytic inflammatory fungal sequestration, treated by superficial lamellar keratectomy, and corneal perforation, managed by penetrating keratoplasty.

582

Curvularia lunata endophthalmitis with secondary keratitis. Kaushik S, Ram J, Chakrabarty A, Dogra MR, Brar GS, Gupta A. Am J Ophthalmol. 2001 Jan;131(1):140-2.

PURPOSE: To report a case of pseudophakic endophthalmitis with secondary keratitis caused by Curvularia lunata. METHODS: A 40-year-old man presented with a fluffy mass in the anterior chamber with low-grade delayed postoperative inflammation in the right eye. RESULTS: The anterior chamber and vitreous aspirate demonstrated C. lunata. A large corneal infiltrate developed after aspiration of the mass. Treatment with systemic, topical, and intraocular antifungal agents cleared the vitreous, but the cornea perforated. CONCLUSION: Delayed low-grade infection with a fluffy mass in the anterior chamber after cataract surgery can rarely be a clinical presentation of dematiaceous fungal infection. Secondary keratitis may result after a diagnostic aspiration.

583

Mycotic keratitis due to Curvularia senegalensis and in vitro antifungal susceptibilities of Curvularia spp. Guarro J, Akiti T, Horta RA, Morizot Leite-Filho LA, Gené J, Ferreira-Gomes S, Aguilar C, Ortoneda M. J Clin Microbiol. 1999 Dec;37(12):4170-3.

Case of mycotic keratitis due to Curvularia senegalensis is reported. This case represents the third known reported infection caused by this rare species. Fungal hyphae were detected in corneal scrapings, and repeated cultures were positive for this fungi. The patient was presumed cured after a corneal transplant and treatment with itraconazole, but the infection recurred and the patient is waiting for a keratoplasty. The in vitro antifungal susceptibilities of the case strain and another 24 strains belonging to seven species of Curvularia were tested for six antifungal agents. With the exception of flucytosine, and occasionally fluconazole, the other drugs assayed (amphotericin B, miconazole, itraconazole, and ketoconazole) were highly effective in vitro.

584

Fungal keratitis caused by Curvularia lunata, with successful medical treatment. Dorey SE, Ayliffe WH, Edrich C, Barrie D, Fison P. Eye. 1997;11 ( Pt 5):754-5.

 

585

Mycotic keratitis caused by Curvularia brachyspora (Boedjin). A report of the first case. Marcus L, Vismer HF, van der Hoven HJ, Gove E, Meewes P. Mycopathologia. 1992 Jul;119(1):29-33.

Curvularia brachyspora has been identified for the first time as a cause of mycotic keratitis. Mycotic infections of the eye have assumed increasing importance in ophthalmology, resulting in a need for fungal identification and early specific treatment for the successful management of cases. A case of mycotic keratitis caused by C. brachyspora is described against the background of other Curvularia species causing mycoses.

586

Atypical skin lesions caused by Curvularia sp. and Pseudallescheria boydii in two patients after allogeneic bone marrow transplantation. Bonduel M, Santos P, Turienzo CF, Chantada G, Paganini H. Bone Marrow Transplant. 2001 Jun;27(12):1311-3.

We report two patients who developed atypical skin lesions caused by Curvularia sp. and Pseudallescheria boydii after allogeneic bone marrow transplantation for severe aplastic anemia. The first patient (female, 18-year-old) had multiple hemorrhagic vesicles on day +30 after her second BMT for graft failure. Pseudallescheria boydii was isolated from a skin biopsy. The patient died of respiratory failure probably as a consequence of systemic fungal infection. The second patient (male, 9-year-old) developed an ecthyma gangrenosum-like lesion on his right palm on day +8. Curvularia sp. was isolated from a skin biopsy. Liposomal amphotericin was given to achieve a total dose of 30 mg/kg and followed by oral itraconazole until steroids were discontinued. The infection resolved completely and the patient has remained disease-free. We conclude that emerging fungal organisms such as those described in this report are increasingly recognized in this setting. Early recognition and biopsy of these cutaneous lesions will allow prompt initiation of therapy to prevent systemic infection.

587

Two cases of cutaneous phaeohyphomycosis caused by Curvularia pallescens. Agrawal A, Singh SM. Mycoses. 1995 Jul-Aug;38(7-8):301-3.

Two cases of cutaneous phaeohyphomycosis caused by Curvularia pallescens are described. Lesions were found on the feet, thigh and thumb and were irregularly marginated, pruritic black and occasionally purulent. Histopathology revealed heavy infection of the stratum corneum and other cutaneous layers as well as host tissue response. The fungus appeared as dark, aggregated to simple branched hyphae. Oxiconazole was most effective 'in vitro' against the pathogen. This is the first report of C. pallescens as an opportunistic pathogen of human skin.

588

Case report: phaeohyphomycosis due to Curvularia lunata involving skin and subcutaneous tissue after an explosion at a chemical plant. Grieshop TJ, Yarbrough D 3rd, Farrar WE. Am J Med Sci. 1993 Jun;305(6):387-9.

Cases of phaeohyphomycosis due to dematiaceous fungi have been reported in increasing numbers and diversity. The optimal roles of antifungal chemotherapy and surgical debridement in the management of these infections have not been determined. A case of acute cutaneous and subcutaneous phaeohyphomycosis due to Curvularia lunata after an explosion at a chemical plant is reported, in which the organisms may have been inoculated into the tissues by the force of the blast. No organisms were found by histopathologic examination or culture of excisional biopsy specimens taken 10 days after initiation of therapy with intravenous amphotericin B; the antifungal therapy may have eradicated the infection.

589

Invasive sinusitis with intracranial extension caused by Curvularia lunata. Ismail Y, Johnson RH, Wells MV, Pusavat J, Douglas K, Arsura EL. Arch Intern Med. 1993 Jul 12;153(13):1604-6.

Curvularia lunata has previously been linked to localized sinus infection in immunocompetent hosts. We treated a case of pansinusitis with extensive bone destruction and intracranial extension caused by C lunata. Curvularia lunata was identified when typical fungal macroconidia appeared on culture. Numerous surgical procedures, in addition to a 12-month course of antifungal therapy consisting of 4 g of intravenous amphotericin B and an 8-month course of 400 mg of oral ketoconazole daily, were required to control the infection. This unusual case of invasive sinusitis caused by C lunata alerts the treating physician to the presence of this mold and gives an overview of diagnostic method as well as the management.

590

Invasive sinusitis and cerebritis due to Curvularia clavata in an immunocompetent adult. Ebright JR, Chandrasekar PH, Marks S, Fairfax MR, Aneziokoro A, McGinnis MR. Clin Infect Dis. 1999 Mar;28(3):687-9.

 

591

Fungal sternal wound infection due to Curvularia lunata in a neonate with congenital heart disease: case report and review. Yau YC, de Nanassy J, Summerbell RC, Matlow AG, Richardson SE. Clin Infect Dis. 1994 Oct;19(4):735-40.

We describe a neonate with congenital heart disease in whom a sternal wound infection caused by the filamentous fungus Curvularia lunata developed following cardiac surgery. Despite their widespread distribution in the environment, Curvularia species rarely cause human infection. We also review the 43 cases of curvularia infection previously reported in the English-language literature; only four of these cases occurred in children. A wide spectrum of infections--including keratitis, cutaneous infections, sinusitis, allergic bronchopulmonary disease, pneumonia, chronic ambulatory peritoneal dialysis-related infections, endocarditis and disseminated infections--have been described. Curvularia is a pathogen that can cause disease in both immunocompetent and immunocompromised hosts, although more severe and disseminated disease occurs in patients with defective immune function. Surgery alone usually is successful for treating locally invasive disease, although a combination of medical and surgical therapy is necessary for treating disseminated infections.

592

Curvularia/Drechslera sinusitis. Killingsworth SM, Wetmore SJ. Laryngoscope. 1990 Sep;100(9):932-7.

Sinusitis due to unusual fungal pathogens is thought to occur primarily in immunocompromised individuals. However, the fungi Curvularia, Drechslera, and others produce sinusitis in healthy young adults. The signs and symptoms produced by these organisms are usually considered to be complications of sinusitis. Of the three cases that we report, two manifested decreased visual acuity, and the third presented with acute onset of seizures. Computed tomography scans were helpful in delineating the extent of disease and in following the results of therapy. Aggressive surgical treatment is necessary; indeed, two of our cases required a second operation to eradicate all disease. If histopathology shows tissue invasion by the fungus, intravenous amphotericin B is recommended. Fungal cultures and smears should be obtained when healthy patients present with complications of sinusitis.

593

Fungal maxillary sinusitis caused by Curvularia lunata. Nishioka G, Schwartz JG, Rinaldi MG, Aufdemorte TB, Mackie E. Arch Otolaryngol Head Neck Surg. 1987 Jun;113(6):665-6.

Recently, reports have surfaced in which saprobic fungi, as well as fungi pathogenic for plants, seem to be evolving as human pathogens. While the bulk of infected patients are immunocompromised, many individuals appear to be immunocompetent. To our knowledge, this is the second known published case of maxillary sinusitis caused by Curvularia lunata in an immunocompetent patient. An interesting feature of this case is that the patient was treated with only surgery (débridement and irrigation) with complete resolution and no recurrence.

594

Curvularia lunata endocarditis treated with terbinafine: case report. Bryan CS, Smith CW, Berg DE, Karp RB. Clin Infect Dis. 1993 Jan;16(1):30-2.

A 44-year-old man developed endocarditis due to Curvularia lunata on a Carpentier-Edwards porcine heterograft with clinical involvement of the ring of the aortic valve and the aortic root. Because curative surgery was considered to be extremely high risk, he was treated with antifungal drugs for nearly 7 years. Initial treatment with amphotericin B and ketoconazole was followed by long-term treatment with terbinafine, an experimental allyamine derivative. No adverse effects were attributed to terbinafine. At surgery nearly 7 years later, the aortic valve ring and aortic root appeared to be uninvolved, and the valve was replaced uneventfully. To our knowledge, this is the first report of successful treatment of curvularia endocarditis.

595

Pulmonary and cerebral mycetoma caused by Curvularia pallescens. Lampert RP, Hutto JH, Donnelly WH, Shulman ST. J Pediatr. 1977 Oct;91(4):603-5.

 

596

Case report. Eumycetoma due to Curvularia lunata. Janaki C, Sentamilselvi G, Janaki VR, Devesh S, Ajithados K. Mycoses. 1999;42(4):345-6.

Eumycetoma caused by Curvularia lunata affecting the right foot is described in a 27-year-old farmer with the mycological and mycopathological features. The patient was being treated with oral ketoconazole 200 mg daily for 2 months and followed.

597

Mycetomas caused by Curvularia lunata, Madurella grisea, Aspergillus nidulans, and Nocardia brasiliensis in Sudan. Mahgoub ES. Sabouraudia. 1973 Jul;11(2):179-82.

 

598

Disseminated Curvularia lunata infection in a football player. Rohwedder JJ, Simmons JL, Colfer H, Gatmaitan B. Arch Intern Med. 1979 Aug;139(8):940-1.

For ten years, a 25-year-old immune-competent man experienced a progressive disseminated infection with the saprophytic soil fungus, Curvularia lunata, following presumptive cutaneous inoculation while playing football. Deep, soft tissue abscesses, pulmonary suppuration, paravertebral abscess, and cerebral abscess all followed leg ulcers from neglected abrasions. The patient's delay in obtaining treatment was partially responsible for the paravertebral-mediastinal-pleural-cutaneous fistula that resulted. The importance of prompt and aggressive surgical drainage procedures is clear. Infection was arrested only by surgery. The fungus was inhibited by miconazole nitrate and amphotericin B but it developed resistance to flucytosine. Miconazole appeared to cause resolution of the cerebral abscess. Amphotericin B (1 mg/kg/day) clearly was beneficial but only after effective drainage procedures were done. The patient refused to continue amphotericin B after 5.4 g had been given in two treatments. He became bedridden one year later from back pain that was caused by recurrent disease.

599

Disseminated Curvularia infection. de la Monte SM, Hutchins GM. Arch Pathol Lab Med. 1985 Sep;109(9):872-4.

Curvularia is a saprophyte that rarely causes infection, and then usually occurs in immunocompromised patients. A 41-year-old man, previously in good health, developed pulmonary and cerebral infection with Curvularia lunata. With surgery and amphotericin B therapy, he recovered and was free of infection one year later.

600

Disseminated Curvularia infection. Additional therapeutic and clinical considerations with evidence of medical cure. Pierce NF, Millan JC, Bender BS, Curtis JL. Arch Pathol Lab Med. 1986 Oct;110(10):959-61.

A previously reported case of cerebral infection due to Curvularia lunata is more fully described. Medical cure was apparently achieved after 30 months' treatment with amphotericin B. Success was achieved only when the drug was given in a dose of 40 mg, three times per week, and was continued for six months after enhanced computed tomographic scans no longer showed cerebral lesions. Immunologic studies suggested the infection was accompanied by an unexplained defect in cell-mediated immunity.

601

Disseminated Curvularia infection. Pierce NF, Millan JC, Bender BS, Curtis JL. Arch Pathol Lab Med. 1986 Oct;110(10):871.

 

604

White grain mycetoma caused by a Cylindrocarpon sp. in India. Hemashettar BM, Siddaramappa B, Padhye AA, Sigler L, Chandler FW. J Clin Microbiol. 2000 Nov;38(11):4288-91.

We describe a case of white grain eumycetoma of the foot of an Indian male caused by a slow-growing, poorly sporulating fungus that does not match any known agent of this infection. Histologic examination of a biopsy tissue specimen showed oval, lobular, white granules composed of hyaline, septate hyphae, and thick-walled chlamydospores. Culture of granules from a draining sinus yielded compact, very-slow-growing, poorly sporulating colonies producing a strong reddish brown pigment that diffused into the medium. The fungus was identified as a Cylindrocarpon sp. based on the development of rare cylindrical conidia borne from solitary phialides lacking collarettes, in addition to chlamydospores formed singly or in short chains.

605

Mycetoma of the foot caused by Cylindrocarpon destructans. Zoutman DE, Sigler L. J Clin Microbiol. 1991 Sep;29(9):1855-9.

A 39-year-old male, originally from Antigua, West Indies, presented with a 12-year history of swelling of the left foot. A pathogen could not be recovered in cultures of three surgical biopsy specimens. During follow-up, pus and grains were expressed from a draining sinus tract and Cylindrocarpon destructans grew in pure culture. Retrospective examination of histologic sections of tissue removed during the third biopsy demonstrated a grain characteristic of eumycotic mycetoma. Although the fungus was susceptible to amphotericin B and ketoconazole in vitro, the patient refused treatment, and the clinical course over almost 19 years has been one of slow but progressive bone destruction. The fungus was identified by its microconidial morphology, the presence of chlamydospores, and an intense brown diffusible pigment. It was compared with another poorly known agent of white grain mycetoma, Phialophora cyanescens, characterized by phialidic conidia, chlamydospores in aggregations, and an intense diffusing pigment.

606

Keratomycosis caused by Cylindrocarpon lichenicola. Mangiaterra M, Giusiano G, Smilasky G, Zamar L, Amado G, Vincentín C. Med Mycol. 2001 Feb;39(1):143-5.

We present a case of keratomycosis caused by Cylindrocarpon lichenicola in a 30-year-old immunocompetent male patient living in a rural area of Formosa Province (north-eastern Argentina). No ocular trauma is reported in his case history. There are no previous reports of infections caused by this fungus in Argentina.

607

Cutaneous infection caused by Cylindrocarpon lichenicola in a patient with acute myelogenous leukemia. Iwen PC, Tarantolo SR, Sutton DA, Rinaldi MG, Hinrichs SH. J Clin Microbiol. 2000 Sep;38(9):3375-8.

Cylindrocarpon lichenicola is a saprophytic soil fungus which has rarely been associated with human disease. We report the first case of localized invasive cutaneous infection caused by this fungus in a 53-year-old male from the rural midwestern United States with relapsed acute myelogenous leukemia. On admission for induction chemotherapy, the patient was noted to have an abrasive laceration between the fourth and fifth metacarpophalangeal joints and on the dorsum of the right hand, which progressed to frank ulceration following chemotherapy. A biopsy provided an initial diagnosis of an invasive fungal infection consistent with aspergillosis based on the histopathological appearance of the mold in tissue. Multiple positive fungal cultures which were obtained from the biopsied tissue were subsequently identified by microscopic and macroscopic characteristics to be C. lichenicola. The infection resolved following marrow regeneration, aggressive debridement of the affected tissue, and treatment with amphotericin B. This case extends the conditions associated with invasive disease caused by C. lichenicola.

608

Peritonitis in continuous ambulatory peritoneal dialysis due to Cylindrocarpon lichenicola infection. Sharma R, Farmer CK, Gransden WR, Ogg CS. Nephrol Dial Transplant. 1998 Oct;13(10):2662-4.

 

609

Disseminated infection due to Cylindrocarpon lichenicola in a patient with acute myeloid leukaemia. James EA, Orchard K, McWhinney PH, Warnock DW, Johnson EM, Mehta AB, Kibbler CC. J Infect. 1997 Jan;34(1):65-7.

We describe what is to our knowledge the first reported case of disseminated infection due to Cylindrocarpon. The presumed source was athlete's foot, a condition with which this fungus has previously been associated. Diagnosis was made by needle aspiration of a cutaneous lesion. Radiographic evidence of pulmonary involvement was present. The infection resolved following marrow regeneration and treatment with amphotericin B. Correct identification of Cylindrocarpon may be useful in guiding antifungal therapy.

612

Subcutaneous phaeohyphomycosis caused by Cyphellophora pluriseptata. Bittencourt AL, Machado PR, Araujo MG. Eur J Dermatol. 2002 Jan-Feb;12(1):103-6.

We present the first case of subcutaneous phaeohyphomycosis caused by Cyphellophora pluriseptata, a fungus described in 1986 by DeVries. The patient was apparently healthy and presented an extensive infiltration of the left ear simulating borderline leprosy. Microscopically a heavy infiltration of lymphocytes admixed with multinucleated giant cells in the dermis was observed in the absence of abscesses. The histopathological diagnosis was achieved through the finding of dematiaceous hyphae. Based on a review of the specific literature the authors discuss the unusual aspects of this case and emphasize the importance of isolating the etiologic agent in cases of phaeohyphomycosis.

613

Keratomycosis caused by Dichotomophthoropsis nymphaearum. Wright ED, Clayton YM, Howlader A, Nazrul I, Husain R. Mycoses. 1990 Sep-Oct;33(9-10):477-81.

A case of Dichotomophthoropsis nymphaearum, a dematiaceous hyphomycete, is described from Bangladesh. This species has not previously been reported as a human pathogen. Hyphae were observed in Gram stained corneal scrapings and the species was grown from cultured corneal material. Treatment with topical econazole and subconjunctival injections of miconazole was successful in the short term but long-term outcome could not be determined. The results of sensitivity tests for six antifungal drugs are reported for the isolate.

620

Intracranial and paranasal sinus infection due to Drechslera. Ruben SJ, Scott TE Jr, Seltzer HM. South Med J. 1987 Aug;80(8):1057-8.

Drechslera, a common soil fungus, has rarely been reported as a human pathogen. We have reported a case of Drechslera paranasal sinus and intracranial infection successfully treated with surgical resection, amphotericin B, and ketoconazole.

621

Prevalence of fungal corneal ulcers in northern India. Chander J, Sharma A. Infection. 1994 May-Jun;22(3):207-9.

Fungal corneal ulcer is common in India due to the tropical climate and a large agrarian population that is at risk. Various factors such as trauma, the injudicious use of topical antibiotics and corticosteroids are involved. Many of the age and sex-related risk factors also play a minor role. This 6-year study from Northern India revealed that fungi were detected in 61 (8.4%) out of 730 patients investigated. Direct microscopy was positive in 51 (7%) and culture in 53 (7.3%) patients. Aspergillus spp. were the most common causative agents accounting for 25 (40.1%) of the isolates, followed by Fusarium sp. with ten (16.4%), Curvularia sp. with five (8.2%), Candida albicans with five (8.2%), Acremonium sp. with four (6.6%), Paecilomyces sp. with three (4.9%), Penicillium sp. with two (3.3%), Alternaria sp. with two (3.3%), Fonsecaea pedrosoi var. cladosporium with two isolates (3.3%) and Pseudallescheria boydii, Drechslera sp. and Aureobasidium pullulans with one isolate (1.6%) each. The prevalence of fungal ulcers in males was three times higher than in females. The affected individuals had a rural background and were in the 51-60 year age group.

622

Studies on mycotic keratitis. Sundaram BM, Badrinath S, Subramanian S. Mycoses. 1989 Nov;32(11):568-72.

One hundred and fifty cases of corneal ulcers from the Government Ophthalmic Hospital, Madras, were investigated during 1980-1982 for the mycoflora. 68 cases (45%) were positive for fungi, comprising species of Aspergillus (36 cases), Penicillium, Fusarium (8 cases each), Curvularia (4 cases), Candida albicans and Mucor (3 cases each), Drechslera (2 cases) and Cladosporium, Cephalosporium, Pullularia, and Allescheria boydii (1 case each). Incidence of these fungi in mycotic keratitis is correlated with factors such as age, sex and occupation of the patients and is discussed in detail.

623

Inhibition of mitochondrial respiration by asteltoxin, a respiratory toxin from Emericella variecolor. Kawai K, Fukushima H, Nozawa Y. Toxicol Lett. 1985 Nov;28(2-3):73-7.

Asteltoxin, a respiratory toxin from Emericella variecolor, was examined for an inhibitory effect on mitochondrial function. Asteltoxin strongly inhibited state 3 respiration, which was released by an uncoupling agent, 2,4-dinitrophenol (DNP), indicating that the action site of asteltoxin is localized in the energy transfer system of mitochondria. Asteltoxin strongly depressed Mg2+-ATPase activity in mitochondria and only slightly affected Na+, K+-activated ATPase in microsomes at the concentration range for inhibition of mitochondrial respiration.

636

Pneumonia due to Fonsecaea pedrosoi and cerebral abscesses due to Emericella nidulans in a bone marrow transplant recipient. Morris A, Schell WA, McDonagh D, Chaffee S, Perfect JR. Clin Infect Dis. 1995 Nov;21(5):1346-8.

 

637

Mycologic identification of Emericella nidulans and Aspergillus flavus causing pulmonary infection. Shao JZ, Liao WQ, Li SQ, Wu SX, Zhang JZ, Huang JJ. Chin Med J (Engl). 1983 Apr;96(4):306-8.

 

638

Case Report. Maxillary sinus infection due to Emericella nidulans. Horré R, Schumacher G, Marklein G, Krömer B, Wardelmann E, Gilges S, De Hoog GS, Wahl G, Schaal KP. Mycoses. 2002 Nov;45(9-10):402-5.

Fungal infections of the maxillary sinus are frequently caused by Aspergillus species, particularly A. fumigatus. In otherwise healthy persons there is an association with overfilling of dental root canals, when zinc-containing filling materials were used. Below, a maxillary sinus aspergilloma is reported in a young immunocompetent female patient caused by Aspergillus (Emericella) nidulans.

639

Emericella nidulans in a maxillary sinus fungal mass. Mitchell RG, Chaplin AJ, Mackenzie DW. J Med Vet Mycol. 1987 Oct;25(5):339-41.

Sexual reproductive stages of fungi are very rarely found within mammalian tissues. We report here coexistence of cleistothecia associated with Emericella nidulans and its conidial state, Aspergillus nidulans, in a fungal mass which developed in a maxillary sinus.

640

Pulmonary adiaspiromycosis: casual finding in a patient who died of yellow fever] Moraes MA, Gomes MI, Vianna LM. Rev Soc Bras Med Trop. 2001 Jan-Feb;34(1):83-5.

During an outbreak of yellow fever (rural form of the infection) occurred recently in the State of Goiás, Brazil, a patient, with clinical manifestations suggestive of the infection, died in the University Hospital of Brasilia, DF, on the fifth day from admission. Postmortem examination revealed, microscopically, the characteristic alterations of the infection, and discovered in the lungs and hilar lymph nodes round microrganisms identified as adiaconidia of Emmonsia parva var. crescens.

641

Pulmonary adiaspiromycosis: report of two cases. dos Santos VM, Fatureto MC, Saldanha JC, Adad SJ. Rev Soc Bras Med Trop. 2000 Sep-Oct;33(5):483-8.

Two cases of human pulmonary adiaspiromycosis are reported. Patients were 29 and 54-year-old males, farm workers, with "grippe-like" symptoms and radiographic findings suggestive of granulomatous interstitial disease. Transthoracoscopic and transbronchial biopsies were performed. Pulmonary function was measured by spirometry. One patient used ketoconazole. Possibility of misdiagnosed pulmonary adiaspiromycosis is emphasized.

642

Pulmonary adiaspiromycosis in a patient with acquired immunodeficiency syndrome. Turner D, Burke M, Bashe E, Blinder S, Yust I. Eur J Clin Microbiol Infect Dis. 1999 Dec;18(12):893-5.

Adiaspiromycosis is a noninfectious, nonarthropod-transmitted fungal infection that occurs worldwide in lower vertebrates, especially rodents. However, humans may become accidental hosts. Reported here is a case of adiaspiromycosis of the lung in an HIV-positive, 40-year-old, bisexual man who first presented with cough and dyspnea. Cultures of a bronchoalveolar lavage and protected brush specimen revealed the presence of fungal elements that were identified as Emmonsia parva var. parva. The patient was successfully treated with amphotericin B and thereafter with fluconazole. This organism should be added to the list of pathogens that cause pulmonary infection in AIDS patients.

643

[Adiaspiromycosis, 2 cases of incidental finding] Thomas De Montpréville V, Huerre M, Dulmet E. Ann Pathol. 1999 Dec;19(6):513-5.

Two apparently solitary granulomas, each containing an adiaconidia, 200 and 300 microm in diameter, were incidentally found in the lung parenchyma on a pleuro-pneumonectomy specimen for malignant mesothelioma, and in the stroma of a pulmonary adenocarcinoma, respectively. These two cases of adiaspiromycosis illustrate well the characteristic morphology of this strictly pulmonary, rare, ubiquitous, and histologically diagnosed mycosis.

644

[Human adiaspiromycosis. A report of a case treated with ketoconazole] Martins RL, Santos CG, França FR, Moraes MA. Rev Soc Bras Med Trop. 1997 Nov-Dec;30(6):507-9.

A case of human disseminated pulmonary adiaspiromycosis is reported. The patient, from Goianésia, GO, was admitted to the Brasilia University Hospital, in November 1992, with wet cough, dyspnea and weight loss--manifestations that had appeared two months before. Prior to admission, he had been treated for a suspected miliary tuberculosis, because a chest roentgenogram had shown a diffuse reticulonodular infiltrate in both lungs. This therapy brought no improvement to the patient status. An open chest biopsy was then performed, and the microscopic examination of the lung tissue revealed the fungal nature of the disease. Ketoconazole, 400mg/day, was started and the patient discharged from the hospital. He was seen again two months later: the respiratory manifestations had disappeared and a new chest roentgenogram showed complete resolution of the pulmonary lesions. The usefulness of ketoconazole is, however, questioned, since, as there is no multiplication of the fungus in the host organism--adiaspiromycosis is believed to be, usually, a self-healing disease--the efficacy of this imidazole derivative against the agent in animal tissues remains to be confirmed.

645

[Disseminated pulmonary adiaspiromycosis. A case report] dos Santos VM, Santana JH, Adad SJ, Lopes GP, Fatureto Mda C. Rev Soc Bras Med Trop. 1997 Sep-Oct;30(5):397-400.

A case of thoracoscopic lung biopsy proven diffuse human adiaspiromycosis is reported. The patient, a 26-year-old male farm worker presented with a three-week history of fever, sweating, dyspnea and unproductive cough. Radiographic findings were those of granulomatous pulmonary interstitial disease. Treated with ketoconazole he improved very well, resuming work normal activities a month later.

646

Pulmonary adiaspiromycosis in a two year old girl. Nuorva K, Pitkänen R, Issakainen J, Huttunen NP, Juhola M. J Clin Pathol. 1997 Jan;50(1):82-5.

A case of disseminated bilateral pulmonary adiaspiromycosis is reported in a two year old Finnish girl. She recovered from this rare infection after treatment with amphotericin B. She is the first human case of adiaspiromycosis in Scandinavia and she is the youngest child with this disease reported so far. Electron microscopy showed that the three layers of the spore wall were not typical; rather, there seemed to be a gradual transition between the main wall zones, which may be split into an indefinite number of thin layers. Varying numbers and thicknesses were seen with different staining methods, and in different spores. Diagnosis relies on recognition of the fungus in a pulmonary biopsy specimen, because there are no reliable serological tests and culture of the fungus is time consuming and not always successful. It was thought that this patient had become infected as a result of contact with soil dust containing the spores in the yard surrounding her home, and as a result of her mother's work in a large garden shop.

647

Adiaspiromycosis: an unusual fungal infection of the lung. Report of 11 cases. England DM, Hochholzer L. Am J Surg Pathol. 1993 Sep;17(9):876-86.

Adiaspiromycosis (ad"i-ah-spi"ro-mi-kósis) is a worldwide, noninfectious, nonarthropod transmitted fungal infection of lower vertebrates, most commonly rodents. Humans become an accidental host by inhaling dust-borne spores (conidia) of the saprophytic soil fungus, Emmonsia crescens (recently renamed Chrysosporium parvum variety crescens). We report 11 cases of this unusual deep mycosis from South America, Europe, and the United States. The severity of the disease depends on the number of spores inhaled. In limited inoculum, the disease remains localized (two cases), whereas in heavy inocula the fungus involves both lungs (nine cases) and presents as a diffuse reticulonodular infiltrate. In this disseminated form, patients usually complain of cough, dyspnea on exertion, and low-grade fever mimicking other systemic fungal infections and tuberculosis. It is difficult to unmask the fungus because it is not easily cultured nor is there a reliable serologic test. Therefore, a biopsy is required and the pathologist must recognize the large (ranging in size from 50 to 500 microns), round, Gomori methenamine-silver nitrate and periodic acid-Schiff reagent-positive spherules with a trilaminar wall. The spherules can be surrounded by either suppuration, epithelioid granulomas with or without necrosis, or concentric, hyalinized fibrosis. In the latter chronic stage, the organism may collapse, forming a variety of sizes and shapes thereby resembling other fungi, helminths, mineral particles, or inhaled pollen grains. Clinically, the infection most commonly regresses spontaneously, but may persist, or rarely progress, requiring surgical intervention with limited resection to attain cure.

648

Disseminated adiaspiromycosis in a patient with AIDS. Echavarria E, Cano EL, Restrepo A. J Med Vet Mycol. 1993;31(1):91-7.

A case of disseminated adiaspiromycosis in an AIDS patient is described. The most notable characteristic of the infection was the extensive osteomyelitis exhibited by the patient. Positive cultures for Chrysosporium parvum var. parvum were obtained from pus taken from a lesion of the wrist during surgery as well as from sputum samples and a bone marrow aspirate. Treatment with amphotericin B controlled the fungal infection.

649

Fulminant disseminated pulmonary adiaspiromycosis in humans. Peres LC, Figueiredo F, Peinado M, Soares FA. Am J Trop Med Hyg. 1992 Feb;46(2):146-50.

A case of fulminant disseminated pulmonary adiaspiromycosis is reported. The patient, a 35-year-old black male farm worker, presented with a four-week history of generalized weakness, unproductive cough, evening fever, and a weight loss of 8 kg. He died 12 days after hospitalization of respiratory failure due to granulomatous lung disease. The clinical and radiographic findings were indistinguishable from those of miliary tuberculosis. Microscopic examination of material obtained at autopsy revealed the large fungus characteristic of adiaspiromycosis in the center of suppurative granulomas throughout the lungs. This is believed to be the first fatal case of pulmonary adiaspiromycosis reported in humans, and it may have been occupationally acquired.

650

Pulmonary adiaspiromycosis] Eri Z, Klem I, Durić B, Durić M, Pavlović S. Plucne Bolesti. 1991 Jan-Jun;43(1-2):69-71.

A 54-yr old male patient with a history of dyspnea and cough is presented. Due to the clinical course of disease and the radiological changes in the chest a diagnosis of sarcoidosis was established. However, the open lung biopsy revealed the true nature of the pulmonary disease: pulmonary adiaspiromycosis, only secondary to asbestosis, siderosis and silicosis as due to the well known occupational exposure to asbestos and other dusts.

651

Human pulmonary adiaspiromycosis. A new case of disseminated form] Moraes MA, Silva AE, Raick AN. Rev Soc Bras Med Trop. 1990 Jul-Sep;23(3):171-4.

A case of disseminated pulmonary form of adiaspiromycosis is reported. This is the second case of the disease found in Brasilia, DF. The patient, a 42-year-old peasant, lived in Corrente - State of Piaui, where he certainly acquired the infection. He was admitted to the Social Security Hospital, in Brasilia, with fever, chills, dry cough and dyspnea. At that time, he had been sick for about ten months and the decision of seeking medical care in Brasilia resulted from an exacerbation of the symptoms that had occurred two months before. At a right thoracotomy for a lung biopsy, disseminated white nodular lesions, a few millimeters in diameter, could be observed on the lung surface. Microscopically, round structures, 300 microns or more in diameter, identified as adiaconidia of Chrysosporium parvum var. crescens were seen in the center of some of these lesions. The tisssue response to the causative agent consisted of microabscesses, surrounded by cells in palisading arrangement, and granulomas of the mixed and foreign body types. The two kinds of lesions were thought to represent evolutive stages of the inflammatory process, and to be related to different exposures to the conidia, on separated occasions. The suppurative lesions would be recent lesions, started some weeks or a few months before, while the others, in which the granulomatous reaction predominated, were possibly older lesions, with an evolutions of at least several months.

652

Chrysosporium parvum keratomycosis. Wagoner MD, Badr IA, Hidayat AA. Cornea. 1999 Sep;18(5):616-20.

PURPOSE: To report a case of corneal infection with Chrysosporium parvum, a filamentous fungus usually associated with pulmonary infections. METHODS: A 43-year-old Saudi man had a corneal stromal infiltrate and perforation of his left eye. He was treated with a therapeutic penetrating keratoplasty and topical and systemic antifungal therapy. Corneal scrapings, microbiologic evaluation, and histopathologic examination of the surgical specimen were performed to establish the diagnosis. After the development of recurrent stromal keratitis at the graft-host junction, similar diagnostic and therapeutic maneuvers were performed. RESULTS: Corneal scrapings and histopathologic examination were positive for numerous septate hyphae with endospores, consistent with a diagnosis of filamentous keratomycosis. Microbiologic isolation confirmed the diagnosis of Chrysosporium parvum. Similar diagnostic maneuvers for recurrent keratitis produced identical results. CONCLUSION: To our knowledge, this is the first case of Chrysosporium parvum keratomycosis.

653

[Peritoneal form of adiaspiromycosis (author's transl)] Drápela J, Viklický J, Novák J, Tousek J, Vána M. Z Erkr Atmungsorgane. 1980;155(3):393-8.

A female patient, aged 30 years was subjected in 1977 to an appendectomy because of a perforated gangrenous appendix associated with purulent peritonitis. Postoperatively she developed an intractable constipation persisting for more than one year. Because of suspected intestinal stenosis an exploratory laparotomy was performed which failed to disclose the presence of stenosis. Histological studies of excised peritoneal specimens were suggestive of tuberculous peritonitis. Since cultivation failed to provide evidence of mycobacteria and the clinical symptoms were not characteristic of a tuberculous involvement of the peritoneum it was decided to carry out a re-evaluation of the original histological slides. This revealed that the patient was infected with adiaspores of the fungus Emmonsia crescens which were disseminated over the entire peritoneum from the perforated appendix. The difficulties associated with the diagnosis which are due to the striking morphologic similarity between the minute nodules in adiasporosis and those in productive miliary tuberculosis, as well as because of the acid-fast adiaspore capsules, are stressed. Since Emmonsia crescens is spread in some regions of Czechoslovakia it may be expected that humans will come into contact with its spores either by inhalation or by alimentary ingestion.

654

Adiaspiromycosis of human skin caused by Emmonsia crescens. Kamalam A, Thambiah AS. Sabouraudia. 1979 Dec;17(4):377-81.

Two cases of cutaneous adiaspiromycosis by Emmonsia crescens are reported. This is the first human skin infection by this species and is the first report of its kind in man from India. In the first patient, the agent was demonstrated in KOH mounts, histology and culture from irregular, pigmented skin plaques on the right gluteal area. The lesion also contained calcium. In the second patient the fungus was demonstrated histologically in a knee lesion. The agent had elicited a histiocytic and giant cell reaction in the dermis in both cases. The first patient suffered from anaemia and epilepsy and the second suffered from nephropathy with chyluria. The skin lesions were surgically excised with skin grafting in the first patient.

655

Engyodontium album endocarditis. Augustinsky J, Kammeyer P, Husain A, deHoog GS, Libertin CR. J Clin Microbiol. 1990 Jun;28(6):1479-81.

This is the first reported case of native valve endocarditis caused by Engyodontium album. This fungus, rarely seen as a human pathogen, is separated from Tritirachium species by its lack of pigmentation and from Beauveria species by the presence of conidiogenous cells in whorls.

668

Prevalence and awareness of tinea pedis in Italian sailors. Ingordo V, Fracchiolla S, Figliola F, D'Andria G, Colecchia B, Naldi L. Dermatology. 2000;201(4):349-50.

BACKGROUND: It is difficult to carry out studies on the prevalence of tinea pedis in the community. Some studies are performed on selected groups of subjects, exposed to the same risk factors, i.e. schoolchildren, public bathers, athletes and military men. OBJECTIVE: The aim of this work was to detect in a sample of military men the prevalence of tinea pedis and the awareness of their condition, and to relate the infection to risk factors of the group as well. METHODS: 410 male Italian navy cadets in an Italian navy petty officers school were clinically examined and mycological cultures were performed, employing the skin scrapings obtained from suspected lesions. RESULTS: Dermatophytes were isolated from toe clefts in 10 subjects, giving a point prevalence of 2.4% (95% confidence interval 1.3-4.4%). The isolated dermatophytes were Trichophyton mentagrophytes (70%), Trichophyton rubrum (20%) and Epidermophyton floccosum (10%). None of the subjects was aware of his disease. No significant association was observed between tinea pedis and risk factors (i.e. hyperhidrosis and habits). CONCLUSION: The prevalence in our sample was lower than that observed in previous studies on military men. That can be attributed to the general amelioration of hygienic conditions and strengthening of preventive habits. Therefore the prevalence of tinea pedis in Italian sailors seems to be reduced but still rather relevant. That is important because these subjects are a reservoir of ringworm infection.

669

The frequency of tinea pedis in patients with tinea cruris in Tehran, Iran. Sadri MF, Farnaghi F, Danesh-Pazhooh M, Shokoohi A. Mycoses. 2000;43(1-2):41-4.

The objective of this study is to define the frequency of tinea pedis in patients with tinea cruris. Sixty patients (46 males and 14 females) entered our study. Epidermophyton floccosum was the most frequently isolated fungus in tinea cruris. Four patients (6.4%) had concurrent tinea pedis and the only isolate from the foot was Trichophyton mentagrophytes. In three of them, the corresponding dermatophyte in the groin was E. floccosum.

670

Epidemiology of dermatomycoses of humans in central Poland. Part III. Tinea pedis. Lupa S, Seneczko F, Jeske J, Głowacka A, Ochecka-Szymańska A. Mycoses. 1999;42(9-10):563-5.

The total number of dermatophytoses (7393) included 2025 (27.4%) tinea pedis cases. Etiological factors in descending order by contribution were: Trichophyton rubrum (41.7%), Trichophyton mentagrophytes var. granulosum (30.9%), T. mentagrophytes var. interdigitale (10.0%), Epidermophyton floccosum (7.4%), T. mentagrophytes var. quinckeanum (6.9%), Trichophyton tonsurans (2.3%), Trichophyton spec. (0.4%), Trichophyton terrestre (0.2%), Trichophyton violaceum (0.1%). In the years 1987-93 the incidence of tinea pedis substantially increased over 1994-96. Today tinea pedis is second by incidence among all clinical forms of dermatophyte infections of skin and skin appendages in the Lódź region.

671

Dermatophytosis in schoolchildren in Ekpoma, Nigeria. Enweani IB, Ozan CC, Agbonlahor DE, Ndip RN. Mycoses. 1996 Jul-Aug;39(7-8):303-5.

Of 1400 pupils from two public primary schools in Ekpoma, Edo State, Nigeria, who were screened for dermatophyte infection, 188 (13.4%) were infected. The causative agents isolated included Microsporum audouinii in 88 (46.8%), Trichophyton mentagrophytes in 48 (25.5%), T. rubrum in 40 (21.3%), T. tonsurans in four (2.1%) and Epidermophyton floccosum in eight (4.3%). There were significant differences in the rate of infection between male and female schoolchildren as well as between children from different socioeconomic backgrounds.

672

Dermatophytoses in Iran. Khosravi AR, Aghamirian MR, Mahmoudi M. Mycoses. 1994 Jan-Feb;37(1-2):43-8.

A total of 12,150 cases of suspected dermatophytoses in different areas of Iran were studied between 1986 and 1991. The age groups most commonly infected were 1-9 and 20-29 years. Clinical diagnosis was confirmed in only 9345 cases by laboratory examination. Of these positive samples, 1633 cases were found to be positive by direct microscopic observation only, 429 by culture only and 7283 by both techniques. Scalp ringworm of children was the most common type of tinea. But according to the rate of infection, tinea corporis, tinea pedis, tinea cruris, tinea manuum, tinea unguium and tinea barbae were the next most prevalent in that order. The frequencies of dermatophytes isolated from patients were as follows: Microsporum canis 19.4%, Trichophyton rubrum 16.5%, Epidermophyton floccosum 14.9%, Trichophyton mentagrophytes var. interdigitale 14.6%, Trichophyton verrucosum 11.5%, Trichophyton mentagrophytes 6%, Trichophyton violaceum 8.7%, Trichophyton schoenleinii 5.5%, Trichophyton tonsurans 1.3%, Trichophyton erinacei 0.8% and Microsporum gallinae 0.2%.

673

Dermatophytosis of children in Kuwait. al-Fouzan AS, Nanda A. Pediatr Dermatol. 1992 Mar;9(1):27-30.

Five hundred fifty-six children constituted 39.5% of total smear- and culture-positive cases of dermatophytosis and 0.6% of the total new dermatology outpatients seen over a period of five years. Males outnumbered females. The youngest child was a 20-day-old neonate (age range 20 days-12 yrs) with a peak of fungal infections seen in patients between 4 and 6 years of age. Microsporum canis was the most prevalent (70.5%) species, followed by Trichophyton violaceum, Microsporum audouinii, Trichophyton rubrum, and Epidermophyton floccosum. Rarely, other species were also isolated. Tinea capitis was the most common (73.7%) clinical type, followed by tinea corporis (19.1%), tinea faciei (3.4%), tinea cruris (3.4%), tinea pedis (0.9%), tinea unguium (0.9%), and tinea manus (0.2%). No racial variations were observed; however, the predominant species differed with the clinical types.

674

A study of dermatophytoses in Bangkok (Thailand). Imwidthaya S, Thianprasit M. Mycopathologia. 1988 Apr;102(1):13-6.

A total of 719 cases of dermatophytoses was studied in the Division of Dermatology, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, during January to December 1986. Infection caused by fungus comprises 12%, while the incidence of dermatophytoses was 5.5% of skin disorders. The age group commonly infected was 12-21 years old (mean age of 18 years); 40% was female and 47.5% was male. In the female patients the common prevalent infections were tinea corporis 29%, tinea cruris 23%, tinea pedis 16%, while in male patients it was 28%, 39% and 14% respectively. Only 4 species of dermatophytes were isolated. The prevailing ones were: Trichophyton rubrum 66%, T. mentagrophytes 15%, Epidermophyton floccorum 13% and Microsporum gypseum 6%.

675

Epidemiology and clinical features of dermatomycoses and dermatophytoses. Svejgaard E. Acta Derm Venereol Suppl (Stockh). 1986;121:19-26.

Dermatophytosis, candidosis and pityriasis versicolor account for the majority of fungal skin diseases in Denmark and are seen in 8% of patients with dermato-venerological problems. In children, zoophilic species like Microsporum canis (from cats), Trichophyton (T) verrucosum (from cattle) and T. mentagrophytes granulare (from rodents) are the common causes of dermatophytosis and are seen in approximately 15% of all cases. Anthropophilic species are the main cause of dermatophytosis in adults and are isolated more often in males than in females. T. rubrum (48%), T. mentagrophytes interdigitale (14%) and Epidermophyton floccosum (10%) are the species usually involved. The feet are the site of infection in about 50% of the cases, toenails, glabrous skin and inguinal folds equally often in 42%, palms in 6% and the scalp in 2%. The prevalence of tinea pedis in 15-year-old school children and 20-year-old males was found to be 4% and 6%, respectively. A relative risk of 3.1 for contracting tinea pedis when being an atopic or having an atopic family was demonstrated in the former group. Pityriasis versicolor and candidosis of skin and mucosal membranes are both secondary dermatomycoses caused by endosaphrophytic yeasts. Local or systemic predisposing disorders are usually required for the development of symptoms.

676

[Tinea manuum. Report of 13 cases] Wanke NC, Wanke B. Med Cutan Ibero Lat Am. 1985;13(6):497-501.

The authors report 13 cases of tinea manuum and emphasize that this condition is not commonly described in the Brazilian medical literature. Eight males and five females, aged 18 to 72 years, presented an infection ranging from 1 month to 20 years. The main clinical picture was of desquamating type on the palms without fingernails lesions. All patients had associated dermatophytosis of the feet. Trichophyton mentagrophytes, T. rubrum and Epidermophyton floccosum were the species isolated from the hands. The trichophytin test was positive in all cases and treatment with oral griseofulvin and topical clotrimazole and miconazole was rather effective. Clinical evaluation at the end of the treatment and afterwards did not show relapses.

677

Fungal diseases in Shiraz. Nikpoor N, Buxton MW, Leppard BJ. Pahlavi Med J. 1978 Jan;9(1):27-49.

In 122 patients with fungal diseases studied over a six month period, sixty were seen with dermatophyte infections. Tinea pedis, cruris and ungruium occurred mainly in adult males attending the private hospital and tinea corporis and capitis children attending the University Hospital. The organisms found were Trichophyton rubrum, T. mentagrophytes, T. schonleinii, T. tonsurans, Epidermophyton floccosum and Microsporum canis. Infections with Candida albicans occurred both in the urban and rural population and included case of familial chronic muco-cutaneous candidiasis. Pityriasis versicolor was the commonest fungal disease seen.

678

Epidemiology of dermatomycoses of humans in central Poland. Part V. Tinea corporis. Jeske J, Lupa S, Seneczko F, Głowacka A, Ochecka-Szymańska A. Mycoses. 1999;42(11-12):661-3.

The total number of dermatophytoses (7393) included 2204 (29.8%) cases of tinea glabrosa. Etiological factors in descending order were: Microsporum canis (23.5%), Trichophyton mentagrophytes var. granulosum (21.6%), Trichophyton rubrum (17.8%), Trichophyton tonsurans (10.4%), Epidermophyton floccosum (7.7%), T. mentagrophytes var. quinckeanum (6.0%), Microsporum gypseum (5.3%), Trichophyton violaceum (3.7%), T. mentagrophytes var. interdigitale (2.3%), Microsporum equinum (0.7%), Trichophyton verrucosum (0.4%), Trichophyton spec. (0.4%), Microsporum cookei (0.14%). At present tinea glabrosa is dominant among all clinical forms of dermatophyte infections of skin and skin appendages in the Lódź region.

679

Case report. Disseminated tinea of the verrucous type due to epidermophyton floccosum. Qiangqiang Z, Limo Q, Qixian Q. Mycoses. 2001;44(7-8):326-9.

A case is presented of an 8-year-old boy suffering from disseminated verrucous lesions with some purulent drainage on his right foot, shank, thigh, scrotum, penis, perianal area and abdomen. Epidermophyton floccosum was isolated from these lesions. The patient was treated with oral ketoconazole for 4 months and the lesions resolved completely. There was no evidence of relapse during a 12-month follow-up.

680

Invasive disease due to Epidermophyton floccosum in an immunocompromised patient with Behcet's syndrome. Seddon ME, Thomas MG. Clin Infect Dis. 1997 Jul;25(1):153-4.

 

690

Onychomycosis due to Exophiala jeanselmei. Boisseau-Garsaud AM, Desbois N, Guillermin ML, Ossondo M, Gueho E, Cales-Quist D. Dermatology. 2002;204(2):150-2.

BACKGROUND: Exophiala jeanselmei is a dematiaceous fungus that may cause invasive diseases, particularly among immunocompromised hosts. Most reports mention cutaneous or subcutaneous lesions, but no case of nail involvement due to this fungus has been reported until now. CASE REPORT: A 60-year-old man presented with hyperkeratosis and black coloration of the nails of the two thumbs and the two big toes of 4 years' duration. He was a renal transplant recipient and had been treated with prednisone and azathioprine. E. jeanselmei was present on direct examination, then isolated in cultures on repeated samplings from all pathologic nails. He was cured after 6 months of treatment with itraconazole. COMMENTARY: We describe the first case of nail infection due to E. jeanselmei. Itraconazole, which provides a broad spectrum of action on fungal species and achieves high levels of active substance in many tissues, including the nails, appeared to be efficient upon such a nail localization of E. jeanselmei.

691

Phaeohyphomycosis caused by Exophiala species in immunocompromised hosts. Liou JM, Wang JT, Wang MH, Wang SS, Hsueh PR. J Formos Med Assoc. 2002 Jul;101(7):523-6.

Exophiala species are rarely implicated in clinical diseases. In the past 2 years, we have treated phaeohyphomycosis caused by Exophiala species in three immunocompromised patients. Two of these patients presented with subcutaneous abscess or cutaneous verrucous lesions due to Exophiala jeanselmei. The former, an 81-year-old woman, had pulmonary tuberculosis and the latter, a 62-year-old man, had undergone heart transplantation and was receiving immunosuppressive treatment. The third patient, a 62-year-old woman, had acute lymphoblastic leukemia and developed lymphadenitis due to Wangiella (Exophiala) dermatitidis. In each case, the fungus was discovered on a Gram stain of the aspirated material and was identified by conventional tests. One patient died of bacterial pneumonia with acute respiratory distress syndrome and the other two were treated successfully with surgical excision and antifungal agents. With the more frequent and widespread use of immunosuppressive agents, the incidence of Exophiala infection will certainly increase. Surgical excision or debridement with or without antifungal agents may offer the possibility of cure for phaeohyphomycosis due to Exophiala species.

692

. Subcutaneous phaeohyphomycotic cysts caused by Exophiala jeanselmei in a lung transplant patient. Xu X, Low DW, Palevsky HI, Elenitsas R. Dermatol Surg. 2001 Apr;27(4):343-6.

BACKGROUND: Phaeohyphomycosis is a skin fungal infection caused by dematiaceous fungi that often affects immunocompromised patients. Local recurrence after medication or surgical treatment is common in these patients. We present a case in which a 42-year-old woman status post-bilateral lung transplant developed phaeohyphomycotic cysts with local recurrence and then was successfully treated by local excision with pre- and postsurgery oral itraconazole treatment. OBJECTIVE: To demonstrate the utility of pre- and postsurgery oral itraconazole in immunocompromised patients with recurrent phaeohyphomycosis. METHODS: Local excision with pre- and postsurgery oral itraconazole treatment. RESULTS: Simple excision or excision with postsurgery oral itraconazole resulted in local recurrence in this patient. Local excision with pre- and postsurgery oral itraconazole was effective in preventing the local recurrence. CONCLUSION: Phaeohyphomycosis can run a prolonged course in immunocompromised patients with multiple recurrences. Local excision with pre- and postsurgery oral itraconazole can be used to treat these patients with recurrent phaeohyphomycosis.

693

A case of cutaneous Exophiala spinifera infection. Oba M, Suzuki Y, Kawasaki M. Nippon Ishinkin Gakkai Zasshi. 2000;41(1):17-21.

A 66-year-old female had a solitary dark-red nodule measuring 1 cm in diameter on her left forearm. She often had trauma to her hands and arms. A histopathologic examination demonstrated granulomatous changes in the dermis. Under the high-power magnification yeast-like cells and short toruloid hyphal elements were observed in the granuloma. A few giant cells contained fungal elements. No sclerotic cells were found. On the basis of the histopathologic and mycologic findings, the lesion was diagnosed as a dematiaceous fungal infection caused by Exophiala spinifera. She was treated with oral itraconazole (200 mg/day) and topical heat therapy. The lesion was clinically improved within 58-days. However, E. spinifera was still isolated from the excisional specimen 92-days later. We believe that surgical excision is the choice of therapy if the lesion is small.

694

Phaeohyphomycosis caused by Exophiala dermatitidis following intra-articular steroid injection. Woollons A, Darley CR, Pandian S, Arnstein P, Blackee J, Paul J. Br J Dermatol. 1996 Sep;135(3):475-7.

A patient with long-standing rheumatoid arthritis presented with a painful pigmented chronic nodule on the dorsum of the right hand, at the site of intra-articular steroid injections undertaken 5 years previously. Histology showed pigmented fungal elements consistent with phaeohyphomycosis. Cultures yielded black yeast-like colonies, identified as Exophiala dermatitidis and sensitive to itraconazole and amphotericin. A 1-month course of itraconazole resulted in marked clinical improvement but surgical excision and skin grafting were required for complete resolution. Phaeohyphomycosis has been related to inoculation injury but association with intra-articular steroid injection appears hitherto to be unreported.

695

Exophiala werneckii endophthalmitis following cartaract surgery in an immunocompetent individual. Huber CE, LaBerge T, Schwiesow T, Carroll K, Bernstein PS, Mamalis N. Ophthalmic Surg Lasers. 2000 Sep-Oct;31(5):417-22.

A case of infectious endophthalmitis caused by the saprophyte Exophiala werneckii is reported. This has not been recognized as a pathogen for ocular infections previously. The infection followed uncomplicated cataract surgery involving phacoemulsification and IOL implant. Clinical presentation was that of an indolent endophthalmitis with relatively acute onset. Pars plana vitrectomy, fungal stains, and culture established the diagnosis. Initial management consisted of empirical intravitreal injection of vancomycin, ceftazidime, and amphotericin B. Treatment was supplemented with a 3-week course of systemic fluconazole and topical therapy with natamycin, atropine, ciprofloxacin, and diclofenac. The visual acuity returned to 20/20-2 with no recurrence of infection. The source of the infection could not be determined. Fungal endophthalmitis has to be considered as a rare, though important, complication following ophthalmic surgery. Specific fungal stains and cultures are helpful for establishing the diagnosis early in the course of disease. E werneckii should be considered in the differential diagnosis of fungal endophthalmitis.

696

Exophiala jeanselmei causing late endophthalmitis after cataract surgery. Hofling-Lima AL, Freitas D, Fischman O, Yu CZ, Roizenblatt R, Belfort R Jr. Am J Ophthalmol. 1999 Oct;128(4):512-4.

PURPOSE: To report two cases of late endophthalmitis caused by Exophiala jeanselmei after cataract surgery. METHODS: Case reports, including clinical evaluation, direct examination, and culture of the aqueous humor. RESULTS: In each case, samples from the anterior chamber had positive growth of yeasts with toruloid hyphae and pseudohyphae. Intravitreal and anterior chamber amphotericin B were used in both cases. Apparent clinical resolution was achieved, but after 3 months in one case and 6 months in the other the infection recurred more aggressively, with severe endophthalmitis leading to ocular atrophy. CONCLUSION: E. jeanselmei causes a severe intraocular infection and isolation, and identification of the agent ensures proper diagnosis and treatment. After clinical resolution of the infection, careful and long-term follow-up is recommended to promptly detect relapse and immediately reintroduce treatment.

697

A case of Exophiala dermatitidis ulceration]. Gerard C, Duchesne B, Hayette MP, Lavalleye B, Marechal-Courtois C. Bull Soc Belge Ophtalmol. 1998;268:103-8.

The authors present one case of corneal Exophiala dermatitidis ulceration. This case is analyzed in the field of corneal mycosis infection. Classification, rate, clinical history, biomicroscopy aspects will be discussed. Technical samples will be described. Anatomopathologic slides will be discussed. Finally the medical or surgical treatment will be considered.

698

A case of Exophiala dermatitidis ulceration]. Gerard C, Duchesne B, Hayette MP, Lavalleye B, Marechal-Courtois C. Bull Soc Belge Ophtalmol. 1998;268:103-8.

The authors present one case of corneal Exophiala dermatitidis ulceration. This case is analyzed in the field of corneal mycosis infection. Classification, rate, clinical history, biomicroscopy aspects will be discussed. Technical samples will be described. Anatomopathologic slides will be discussed. Finally the medical or surgical treatment will be considered.

699

Pulmonary infection due to Exophiala jeanselmei: successful treatment with ketoconazole. Manian FA, Brischetto MJ. Clin Infect Dis. 1993 Mar;16(3):445-6.

 

700

Exophiala dermatitidis pneumonia in cystic fibrosis. Kusenbach G, Skopnik H, Haase G, Friedrichs F, Dohmen H. Eur J Pediatr. 1992 May;151(5):344-6.

The chest X-ray film of a girl with cystic fibrosis (CF) showed slowly increasing mottled densities during the 6th and 7th year of her life. Pulmonary symptoms and distress proceeded fast in spite of intensive treatment with antibiotics, corticosteroids, and physiotherapy. Three different fungal organisms were repeatedly cultured from the sputum: Candida albicans, Aspergillus fumigatus, and Exophiala dermatitidis. Antibodies against C. albicans were in the normal range. Candida antigen in blood and antibodies against A. fumigatus were absent. Antibodies against E. dermatitidis were detected by a recently developed indirect immunofluorescence assay. It seems most probable that E. dermatitidis was the causal agent for fungal pneumonia in this case. Under therapy with amphotericin B and flucytosine the clinical course and radiological appearance improved but definitive eradication of E. dermatitidis was only achieved after treatment with itraconazole. The isolation of this fungus from the sputum of a CF patient is reported for the first time. The significance of fungal infections in CF is discussed.

701

Pulmonary phaeohyphomycosis in a patient with hemoptysis. Barenfanger J, Ramirez F, Tewari RP, Eagleton L. Chest. 1989 May;95(5):1158-60.

A 79-year-old retired schoolteacher had a history of bronchiectasis. She developed recurrent hemoptysis requiring multiple blood transfusions. Exophiala dermatitidis was cultured repeatedly from bronchial lavages. To our knowledge, this is the first documented case of isolated pulmonary phaeohyphomycosis due to E dermatitidis, and it was successfully treated with amphotericin B and 5-fluocytosine.

702

Acute cerebral phaeohyphomycosis due to Wangiella dermatitidis accompanied by cerebrospinal fluid eosinophilia. Chang CL, Kim DS, Park DJ, Kim HJ, Lee CH, Shin JH. J Clin Microbiol. 2000 May;38(5):1965-6.

We report a case of cerebral phaeohyphomycosis due to Wangiella dermaitidis in an immunocompetent adult man. His cerebrospinal fluid (CSF) showed pleocytosis with a high eosinophil count but without peripheral blood eosinophilia. The present case suggested that this black yeast-like fungus should be included when the causes of CSF eosinophilia are considered, even though it is an extremely rare pathogen.

703

Brain abscess caused by Wangiella dermatitidis: case report. Ajanee N, Alam M, Holmberg K, Khan J. Clin Infect Dis. 1996 Jul;23(1):197-8.

 

704

Isolation of Exophiala (Wangiella) dermatitidis in a case of otitis externa. Kerkmann ML, Piontek K, Mitze H, Haase G. Clin Infect Dis. 1999 Oct;29(4):939-40.

 

705

Wangiella dermatitidis peritonitis in a CAPD patient.Vlassopoulos D, Kouppari G, Arvanitis D, Papaefstathiou K, Dounavis A, Velegraki A, Hadjiconstantinou V. Perit Dial Int. 2001 Jan-Feb;21(1):96-7.

 

706

Chromoblastomycosis in a patient with a cardiac transplant. Kinkead S, Jancic V, Stasko T, Boyd AS. Cutis. 1996 Nov;58(5):367-70.

Cases of chromoblastomycosis have been reported in immunocompromised patients. However, chromoblastomycosis is rarely caused by Exophiala jeanselmei. While this organism has been reported to induce pheohyphomycosis in a recipient of a cardiac transplant, chromoblastomycosis has not been described. We present a case of chromoblastomycosis caused by Exophiala jeanselmei in a patient who had received a cardiac transplant.

707

Chromoblastomycosis caused by Exophiala spinifera. Padhye AA, Hampton AA, Hampton MT, Hutton NW, Prevost-Smith E, Davis MS. Clin Infect Dis. 1996 Feb;22(2):331-5.

We report the second case of chromoblastomycosis caused by Exophiala spinifera; this is the first known case in the United States. Examination of biopsied tissue showed thick-walled, internally septated, chestnut brown muriform cells (sclerotic bodies) within multinucleated giant cells present in the dermis that were characteristic of chromoblastomycosis. The individual cells within the muriform cells disarticulated from the outer wall of the parent cell and from each other to form endoconidia within the outer walls of the parent cells. After fracture of the outer walls, the endoconidia were released. This unique process of endoconidial formation in vivo for the propagation of muriform cells was observed for the first time. Initial treatment with itraconazole and 5-fluorocytosine followed by treatment with itraconazole and heat resulted in marked improvement in the patient's lesions. This infection reiterates the fact that the dematiaceous fungus E. spinifera, a well-known etiologic agent of phaeohyphomycosis, can cause more than one type of infection and supports earlier observations that chromoblastomycosis and phaeohyphomycosis represent extremes of a continuum of infections.

708

Human infection caused by Exophiala pisciphila: case report and review. Sughayer M, DeGirolami PC, Khettry U, Korzeniowski D, Grumney A, Pasarell L, McGinnis MR. Rev Infect Dis. 1991 May-Jun;13(3):379-82.

Fungi have become increasingly important causes of nosocomial bloodstream infections. The major cause of nosocomial fungemia has been Candida spp, but increasingly molds and other yeasts have caused disease. Exophiala jeanselmei and members of the genus Rhinocladiella are dematiaceous moulds, which have been infrequently associated with systemic infection and have not been described as causes of fungemia. In this paper, the occurrence of 23 cases of fungemia due to these organisms over a 10-month period is reported and the clinical characteristics of patients and outcomes are described. The majority of patients were immunosuppressed; 21 of 23 (91%) had received blood products and 78% had a central venous catheter. All patients had at least one manifestation of fever, but only one patient had signs or symptoms suggesting deep-seated infection. Antifungal therapy was given to 19 of the 23 patients; of those who did not receive therapy, 3 died prior to the culture result and 1 had been discharged without therapy. Antifungal susceptibility of the organisms showed activity of amphotericin B, itraconazole, and the new triazole antifungals voriconazole and posaconazole. E. jeanselmei and Rhinocladiella species are potential causes of nosocomial fungemia and may be associated with systemic infection.

709

Antimycotic susceptibility testing of agents of black grain eumycetoma. Venugopal PV, Venugopal TV, Ramakrishna ES, Ilavarasi S. J Med Vet Mycol. 1993;31(2):161-4.

Antimycotic susceptibility testing of 17 strains of eumycetes including Madurella mycetomatis, Madurella grisea, Pyrenochaeta romeroi, Exophiala jeanselmei and Leptosphaeria tompkinsii, isolated from cases of black grain mycetoma, was carried out against ketoconazole, itraconazole, miconazole and econazole by broth microdilution and agar dilution methods. Itraconazole and ketoconazole were more active inhibiting 50% of the strains (MIC 50) at 0.5 and 1 microgram ml-1 and 90% (MIC 90) at 2.5 and 5 micrograms ml-1, respectively. The MIC 50s of econazole and miconazole were 2.5 and 5 micrograms ml-1 and MIC 90s 10 micrograms ml-1 for both drugs.

710

Nosocomial outbreak of Exophiala jeanselmei fungemia associated with contamination of hospital water. Nucci M, Akiti T, Barreiros G, Silveira F, Revankar SG, Wickes BL, Sutton DA, Patterson TF. Clin Infect Dis. 2002 Jun 1;34(11):1475-80.

From December 1996 through September 1997, we diagnosed 19 cases of fungemia due to Exophiala jeanselmei. We conducted a matched case-control study in which we cultured specimens of blood products, intravenous solutions, and water from a hospital water system. Isolates from environmental cultures were compared to those recovered from patients by random amplification of polymorphic DNA (RAPD). Multivariate analysis showed that neutropenia, longer duration of hospitalization, and use of corticosteroids were risk factors for infection. Environmental cultures yielded E. jeanselmei from 3 of 85 sources: deionized water from the hospital pharmacy, 1 water tank, and water from a sink in a non-patient care area. Use of deionized pharmacy water to prepare antiseptic solutions was discontinued, and no additional cases of infection occurred. RAPD typing showed that isolates from case patients and isolates from the pharmacy water were highly related, whereas the patterns of isolates recovered from the 2 other sources of water were distinct.

711

Nosocomial fungemia due to Exophiala jeanselmei var. jeanselmei and a Rhinocladiella species: newly described causes of bloodstream infection. Nucci M, Akiti T, Barreiros G, Silveira F, Revankar SG, Sutton DA, Patterson TF. J Clin Microbiol. 2001 Feb;39(2):514-8.

Fungi have become increasingly important causes of nosocomial bloodstream infections. The major cause of nosocomial fungemia has been Candida spp, but increasingly molds and other yeasts have caused disease. Exophiala jeanselmei and members of the genus Rhinocladiella are dematiaceous moulds, which have been infrequently associated with systemic infection and have not been described as causes of fungemia. In this paper, the occurrence of 23 cases of fungemia due to these organisms over a 10-month period is reported and the clinical characteristics of patients and outcomes are described. The majority of patients were immunosuppressed; 21 of 23 (91%) had received blood products and 78% had a central venous catheter. All patients had at least one manifestation of fever, but only one patient had signs or symptoms suggesting deep-seated infection. Antifungal therapy was given to 19 of the 23 patients; of those who did not receive therapy, 3 died prior to the culture result and 1 had been discharged without therapy. Antifungal susceptibility of the organisms showed activity of amphotericin B, itraconazole, and the new triazole antifungals voriconazole and posaconazole. E. jeanselmei and Rhinocladiella species are potential causes of nosocomial fungemia and may be associated with systemic infection.

712

Catheter-associated fungemia due to Wangiella (Exophiala) dermatitidis. Nachman S, Alpan O, Malowitz R, Spitzer ED. J Clin Microbiol. 1996 Apr;34(4):1011-3.

We describe a case of catheter-associated Wangiella (Exophiala) dermatitidis fungemia in a human immunodeficiency virus-infected child who was successfully treated with antifungal therapy and catheter removal. Catheter-associated W. dermatitidis fungemia appears to be distinct from previously described cases of disseminated infection with organ involvement.

713

Exserohilum rostratum causing keratitis in India. Mathews MS, Maharajan SV. Med Mycol. 1999 Apr;37(2):131-2.

A case of mycotic keratitis due to atypical Exserohilum rostratum is reported in a 42-year-old male with Hansens disease.

714

Corneal phaeohyphomycosis due to Exserohilum rostratum. A case report and brief review. Kanungo R, Srinivasan R. Acta Ophthalmol Scand. 1996 Apr;74(2):197-9

We report a rare case of corneal phaeohyphomycosis due to Exserohilum rostratum following organic trauma. A known cause of cutaneous and subcutaneous phaeohyphomycosis, this fungus has been very rarely associated with infections of the eye. Being a plant pathogen, along with other saprophytic dematiaceous fungi the possible role in keratomycosis is discussed.

715

A case of cutaneous phaeohyphomycosis caused by Exserohilum rostratum, its in vitro sensitivity and review of literature. Agarwal A, Singh SM. Mycopathologia. 1995 Jul;131(1):9-12.

A 40 year old woman presented with the infection of skin of 3 years duration on the upper anterior aspect of fore-arm. Histologic examination of the skin tissue revealed dematiaceous hyphae, aggregated structures or single celled elements. On detailed mycological examination the isolate was identified as Exserohilum rostratum. Among the antimycotic tested in vitro amorolfine was found to be most effective with MIC value of 3 mcg/ml. This is the first report of E. rostratum infection of man from India.

716

Corneal ulcer due to Exserohilum longirostratum. Bouchon CL, Greer DL, Genre CF. Am J Clin Pathol. 1994 Apr;101(4):452-5.

A 47-year-old man sustained a traumatic injury to the left eye, and a corneal ulcer subsequently developed. Histologic examination of the corneal tissue revealed septate hyphae with acute angle branching. The mycologic and bacterial cultures yielded a dematiaceous fungus with ellipsoidal pigmented macroconidia borne sympodially on geniculate conidiophores. The multicellular macroconidia had prominent, protruding, truncated hila. The shorter macroconidia averaged 5-7 septa, and the longer conidia 13-21 septa. Growth on V-8 agar, alternating between fluorescent light and the dark, produced macroconidia more than 200 microns in length. The isolate was identified as Exserohilum longirostratum. This is believed to be the first documented case of mycotic keratitis caused by the phaeohyphomycete E longirostratum.

717

Cutaneous and subcutaneous phaeohyphomycosis caused by Exserohilum rostratum. Hsu MM, Lee JY. J Am Acad Dermatol. 1993 Feb;28(2 Pt 2):340-4.

Phaeohyphomycosis of the skin caused by Exserohilum is rare. Four cases have been reported; all were subcutaneous in type and all were caused by Exserohilum rostratum. We report two types of skin infection, cutaneous and subcutaneous, that were caused by E. rostratum in two immunocompromised men. Pleomorphic fungal elements were noted within the dermal suppurative and granulomatous infiltrate in case 1 and only within the central hyperkeratotic horny layer of a porokeratosis-like lesion in case 2. E. rostratum was isolated in both cases. Case 2 represents the first documented case of cutaneous Exserohilum phaeohyphomycosis. The clinical and histologic features in this case resembled superficial porokeratosis. To the best of our knowledge these findings have not been reported previously in fungal infections of the skin. The ambiguous terminology that is used in the classification of phaeohyphomycosis is also discussed.

718

Phaeohyphomycosis of the eye caused by Exserohilum rostratum in India. Anandi V, George JA, Thomas R, Brahmadathan KN, John TJ. Mycoses. 1991 Nov-Dec;34(11-12):489-91.

A 40-year-old woman developed a corneal ulcer with hypopyon following a traumatic episode. In a KOH mount dematiaceous, septate, branched hyphae were demonstrated, and heavy growth of Exserohilum rostratum was obtained in culture. No bacterial pathogens were isolated. The patient was treated with natamycin and subsequently with ketoconazole. In spite of antimycotic therapy a descemetocele of the eye remained. This observation represents the first documented case of an Exserohilum infection in India.

719

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.

720

Emerging agents of phaeohyphomycosis: pathogenic species of Bipolaris and Exserohilum. McGinnis MR, Rinaldi MG, Winn RE. J Clin Microbiol. 1986 Aug;24(2):250-9.

Study of numerous living isolates of Bipolaris, Drechslera, Exserohilum, and Helminthosporium spp., as well as a mycological assessment of published case reports of phaeohyphomycosis attributed to these fungi, showed that Bipolaris australiensis, B. hawaiiensis, B. spicifera, Exserohilum longirostratum, E. mcginnisii, and E. rostratum are well-documented pathogens. Conidial shape, septation, and size, hilar characteristics, the origin of the germ tube from the basal cell and, to a lesser extent, from other conidial cells, and the sequence and location of the conidial septa are useful criteria for distinguishing these taxa.

721

Human Exserohilum and Bipolaris infections: report of Exserohilum nasal infection in a neutropenic patient with acute leukemia and review of the literature. Douer D, Goldschmied-Reouven A, Segev S, Ben-Bassat I. J Med Vet Mycol. 1987 Aug;25(4):235-41.

A neutropenic patient with acute myeloid leukemia developed nasal and perinasal infection caused by the fungus Exserohilum rostratum. Early amphotericin B treatment along with marrow recovery resulted in resolution of the infection. A review of other previously reported cases of Exserohilum and Bipolaris infections show a favourable outcome in most patients who receive systemic antifungal treatment with amphotericin B.

722

Phaeohyphomycosis of the nasal sinuses caused by a new species of Exserohilum. Padhye AA, Ajello L, Wieden MA, Steinbronn KK. J Clin Microbiol. 1986 Aug;24(2):245-9.

A 27-year-old man with a 6-year history of allergies developed nasal polyps that occluded his nose and prevented visual examination beyond the nasal vestibules. Histological examination of the polyps and bony tissue revealed septate, dematiaceous hyphae invading the bone trabeculae. A dematiaceous fungus was isolated in pure culture from the diseased tissue. Detailed mycological examination of the isolate showed that it produced numerous, distinctive poroconidia from erect, geniculate, sympodial conidiophores. The conidia were straight and cylindroellipsoidal, had 8 to 13 distosepta, and had protruding hila. The outer cell walls of the conidia, which were initially smooth, became unevenly roughened on aging. Comparison with other Exserohilum species revealed that the isolate represented an undescribed species; it is named Exserohilum mcginnisii sp. nov.

723

Fatal disseminated infection due to Exserohilum rostratum in a patient with aplastic anemia: case report and review. Aquino VM, Norvell JM, Krisher K, Mustafa MM. Clin Infect Dis. 1995 Jan;20(1):176-8.

Exserohilum rostratum is a dematiaceous fungus that rarely causes infection in humans. We describe a patient with severe aplastic anemia who developed fatal disseminated disease caused by E. rostratum, and we review the English-language literature on this unusual agent. Our patient initially presented with signs and symptoms of sinusitis, which progressed to invasive pulmonary disease. The clinical course and histopathologic findings at autopsy were similar to those seen in cases of invasive aspergillosis or mucormycosis in that a propensity for vascular invasion and dissemination was seen.

726

Chromoblastomycosis: a review of 100 cases in the state of Rio Grande do Sul, Brazil. Minotto R, Bernardi CD, Mallmann LF, Edelweiss MI, Scroferneker ML. J Am Acad Dermatol. 2001 Apr;44(4):585-92.

BACKGROUND: If not diagnosed earlier, chromoblastomycosis has a chronic evolutional course that may cause several problems, such as difficulty in managing therapy because of the recrudescent character of the disease, potential association with the growth of epidermoid carcinoma in affected regions, and poor quality of life and work incapacity to the patient. Although infrequent, new cases are reported in the state of Rio Grande do Sul every year, ratifying the necessity for further studies on this disease. OBJECTIVE: The purpose of this study was to review clinical features and response to therapy in patients with chromoblastomycosis and present data on the demography and history of this disease in the state of Rio Grande do Sul, Brazil. METHODS: We reviewed case records of 100 patients with skin lesions caused by chromoblastomycosis, who were treated between 1963 and 1998. The cases were confirmed by the histopathologic and mycologic analyses made by the Dermatology Service of the Universidade Federal do Rio Grande do Sul at the Santa Casa de Misericórdia Hospital. RESULTS: There was a predominance of male patients (4:1) and of white farmers whose ages ranged from 50 to 59 years, with lesions on their lower limbs. Most of them were from the northern regions of the state. The average time between the appearance of the disease and medical diagnosis was 14 years. The verrucous type proved to be the most frequently reported lesion (53%). Thorn wounds were associated with the disease in 16% of the cases. Lesions uncommon to some parts of the body were also reported. In two of the cases, cutaneous lesions caused by paracoccidioidomycosis and chromoblastomycosis were found in the same patient. Epidermoid carcinoma was found in the same parts of the body affected by chromoblastomycosis. Eumycotic mycetoma and chromoblastomycosis were associated. Fonsecaea pedrosoi was found in 96% of the cases, and Phialophora verrucosa in 4% of the cases. CONCLUSION: In our study, we observed a predominance of cases in the regions of Missões and Alto Uruguay, followed by the upper and lower northeastern slopes and the lowlands. Severe cases of chromoblastomycosis with intense skin involvement (eg, lesions with carcinoma) were observed. Statistical analysis showed recrudescence of the disease in 43% of cases despite the treatment used.

727

Chromoblastomycosis in India. Sharma NL, Sharma RC, Grover PS, Gupta ML, Sharma AK, Mahajan VK. Int J Dermatol. 1999 Nov;38(11):846-51.

BACKGROUND: Four patients with chromoblastomycosis are presented. An additional 30 infected Indian patients are reviewed. RESULTS: These 34 patients ranged in age from 12 to 80 years with a male to female ratio of 5.8 : 1. Onset before the age of 20 years was seen in 24% of cases which was comparatively high. Culture was positive in 72% of cases and sclerotic bodies were observed in 84% of cases. A relatively higher prevalence (15%) of Fonsecaea compacta was observed. Unusual cutaneous sites afflicted were the penile shaft, vulva, and ala of the nose, and unusual extracutaneous spread was seen in the pleural cavity, ileocecal region, laryngotracheal area, and tonsils. Extracutaneous involvement was seen in 24% of cases. Overlapping infection with another fungus, Geotrichum candidum, was seen in one case. CONCLUSIONS: Combination therapy with two azoles was attempted with some success for clinical cure.

728

Chromoblastomycosis--a clinical and mycological study of 71 cases from Sri Lanka. Attapattu MC. Mycopathologia. 1997;137(3):145-51.

Chromoblastomycosis, a well-documented chronic fungal infection, represents a specific clinical entity with typical warty cutaneous nodules and a worldwide distribution. Although more prevalent in tropical and subtropical regions, only a few reports are available from Sri Lanka or from Asia. Five etiologic agents of chromoblastomycosis have been recognized worldwide. Of these the majority of infections have been caused by Fonsecaea pedrosoi. During the period from 1952 to 1962, only twelve culturally proven cases of this disease had been recorded from Sri Lanka. The fungus responsible was F. pedrosoi. The present report presents a study of the clinical and mycological features of 71 Sri Lankan patients with chromoblastomycosis for the 16-year period from 1978 to 1993. It documents three etiological agents. Culture identification was made in 69 cases. The three fungal species were Fonsecaea pedrosoi (64), Phialophora verrucosa (3) and a fungus compatible morphologically with F. compacta (2). The isolation of a fungus morphologically compatible with F. compacta is of significance since only 12 cases have been documented in the world's literature so far.

729

Corneal chromoblastomycosis. Barton K, Miller D, Pflugfelder SC. Cornea. 1997 Mar;16(2):235-9.

PURPOSE: We sought to illustrate the difficulty in managing uncommon, pigmented mold-related corneal ulceration and to highlight the role of itraconazole in treating these patients. METHOD: We describe the management and clinical course of a patient with a recurring corneal infection caused by Fonsecaea pedrosoi and discuss this experience in the light of existing literature on management of cutaneous chromoblastomycosis. RESULTS: A corneal ulcer caused by this organism healed initially on treatment with topical and systemic antifungal medication, but infection recurred in the deep stroma 4 months after cessation of therapy. After failure to respond to a further period of medical therapy, a small therapeutic penetrating keratoplasty was performed. Culture of a fibrinous membrane from the anterior iris surface demonstrated intraocular fungal infection, and postoperatively, an episode of marked fibrinous uveitis developed, suggesting the presence of viable intraocular fungal elements. A large penetrating keratoplasty was therefore performed with excision of involved iris in combination with extracapsular cataract extraction. F. pedrosoi was again cultured from the fibrinous membrane adherent to the iris and from the anterior lens capsule. Postoperatively the patient received a 5-month course of systemic itraconazole, and no further recurrences have been encountered after a further 2 months. CONCLUSION: F. pedrosoi is the organism most commonly isolated from the chronic cutaneous mycosis, chromoblastomycosis, and is relatively resistant to medical therapy. As has been reported for cutaneous disease, surgery in combination with systemic itraconazole may provide the best chance of cure in corneal chromoblastomycosis.

730

Chromoblastomycosis in Gabon. Study of 64 cases] Kombila M, Gomez de Diaz M, Richard-Lenoble D, Renders A, Walter P, Billiault X, Joire A, Coniquet-Folquet S, Duong TH, de Bièvre C. Sante. 1995 Jul-Aug;5(4):235-44.

During the last 25 years, 64 cases of chromoblastomycosis were diagnosed in Gabon. They came from the entire territory, where living in rural zones men as well as women were affected. The evolution of the disease has lasted for more than 10 years for the majority of the cases. The preferential location is the lower limb for 78.5% of the patients, with a double localization for one case and an exceptional malignant transformation for another case. Two clinical aspects emerged, despite an apparent polymorphism: extensive patches and warty nodules, spread apart from or adjacent to the others. The histological images were classical and the fumagoid cells, sometimes budding and filamentous, were easily detected during examination of the squama and scabs. Fonsecaea pedrosoï was the only identified species. The 5-fluorocytosine treatment constantly led to an improvement of the lesions. The major problem for these destitute patients is economic, concerning the cost of the therapy.

731

Chromomycosis: a twenty-year analysis of histologically confirmed cases in Jamaica. Bansal AS, Prabhakar P. Trop Geogr Med. 1989 Jul;41(3):222-6.

Thirty-one cases of histologically confirmed chromomycosis seen at the University Hospital of the West Indies (UHWI) between 1967 and 1986 were reviewed. A mean age of 56 years and a 5 to 1 male to female ratio were recorded. The lower limb was infected most frequently and both the macroscopic and microscopic disease showed typical features. Fonsecaea species were isolated in all 16 cases in whom mycological information was available (14 cases of F. pedrosoi). Surgical excision and split skin grafting produced long term cure in 7 to 10 cases with limited disease. Chromomycosis is more common in Jamaica than previous records would suggest.

732

Cerebral phaeohyphomycosis caused by Fonsecaea pedrosoi in Saudi Arabia. al-Hedaithy SS, Jamjoom ZA, Saeed ES. APMIS Suppl. 1988;3:94-100.

A case of cerebral phaeohyphomycosis (CPM) in a 70-yr-old Saudi male was diagnosed recently at King Khalid University Hospital in Riyadh. Computerized tomography (CT) scans of the patient's brain unveiled 2 abscesses in the left frontal and a 3rd abscess in the right frontal lobes. Aspirated pus from the abscesses contained branched, septate, brown hyphae diagnostic of CPM. Culturing of pus yielded a slow-growing, dematiaceous fungus which was identified as Fonsecaea pedrosoi. Combined therapy of amphotericin B and 5-fluorocytosine had little or no effect as the patient continued to have spiking fever and his condition remained more or less unchanged. Medical care of the patient was unfortunately discontinued as he was discharged, with a rather poor prognosis, at the insistence of his family and against medical advice. Prior to this case, work had been done on identifying the agents responsible for two previously diagnosed cases of CPM in Saudi patients with fatal outcome. The dematiaceous fungi that were isolated remained sterile for quite a time before we succeeded in inducing sporulation. Both these isolates were also identified as being Fonsecaea pedrosoi.

733

Experience with brain abscess in the central province of Saudi Arabia. Jamjoom A, Jamjoom ZA, Naim-Ur-Rahman, Tahan A, Malabarey T, Kambal A. Trop Geogr Med. 1994;46(3):154-6.

The characteristics of brain abscess in the Central Province of Saudi Arabia are outlined in this report which is a review of 22 consecutive cases that were treated at King Khalid University Hospital between 1985-1991. The incidence of brain abscess in Saudi Arabia is calculated to be 3.6 cases/500,000 population/year which is twice as high as the incidence reported from the West. There were 17 males and 5 females with an age range of 8 months-80 years (mean 29.9 years). The parietal lobe was involved in 27%, while the abscess was in the posterior fossa in 14% and multiple in another 14% of cases. The primary source of sepsis was unknown in 50%, post-traumatic in 18% and from a dental and mastoid origin in 14% of cases only. Duration of symptoms ranged between 4-30 days (mean 12 days). Fever was present in 55% of cases and epilepsy in 23%. Sixteen (73%) cases had burr hole aspiration, while 3 (14%) had craniotomy and excision, and 3 (14%) cases were managed with antimicrobial treatment only. Staphylococci were the pathogens in 27%, while streptococci were cultured in 23% cases and the culture was negative in 23%. Three (14%) cases all of which died had fungal abscesses caused by Fonsecaea pedrosoi. The mortality was 18%, good recovery in 68% and fair recovery in 14%. Follow-up was from 3 months to 5.5 years (mean 1.8 years).

734

Primary mycotic abscess of the brain caused by Fonsecaea pedrosoi. Case report. Santosh V, Khanna N, Shankar SK, Pal L, Das S, Chandramukhi A, Kolluri VR. J Neurosurg. 1995 Jan;82(1):128-30.

A case of cerebral abscess caused by Fonsecaea pedrosoi is reported in a nonimmunocompromised 15-year-old boy. In the absence of a primary cutaneous lesion, this fungus was considered to be a primary neuropathogen. The fungus was cultured and characterized from the abscess material obtained at surgery. Prompt therapy using amphotericin B and 5-flucytosine helped in the successful recovery of this patient.

773

Cutaneous infection by Fusarium species in healthy and immunocompromised hosts: implications for diagnosis and management. Nucci M, Anaissie E. Clin Infect Dis. 2002 Oct 15;35(8):909-20.

IInfections by Fusarium species frequently involve the skin, either as the primary or the metastatic site. To better understand the pathophysiology of these infections, 43 new patients with fusariosis were evaluated, and the literature was reviewed. A total of 259 patients (232 immunocompromised and 27 immunocompetent) were identified. Skin involvement was present in 70% of patients, particularly in immunocompromised patients (72% vs. 52%; P=.03). In immunocompetent patients, cutaneous infections were characterized by preceding skin breakdown, localized involvement, slow pace of progression, and good response to therapy. In contrast, skin involvement in immunocompromised patients was only occasionally preceded by skin breakdown and typically was presented as rapidly progressive disseminated lesions at various stages of evolution. Metastatic skin lesions were associated with fungemia, neutropenia, and death. Skin was the single source of diagnosis for the majority of immunocompromised and immunocompetent patients. Recommendations for the prevention of fatal fusariosis originating from skin are presented.

774

Fusarium infections of the skin. Gupta AK, Baran R, Summerbell RC. Curr Opin Infect Dis. 2000 Apr;13(2):121-128.

Fusarium species are ubiquitous and may be found in the soil, air and on plants. Fusarium species can cause mycotoxicosis in humans following ingestion of food that has been colonized by the fungal organism. In humans, Fusarium species can also cause disease that is localized, focally invasive or disseminated. The pathogen generally affects immunocompromised individuals with infection of immunocompetent persons being rarely reported. Localized infection includes septic arthritis, endophthalmitis, osteomyelitis, cystitis and brain abscess. In these situations relatively good response may be expected following appropriate surgery and oral antifungal therapy. Disseminated infection occurs when two or more noncontiguous sites are involved. Over eighty cases have been reported, many of which had a hematologic malignancy including neutropenia. The species most commonly involved include Fusarium solani, Fusarium oxysporum, and Fusarium moniliforme (also termed F. verticillioides). The diagnosis of Fusarium infection may be made on histopathology, gram stain, mycology, blood culture, or serology. Portals of entry of disseminated infection include the respiratory tract, the gastrointestinal tract, and cutaneous sites.The skin can be an important and an early clue to diagnosis since cutaneous lesions may be observed at an early stage of the disease and in about seventy-five cases of disseminated Fusarium infection. Typical skin lesions may be painful red or violaceous nodules, the center of which often becomes ulcerated and covered by a black eschar. The multiple necrotizing lesions are often observed on the trunk and the extremities. Onychomycosis most commonly due to F. oxysporum or F. solani has been reported. The onychomycosis may be of several types: distal and lateral subungual (DLSO), white superficial (WSO), and proximal subungual (PSO). In proximal subungual onychomycosis there may be associated leukonychia and/or periungual inflammation. Patients with Fusarium onychomycosis have been cured following therapy with itraconazole, terbinafine, ciclopirox olamine lacquer, or topical antifungal agent. In other instances nail avulsion plus antifungal therapy has been successful. In patients with hematologic malignancy or bone marrow transplant, who may experience prolonged or severe neutropenia during the course of therapy, the skin and nails should be carefully examined and consideration given to treating potential infection sites that may serve as portals for systemic dissemination. When disseminated Fusarium infection is present therapy with antifungal agents has generally been disappointing with the chances of a successful resolution being enhanced if the neutropenia can be corrected in a timely manner.

775

Mycetoma caused by Fusarium solani with osteolytic lesions on the hand: case report. Tomimori-Yamashita J, Ogawa MM, Hirata SH, Fischman O, Michalany NS, Yamashita HK, Alchorne M. Mycopathologia. 2002;153(1):11-4.

Eumycetoma is a mycotic disease caused by saprophytic soil fungi that are usually inoculated through minor injuries. A case of mycetoma in a Brazilian farmer aged 71 years is reported. This patient presented erythema and edema on the dorsal surface of the left hand with multiple crusted and cicatricial lesions. No macroscopic grains were observed. The histopathological findings showed grains consisted of numerous hyphae which stained well with Gomori-Grocott method. This material obtained by cutaneous biopsy was submitted to culture on Sabouraud's medium and the colonies were identified as Fusarium solani. The radiological studies revealed bone osteolytic lesions and the ultrasound showed pseudocysts and fistulae at the site of this infection. The patient was treated with oral ketoconazole with a good clinical response.

776

A cutaneous ulcer induced by fungi of the genus Fusarium] Negroni R, Martino O, Robles AM, Orduna T, Arechavala A, Brusca S, Helou S. Rev Soc Bras Med Trop. 1997 Jul-Aug;30(4):323-8.

A case of cutaneous hyalohyphomycosis, due to Fusarium oxysporum, in a 40 years old man is presented. The patient came from Paraguay where he worked in a tropical rural area. His disease had begun 2 months before his admission as a skin ulcer located in the left leg. Clinical characteristics, diagnosis methods, differential diagnosis with other ulcers of the legs in tropical areas as well as therapeutic measures are discussed in this presentation.

777

Skin lesions associated with Fusarium infection. Bodey GP, Boktour M, Mays S, Duvic M, Kontoyiannis D, Hachem R, Raad I. J Am Acad Dermatol. 2002 Nov;47(5):659-66.

Infections caused by Fusarium species are increasing in frequency among immunocompromised hosts. We identified 35 patients with cancer who had Fusarium skin lesions. Twenty patients had disseminated infection, 6 had primary localized skin infections, 4 had skin lesions associated with sinus infections, and 5 had onychomycosis. All patients (except 3 with onychomycosis) had hematologic malignancies and neutropenia. Skin lesions associated with disseminated infection included red or gray macules, papules (some with central necrosis or eschar), pustules, and subcutaneous nodules. Most patients had a variety of lesions simultaneously. Multiple red or gray macules with central ulceration or black eschar are characteristic of Fusarium infection. Disseminated infection may originate from skin lesions or onychomycosis. Most infections fail to respond to antifungal therapy unless there is resolution of the patient's neutropenia.

778

Subcutaneous Fusarium foot abscess in a renal transplant patient. Girardi M, Glusac EJ, Imaeda S. Cutis. 1999 May;63(5):267-70.

Fusarium species are ubiquitous plant and grain phytopathogens that rarely cause opportunistic infections in immunocompromised patients. While disseminated Fusarium infections are almost always fatal, localized infections may be responsive to a combination of systemic antibiotic therapy and surgical debridement. We present a diabetic renal transplant patient who developed a foot abscess due to Fusarium solani. Infection persisted despite aggressive surgical debridement and a 3-month course of intravenous liposomal amphotericin B.

779

Extensive subcutaneous hyphomycosis caused by Fusarium oxysporum. Attapattu MC, Anandakrishnan C. J Med Vet Mycol. 1986 Apr;24(2):105-11.

Subcutaneous granulomatous lesions by hyaline moulds are rare. This report describes a case of hyalohyphomycosis by Fusarium oxysporum. The patient was a 16-year-old Sri Lankan girl who had had extensive lesions in both arms almost from infancy. The fungus was demonstrated in KOH mounts and in histopathological sections. It was isolated repeatedly from her lesions over a period of 10 months. Combined therapy with ketoconazole and 5-fluorocytosine resulted in marked improvement. An inherent immune defect is postulated to account for the prolonged and extensive infection by a relatively non-aggressive fungus.

780

Cutaneous infection in man caused by Fusarium moniliforme. Collins MS, Rinaldi MG. Sabouraudia. 1977 Jul;15(2):151-60.

Fusarium moniliforme was isolated from a pustular lesion on the hand of an otherwise healthy male. Branching hyphae were seen in pus stained by the periodic acid-Schiff method. Pustular lesions containing branching hyphae were produced in mice after subcutaneous injection of microconidia. The experimental infection in mice and the naturally occurring lesion in man healed without treatment in 1 to 2 weeks. Although production of catenulate microconida was abundant on several common laboratory media, the characteristic macroconidia of F. moniliforme were produced only on barley-pea-rice straw agar.

781

Primary pulmonary involvement of Fusarium solani in a lung transplant recipient. Arney KL, Tiernan R, Judson MA. Chest. 1997 Oct;112(4):1128-30.

A case of cavitary lung disease caused by Fusarium solani in a lung transplant recipient is presented. A mechanism for development of this infection is proposed. Lipid complex amphotericin B (Abelcet) was effective in eradicating this infection. To our knowledge, invasive lung disease caused by the Fusarium species has not been previously reported in a solid organ transplant recipient.

782

Operative treatment of Fusarium fungal infection of the lung. Lupinetti FM, Giller RH, Trigg ME. Ann Thorac Surg. 1990 Jun;49(6):991-2.

Systemic fungal infections with Fusarium occur predominantly in immunocompromised patients and are usually fatal. We report a patient with acute lymphocytic leukemia and fusariosis involving the skin and lungs. This patient underwent antifungal chemotherapy and bilateral pulmonary resections. She subsequently had successful bone marrow transplantation. The results of this treatment suggest that this aggressive management of pulmonary fusariosis offers the best chance of survival.

783

Endocarditis due to Fusarium dimerum four years after coronary artery bypass grafting. Camin AM, Michelet C, Langanay T, de Place C, Chevrier S, Guého E, Guiguen C. Clin Infect Dis. 1999 Jan;28(1):150.

 

784

Disseminated Fusarium solani infection with endocarditis in a lung transplant recipient. Guinvarc'h A, Guilbert L, Marmorat-Khuong A, Lavarde V, Chevalier P, Amrein C, Guillemain R, Berrebi A. Mycoses. 1998 Jan-Feb;41(1-2):59-61.

Eleven days after double lung transplantation for cystic fibrosis, an 18-year-old patient developed a disseminated Fusarium solani infection with tricuspid valve endocarditis. This infection occurred under fluconazole and immunosuppressive therapy with cyclosporin, prednisone and azathioprine, with a normal leucocyte count. Liposomal amphotericin B allowed blood culture negativation. The patient died from a bacterial septic shock.

785

Fatal Fusarium endocarditis complicated by hemolytic anemia and thrombocytopenia in an infant. Hsu CM, Lee PI, Chen JM, Huang LM, Wu MH, Chiu IS, Lee CY. Pediatr Infect Dis J. 1994 Dec;13(12):1146-8.

 

786

Fusarium endocarditis involving aortic valve following coronary artery surgery. Jorens PG, Van Den Heuvel PA, Van Cauwelaert PA, Parizel GA, Mertens AN. Eur Heart J. 1990 May;11(5):476-8.

This article describes a case of infective aortic valve endocarditis due to Fusarium oxysporum occurring 4 years after coronary artery bypass grafting. It is the first reported case of endocarditis caused by Fusarium.

787

Mycetoma of the renal pelvis caused by Fusarium species. Nakar C, Livny G, Levy I, Samra Z, Linder N, Ashkenazi S, Livne P, Sirota L. Pediatr Infect Dis J. 2001 Dec;20(12):1182-3.

A preterm infant, with posterior urethral valves had a mycetoma of the renal pelvis caused by Fusarium species. Prolonged treatment with amphotericin B alone or with flucytosine failed. Combined surgical drainage and medical therapy resulted in full resolution.

788

Mycetoma of the foot due to Fusarium sp. treated with oral ketoconazole. Baudraz-Rosselet F, Monod M, Borradori L, Ginalsky JM, Vion B, Boccard C, Frenk E. Dermatology. 1992;184(4):303-5.

We report the case of a 30-year-old Nigerian patient with mycetoma of the foot without bone involvement caused by Fusarium sp..Long-term administration of ketoconazole produced a significant improvement with good clinical and biological tolerance.

789

Fusarium moniliforme, a new mycetoma agent. Restudy of a European case. Ajello L, Padhye AA, Chandler FW, McGinnis MR, Morganti L, Alberici F. Eur J Epidemiol. 1985 Mar;1(1):5-10.

Fusarium moniliforme was demonstrated to be the etiologic agent in an Italian case of eumycotic mycetoma. The fungus produced white granules, which measured 80 X 133 by 212 X 478 microns. Their edges were entire or lobed and were surrounded by an eosinophilic homogeneous material. The hyphae comprising the granules were not embedded in cement. The etiologic agent, first considered to be an Acremonium species, was restudied and identified as F. moniliforme on the basis that it not only produced chains of microconidia but also curved, multi-septate macroconidia typical of the genus Fusarium.

790

Clinical patterns of Fusarium infections in immunocompromised patients. Martino P, Gastaldi R, Raccah R, Girmenia C. J Infect. 1994 May;28 Suppl 1:7-15.

Fusarium is an ubiquitous fungus commonly found in soil and on plants. Human infection usually occurs as a result of inoculation of the organism through the body surface, thus causing skin infection, onychomycosis, keratitis, endophthalmitis and arthritis. Dissemination may occur in subjects with underlying immunodeficiency. Among immunocompromised hosts, Fusarium sp. is an emerging pathogen in neutropenic patients. To our knowledge, since 1973, when the first disseminated fusariosis in a child with acute leukemia was reported, about 80 new cases have been reported, mainly occurring in patients with haematologic malignancies. Specific portals of entry are not well understood, nevertheless the respiratory tract, colonised gastrointestinal tract, onychomycosis, disrupted skin barrier and central venous catheter have been reported as entry sites of deep seated Fusarium infections. Fever, positive blood cultures, severe myalgias, disseminated ecthyma gangrenosum-like skin lesions, ocular symptoms and multiple-organ-system involvement are distinctive features in most cases of disseminated fusariosis. The prognosis is very poor with death generally following despite antifungal therapy, unless an increase in the white blood cell count occurs. All available antifungal drugs show a low activity against the various species of Fusarium. Nevertheless, amphotericin B seems to have the highest in vitro activity and, even if it does not appear to be effective in persistently neutropenic patients, it should be currently considered to be the treatment of choice.

791

Septic arthritis due to Fusarium moniliforme. Gradon JD, Lerman A, Lutwick LI. Rev Infect Dis. 1990 Jul-Aug;12(4):716-7.

 

792

Treatment of Fusarium peritonitis in a peritoneal dialysis patient. Giacchino F, Belardi P, Merlino C, Aimino M, Garneri G, Cuffini AM, Tullio V. Perit Dial Int. 1997 Jul-Aug;17(4):403-4.

 

793

Fusarium peritonitis in a child on peritoneal dialysis: case report and review of the literature. Flynn JT, Meislich D, Kaiser BA, Polinsky MS, Baluarte HJ. Perit Dial Int. 1996 Jan-Feb;16(1):52-7.

OBJECTIVE: To review various aspects of the management of peritonitis due to Fusarium, a soil mold which infrequently causes infections in humans. DATA SOURCES: A case of Fusarium peritonitis in a child on chronic peritoneal dialysis (PD) is presented. The child developed Fusarium peritonitis 2 weeks after an episode of bacterial peritonitis. His Tenckhoff catheter was removed, and he was maintained on hemodialysis while receiving intravenous amphotericin. Following 2 weeks of treatment with amphotericin, he was successfully returned to PD. A literature review of all previously reported cases of Fusarium peritonitis was then conducted to determine features common to infections caused by Fusarium. Emphasis was also placed on unique characteristics of the organism that may affect patient management, as well as patient characteristics that may increase the risk for infection by Fusarium. RESULTS: Fusarium may cause infection in immunosuppressed individuals, such as cancer patients or patients on chronic PD. The organism has a propensity to attach to foreign bodies such as intravascular and intraperitoneal catheters. Therefore, successful treatment of infections caused by Fusarium may require catheter removal in addition to systemic antifungal therapy. CONCLUSIONS: This report presents the first known case of Fusarium peritonitis in a child. In view of the difficulties posed by this unusual organism, optimal therapy of Fusarium peritonitis should consist of immediate catheter removal and treatment with systemic antifungal drugs.

794

Fusarium solani peritonitis: infrequent complication of peritoneal dialysis] Nuño E, Cisneros JM, Regordan C, Montes R, Guerrero MA, Martín C. Enferm Infecc Microbiol Clin. 1995 Mar;13(3):196-7.

 

795

Fusarium peritonitis in peritoneal dialysis: report of two cases. Chiaradia V, Schinella D, Pascoli L, Tesio F, Santini GF. Microbiologica. 1990 Jan;13(1):77-8.

This report describes two cases of peritoneal dialysis-related peritonitis caused by Fusarium species which have been incriminated in a variety of disease conditions. Treatment with 5-Fluorocytosine was unsuccessful, but removal of the catheter resulted in a rapid resolution of the infections.

796

Disseminated cutaneous and peritoneal hyalohyphomycosis caused by Fusarium species: three cases and review of the literature. Rippon JW, Larson RA, Rosenthal DM, Clayman J. Mycopathologia. 1988 Feb;101(2):105-11.

Three recent cases of hyalohyphomycosis caused by Fusarium sp. illustrate differing aspects of infections produced by these organisms. One patient was undergoing continuous ambulatory peritoneal dialysis when peritonitis developed caused by Fusarium moniliforme. Removal of the catheter and amphotericin B were used in successful management. In a neutropenic patient on therapy for leukemia, multiple persistent infections occurred including JK diptheroids, and Candida albicans sepsis. Finally, numerous florid skin lesions caused by Fusarium oxysporum developed even while the patient was receiving amphotericin B and he died. In a second neutropenic patient on treatment for leukemia, sinus and cutaneous lesions developed due to Fusarium. These resolved on amphotericin B therapy following the return of circulating neutrophils. The literature on Fusarium infections and aspects of the biology of the organism are reviewed.

797

Granulomatous peritonitis in fish associated with Fusarium solani. Ostland VE, Ferguson HW, Armstrong RD, Asselin A, Hall R. Vet Rec. 1987 Dec 19-26;121(25-26):595-6.

 

798

Fungal peritonitis in patients on continuous ambulatory peritoneal dialysis. Kerr CM, Perfect JR, Craven PC, Jorgensen JH, Drutz DJ, Shelburne JD, Gallis HA, Gutman RA. Ann Intern Med. 1983 Sep;99(3):334-6.

Fungal peritonitis is a rare complication in patients on continuous ambulatory peritoneal dialysis. We report five recent cases and their management. The fungi isolated were Candida albicans, C. parapsilosis, Exophiala jeanselmei, Drechslera spicifera, and a Fusarium species. Chemotherapy was attempted with various regimens including oral ketoconazole, intravenous or intraperitoneal amphotericin B, and oral flucytosine. Pharmacokinetic studies were done in two patients receiving treatment with one of these drugs. Three patients were cured of their fungal infection. Three patients whose Tenckhoff catheters were left in situ died, whereas two patients whose catheters were removed survived. Our experience suggests that removal of the peritoneal catheter should be considered once the diagnosis of fungal peritonitis is established.

799

Brain abscesses in children with cancer. Antunes NL, Hariharan S, DeAngelis LM. Med Pediatr Oncol. 1998 Jul;31(1):19-21.

BACKGROUND: Brain abscesses in pediatric patients are rare events, and the causative organism and prognosis vary with the population under study. Children with cancer seem to be particularly susceptible to the development of brain abscesses because of the immunological changes induced by cancer and its treatment. We reviewed the records of children who developed a brain abscess during treatment of a malignancy to define the clinical characteristics, prognosis, and management of these patients. PROCEDURE: We performed a retrospective review of the clinical and laboratory characteristics of all cancer patients younger than age 20 years who were admitted to our institution between 1980 and 1996 for a brain abscess. RESULTS: Twelve children were identified. Cancer diagnoses were brain tumor in two, systemic PNET in two, and leukemia in eight. Six patients had multiple abscesses. Eleven received prior chemotherapy. Abscesses were surgically excised or aspirated in seven, and empiric antibiotics were given to the other five. At surgery, Listeria monocytogenes, Aspergillus fumigatus (3), Fusarium, and Candida lusitanea were cultured. Aspergillus was identified in other locations in four patients. Abscesses were successfully treated in seven patients, two of whom received antibiotics only; five patients (42%) died from infection. CONCLUSIONS: Mortality is high in this immunosuppressed population, in part due to the preponderance of fungal infection. The finding of very rare organisms suggests that drainage and culture should be performed whenever possible; empiric antibiotics that include an antifungal agent may, on occasion, be successful.

800

Fusarium meningoencephalitis in a child with acute leukemia. Agamanolis DP, Kalwinsky DK, Krill CE Jr, Dasu S, Halasa B, Galloway PG. Neuropediatrics. 1991 May;22(2):110-2.

A 15-year-old boy with acute lymphoblastic leukemia (ALL) developed disseminated fusarium infection with meningoencephalitis following a contaminated skin wound. With antifungal therapy, the cutaneous lesions cleared but central nervous system (CNS) infection persisted causing a fibrosing meningitis and a brain granuloma. Fusaria are soil saprophytes that are more commonly associated with superficial eye and skin lesions, but may also cause severe systemic infections with CNS involvement in immuno-compromised patients. The organism may be confused with Aspergillus in tissue sections, and can only be diagnosed by culture.

801

The spectrum of Fusarium infection in immunocompromised patients with haematological malignancies and in non-immunocompromised patients: a single institution experience over 10 years. Musa MO, Al Eisa A, Halim M, Sahovic E, Gyger M, Chaudhri N, Al Mohareb F, Seth P, Aslam M, Aljurf M. Br J Haematol. 2000 Mar;108(3):544-8.

Fusarium is a newly emerging fungal pathogen associated with significant morbidity and mortality in the immunocompromised host. We have reviewed our hospital's experience with Fusarium between 1985 and 1995. Fusarium species were isolated from 22 specimens, representing 11 patients. Cases were not clustered by time period. The median age of the patients was 36.5 years (range 17-69 years). The sources of the organism were 12 skin lesions from eight patients, seven blood cultures from two patients and one specimen each from a Hickman catheter tip, nail clippings and a bronchoalveolar lavage. Seven of the patients had chemotherapy-induced neutropenia when the Fusarium was isolated. Five of them developed invasive fusarosis during acute leukaemia induction treatment. They remained neutropenic, and none survived. The other two patients recovered from neutropenia and were treated successfully for this infection. The remaining four patients were not neutropenic or immunocompromised. Three grew Fusarium from skin or nail clippings and one from bronchial alveolar lavage (BAL). There was no evidence of invasive disease in any of the four. None of them received antifungal therapy, and they were all alive at last follow-up. We conclude that Fusarium is a newly emerging infection in neutropenic patients. A high index of suspicion, especially for skin lesions, will help in early diagnosis before systemic and visceral dissemination. Excision of the initial focus of infection and antifungal therapy, aided by speedy neutrophil recovery, are likely to protect patients threatened with these fatal infections. Fusarium isolated from non-neutropenic, non-immunosuppressed patients is not significant and does not merit systemic antifungal treatment.

802

Disseminated Fusarium infection identified by the immunohistochemical staining in a patient with a refractory leukemia. Saito T, Imaizumi M, Kudo K, Hotchi M, Chikaoka S, Yoshinari M, Suwabe N, Sato A, Suzuki H, Iinuma K. Tohoku J Exp Med. 1999 Jan;187(1):71-7.

The difficulty and uncertainty encountered in diagnosing a systemic mycosis often lead to a delay in starting antifungal therapy. We reported a disseminated infection of multiple fungal isolates including Fusarium species during donor leukocyte transfusion (DLT) after allogeneic bone marrow transplantation in a 20-year-old woman with a refractory leukemia. Skin lesions are the feature of Fusarium and occur in the early period of the infection. In this case, during immunosuppression state after DLT, she presented with the whole body ache and erythematous lesions which appeared rapidly on her trunk and extremities. While administration of amphotericin B was started, her condition was further deteriorated and she died. Autopsy materials revealed that she had multiple fungal infection with different isolates, including Aspergillus and Candida in the brain, lung and liver, but not in the skin. With the immunohistochemical staining with specific antibody, Fusarium or Aspergillus infection was identified from the biopsy skin or autopsy brain, respectively. This rapid and specific immunohistochemical method may be useful for the diagnosis and treatment of invasive fungal infection without delay.

803

Systemic Fusarium oxysporum infection in an immunocompetent patient with an adult respiratory distress syndrome (ARDS) and extracorporal membrane oxygenation (ECMO). Sander A, Beyer U, Amberg R. Mycoses. 1998 Mar-Apr;41(3-4):109-11.

We report a case of disseminated fusariosis in a 42-year-old patient with adult respiratory distress syndrome (ARDS) and extracorporal membrane oxygenation (ECMO), but without definite immunosuppression. Fusarium oxysporum was isolated from a bronchial lavage taken 6 days ante mortem. Despite antifungal treatment with amphotericin B and flucytosine the patient died in septic multiorgan failure. A post-mortem examination was performed. The patient's liver was found to contain fungus cells and F. oxysporum could be cultured from ascites.

804

Fungaemia due to Fusarium spp. in cancer patients. Krcmery V Jr, Jesenska Z, Spanik S, Gyarfas J, Nogova J, Botek R, Mardiak J, Sufliarsky J, Sisolakova J, Vanickova M, Kunova A, Studena M, Trupl J. J Hosp Infect. 1997 Jul;36(3):223-8.

Five cases of fungaemia due to Fusarium spp. in cancer patients are described. Two were breakthrough cases, despite ongoing therapy with amphotericin B. Three were caused by Fusarium solani, one by F. oxysporum and one by F. dimerum. Four patients died, three of them despite therapy with amphotericin B for between 5-37 days. We describe only the second reported case of F. dimerum fungaemia. Since 1972, 93 cases of systemic infection with Fusarium spp. have been described: 43 had positive blood cultures and the overall mortality was 72%.

805

Systemic Fusarium nygamai infection in a patient with lymphoblastic non-Hodgkin's lymphoma. Krulder JW, Brimicombe RW, Wijermans PW, Gams W. Mycoses. 1996 Mar-Apr;39(3-4):121-3.

We report the case history of a 35-year-old male patient with lymphoblastic non-Hodgkin's lymphoma who acquired a systemic infection with Fusarium nygamai during the granulocytopenic phase of cytostatic treatment. The patient survived this infection after haematological recovery and treatment with intravenous amphotericin B (total dose 543 mg). Subsequent chemotherapy courses were not complicated by fungal infections. A recent trip to Egypt and severe chemotherapy-induced mucositis were probably the major causes of this severe infection.

814

Oral Geotrichum candidum infection associated with HIV infection. A case report. Heinic GS, Greenspan D, MacPhail LA, Greenspan JS. Oral Surg Oral Med Oral Pathol. 1992 Jun;73(6):726-8.

Infections with Geotrichum species, although rare, are sometimes seen in immunocompromised hosts. We report a case of oral geotrichosis in a patient seropositive for human immunodeficiency virus who had erythematous mandibular and maxillary gingiva but was otherwise free of any active systemic disease. Geotrichum candidum was shown by both culture and histopathology to be present in the lesion and was deduced to be the causative organism. The patient responded well to several weeks of treatment involving oral topical administration of nystatin vaginal tablets.

815

[A case of high intestinal obstruction caused by mycotic bezoar of the duodenum] Goszcz A, Mach T, Bogdał J. Pol Tyg Lek. 1989 Apr 10-17;44(15-16):367-9.

A case of the mycotic bezoar in the female patient with gastric hypersecretion is reported. The symptoms of the high intestinal obstruction accompanied underlying disease. Bezoar formed of Geotrichum candidum was fragmentated with biopsical forceps of "alligator" type. Then, natamycin was administered for 5 weeks. The patients recovered completely.

816

Gastrointestinal phycomycosis in acute nonlymphatic leukemia. Mozes B, Pines A, Segev S, Horowitz A, Goldschmied-Reouven A, Douer D, Ben-Bassat I. Isr J Med Sci. 1988 Feb;24(2):93-5.

A 37-year-old patient with acute nonlymphatic leukemia developed gastrointestinal phycomycosis during failure in bone marrow production. The clinical presentation was of acute typhlitis. Laparotomy revealed a necrotic mass in the region of the iliocecal valve, and on histologic examination hyphae of phycomycetes with invasion of the blood vessels were seen. The patient died as a result of widespread infection.

MeSH Terms: Acute Disease Adult Appendicitis/*etiology/pathology Case Report *Geotrichosis/microbiology/pathology Geotrichum/isolation & purification Human Leukemia/*complications

817

Fungal diarrhoea: association of different fungi and seasonal variation in their incidence. Talwar P, Chakrabarti A, Chawla A, Mehta S, Walia BN, Kumar L, Chugh KS. Mycopathologia. 1990 May;110(2):101-5.

A total of 854 patients (640 children and 214 adults) admitted with acute or chronic diarrhoea suspected of non-invasive overgrowth of fungi in intestine were screened during a period of 3 years. Fungal proliferation was noted in 54.8% of these patients (53.6% in children, 58.4% in adults). The predominant fungal species isolated were Candida albicans (64.5%), followed by C. tropicalis (23.3%) C. krusei (6.9%). Torulopsis glabrata (1.6%). Trichosporon sp. and Geotrichum sp. were found to be responsible in 2.3% of adults. As seen in bacterial diarrhoea, higher incidence was noted in children from April to August. No such seasonal variation was noted in adults.

818

Brain abscesses due to Geotrichum candidum. Kasantikul V, Chamsuwan A. Southeast Asian J Trop Med Public Health. 1995 Dec;26(4):805-7.

 

819

Geotrichum septicemia. Sheehy TW, Honeycutt BK, Spencer JT. JAMA. 1976 Mar 8;235(10):1035-7.

Although disseminated geotrichosis is an unusual disease (to our knowledge, only six cases have been reported), Geotrichum candidum is not a very virulent fungus. In our case, there was neutrophillic phagocytosis of the arthrosphores of G candidum, with rapid clearance of the fungus from the plasma of a chronically ill patient whose immune defenses were still intact.

840

Hansenula anomala outbreak at a surgical intensive care unit: a search for risk factors. Kalenic S, Jandrlic M, Vegar V, Zuech N, Sekulic A, Mlinaric-Missoni E. Eur J Epidemiol. 2001;17(5):491-6.

During a 5-month period, Hansenula anomala (H. anomala), an opportunistic fungus, caused an outbreak of infections in eight adult patients treated at a surgical intensive care unit (ICU). The source of the infections and route of transmission could not be identified. A case-control study included 32 patients treated simultaneously at the surgical ICU. Univariate analysis pointed to the following significant risk factors: blood alkalosis, reduced urea, duration of hospitalization, bacteremia and colonization with Pseudomonas aeruginosa, and an APACHE II score >17 (during bacteremia or fungemia). The stepwise logistic regression multivariate analysis showed only the duration of blood alkalosis to be significant in case patients.

841

Pichia anomala outbreak in a nursery: exogenous source? Aragão PA, Oshiro IC, Manrique EI, Gomes CC, Matsuo LL, Leone C, Moretti-Branchini ML, Levin AS; IRIS Study Group Pediatr Infect Dis J. 2001 Sep;20(9):843-8.

BACKGROUND: Pichia anomala is a rare cause of fungemia. From February to April, 1998, eight cases of fungemia occurred in the intensive care and high risk units of the Nursery. There were four infants with P. anomala infection, one of whom also had Candida parapsilosis infection, two cases with C. parapsilosis infection and two with Candida albicans infection. OBJECTIVE: To determine factors associated with fungemia in the intensive care and high risk units of the Nursery, especially P. anomala. METHODS: A cohort study with 59 newborns. RESULTS: Factors associated with fungemia were: central venous catheter (CVC) (P = 0.0006); total parenteral nutrition (TPN) (P = 0.0005); lipid emulsion (P = 0.002); previous antimicrobial use (P = 0.002); and other invasive procedures (P = 0.002). Factors associated with P. anomala fungemia were: CVC (P = 0.004); TPN (P = 0.018); previous antibiotic use (P = 0.037); and other invasive procedures (P = 0.037). Evaluation of the units demonstrated that there were several technical problems involving administration of TPN that was manipulated in the Nursery without precautions. Changes in TPN formulation and education as to adequate technique were implemented. During follow-up (1998 to 1999) only two fungemias occurred that were caused by C. albicans. Cultures of hands of personnel were negative for P. anomala. Electrophoretic karyotyping of P. anomala showed three profiles. CONCLUSIONS: Factors associated with fungemia were catheter use, invasive procedures and total parenteral nutrition, suggesting that the acquisition of P. anomala was exogenous.

842

Outbreak of Pichia anomala infection in the pediatric service of a tertiary-care center in Northern India. Chakrabarti A, Singh K, Narang A, Singhi S, Batra R, Rao KL, Ray P, Gopalan S, Das S, Gupta V, Gupta AK, Bose SM, McNeil MM. J Clin Microbiol. 2001 May;39(5):1702-6.

An outbreak of nosocomial fungemia due to the unusual yeast, Pichia anomala occurred in the pediatric wards of our hospital over a period of 23 months (April 1996 to February 1998). A total of 379 neonates and children (4.2% admissions) were infected. The probable index case was admitted to the pediatric emergency ward, with subsequent transmission to the premature nursery, pediatric intensive care units, and other children wards. Carriage on the hands of health care personnel was likely to be responsible for dissemination of the fungus. The outbreak could only be controlled after a health education campaign to improve hand-washing practices was instituted and after nystatin-fluconazole prophylaxis to all premature neonates and high-risk infants was introduced. In a case-control study, we identified a lower gestational age, a very low birth weight (<1,500 g), and a longer duration of hospital stay as significant risk factors associated with P. anomala fungemia in premature neonates. We conducted a culture prevalence survey of 50 consecutive premature neonates and found that 28% were colonized with P. anomala at a skin or mucosal site on the date of delivery and that 20% of these neonates subsequently developed P. anomala fungemia. We performed multilocus enzyme electrophoresis on 40 P. anomala outbreak isolates (including patient and health care workers' hand isolates), and the results suggested that these isolates were identical. Our study highlights the importance of P. anomala as an emerging nosocomial fungal pathogen.

843

Pichia ohmeri fungemia. Bergman MM, Gagnon D, Doern GV. Diagn Microbiol Infect Dis. 1998 Mar;30(3):229-31.

A patient with a history of diabetes, coronary artery disease, stroke, previous renal transplantation, and multiple hospital admissions for recurrent pancreatitis was transferred to the hospital from a chronic care facility because of fever and severe epigastric discomfort. At the time of admission, she was receiving hyperalimentation through a central venous TPN catheter. Multiple blood cultures obtained on the first and second hospital days yielded pure cultures of the yeast, Pichia ohmeri. The patient developed acute renal failure, and despite high-dose amphotericin B therapy, ultimately expired.

844

Fungaemia caused by Hansenula anomala--an outbreak in a cancer hospital. Thuler LC, Faivichenco S, Velasco E, Martins CA, Nascimento CR, Castilho IA. Mycoses. 1997 Oct;40(5-6):193-6.

Yeasts belonging to the genus Hansenula are rarely encountered as the cause of infection in clinical practice. A wide spectrum of infections caused by these fungi can be seen, ranging from asymptomatic fungaemia to severe disease. We describe an outbreak of 24 cases of infection due to H. anomala in an oncological hospital in Rio de Janeiro, Brazil. The median age of the patients was 11 years, of whom 54.2% were female; 91.7% of the Hansenula fungaemia occurred in the haematology unit. The most frequent primary disease diagnosis was leukaemia (62.5%), and all of those infected had had a central venous catheter or peripheral venous catheter and had been treated previously with broad-spectrum antibiotics. Numerous other risk factors were observed in our cases: previous use of steroids, chemotherapy, radiation therapy and neutropenia (data not shown). No deaths could be attributed to Hansenula.

845

Hansenula anomala infection in acute leukemia] López F, Martín G, Paz ML, Sanz MA. Enferm Infecc Microbiol Clin. 1990 Jun-Jul;8(6):363-4.

Hansenula anomala infection is a clinical rarity which has only been reported in 21 cases. Although most reported cases had one or more of the risk factors of fungemia, only three developed in hematological patients. In the present study we report two cases of Hansenula anomala infection in acute leukemia, one in its teleomorphic form and another in the asexual form of this yeast, Candida pelliculosa. The sustained chemotherapy and steroid and antibiotic treatment were some of the risk factors of fungemia which were present in these patients, one of which was a carrier of a central venous catheter. As it has been suggested that Hansenula anomala has a low virulence and a high susceptibility to amphotericin B, we emphasize the potential morbidity and mortality that this organism can induce in patients with hematological disease.

846

Hansenula anomala fungemia. Haron E, Anaissie E, Dumphy F, McCredie K, Fainstein V. Rev Infect Dis. 1988 Nov-Dec;10(6):1182-6.

Fungi of the genus Hansenula have rarely been reported as pathogenic in humans. A case of catheter-related Hansenula anomala fungemia in a patient with acute leukemia in remission is presented, and the clinical features of 11 additional patients infected with Hansenula species are reviewed. The spectrum of disease with these organisms ranges from asymptomatic fungemia to life-threatening disseminated infection. Predisposing factors appear to be immunosuppression, use of intravenous devices, and previous treatment with antibacterial drugs. Clinical experience and limited in vitro susceptibility data show that amphotericin B remains the drug of choice in the treatment of hansenula infections.

847

Infection and colonisation of neonates by Hansenula anomala. Murphy N, Buchanan CR, Damjanovic V, Whitaker R, Hart CA, Cooke RW. Lancet. 1986 Feb 8;1(8476):291-3.

Over a 13-month period 52 neonates (10% of those admitted to the Mersey Regional Neonatal Intensive Care Unit) were found to be colonised with the ascosporagenous yeast Hansenula anomala. 8 babies became infected, all but 1 of whom were heavily colonised before infection. 7 of the 8 infected babies were of very low birth-weight (less than 1500 g). All 8 had multiple problems associated with low birth-weight and prematurity and were kept in the intensive care unit. 5 babies had fungaemia, 2 had fungaemia and ventriculitis, and 1 had ventriculitis only. In each case H anomala was the sole pathogen isolated. Anti-Hansenula antibodies developed in 5 babies within 3 months of infection. Infected babies were successfully treated with a combination of 5-flucytosine and amphotericin B. Despite extensive searches the babies appeared to be the only reservoir of the yeast.

848

Infective endocarditis of a bicuspid aortic valve caused by Hansenula anomala. Nohinek B, Zee-Cheng CS, Barnes WG, Dall L, Gibbs HR. Am J Med. 1987 Jan;82(1):165-8.

Infective endocarditis due to Hansenula anomala developed on a bicuspid aortic valve in a 40-year-old man. H. anomala, an ascomycetous yeast, may be a member of the normal flora of the throat and alimentary tract in humans but has not been previously known to be pathogenic in humans. A past history of intravenous drug use may have contributed to the development of disease in this patient.

849

Catheter-related infections by Hansenula anomala in children. Yamada S, Maruoka T, Nagai K, Tsumura N, Yamada T, Sakata Y, Tominaga K, Motohiro T, Kato H, Makimura K. Scand J Infect Dis. 1995;27(1):85-7.

During August and September, 1992, we experienced 4 cases of Hansenula anomala (H. anomala, synonym Pichia anomala) fungemia in immunocompromised patients. Two patients had been suffering from a malignant disease, 3 of them had received broad-spectrum antibiotics and a central venous catheter (CVC) had been inserted in all of them. H. anomala was isolated as the sole pathogen from all 4 patients. Three of them responded favorably to fluconazole after withdrawal of the catheter, but one failed. H. anomala should be considered as a possible cause of catheter-related infections.

850

Hansenula polymorpha infection in a child with chronic granulomatous disease. McGinnis MR, Walker DH, Folds JD. Arch Pathol Lab Med. 1980 Jun;104(6):290-2.

In a patient with chronic granulomatous disease of childhood documented by the nitroblue tetrazolium test, an infection of the mediastinal lymph nodes developed that was caused by Hansenula polymorpha, an ascomycetous yeast. To our knowledge, this yeast has not been previously shown to be an etiologic agent of disease in man. The diagnosis was made by growing the yeast from cultures of several biopsy specimens collected at the time of thoracotomy. Susceptibility testing showed that the yeast was sensitive to amphotericin B. Treatment with amphotericin B reversed this life-threatening episode.

865

Helminthosporium corneal ulcers. Harris R, Smith RE, Wood TR, Biddle M. Ann Ophthalmol. 1978 Jun;10(6):729-33.

Two cases of fungal corneal ulcer caused by Helminthosporium are discussed. Dematiacious fungi are pigmented filamentary molds of which Helminthosporium is representative. Ulcers due to such dematiacious fungi seem to have a better prognosis than other types of fungal corneal ulcers. The importance of classifying fungal ulcers is emphasized. Therapy is considered for these keratomycoses.

866

Helminthosporium corneal ulcers. McGinnes MR. Am J Ophthalmol. 1978 Dec;86(6):853.

 

867

Helminthosporium corneal ulcers. Krachmer JH, Anderson RL, Binder PS, Waring GO, Rowsey JJ, Meek ES. Am J Ophthalmol. 1978 May;85(5 Pt 1):666-70.

We studied four cases of Helminthosporium corneal ulcers from four different institutions. One case occurred in an immune-deficient infant, another in a patient three months after removal of a foreign body; the third case occurred in a patient with a corneal dystrophy who was wearing soft contact lenses and using topical corticosteroids; and the fourth occurred in a patient with a history of multiple foreign bodies. Antifungal sensitivities were performed in three cases and showed relatively good sensitivity to available antifungal medications; even though all four patients improved, there was poor correlation between in vitro sensitivities and clinical response.

868

Corneal perforation due to Helminthosporium and Mima polymorpha. Chin GN. Ann Ophthalmol. 1978 Apr;10(5):607-9.

This apparently is the first reported case of corneal perforation due to a mixed infection of Helminthosporium species and Mima polymorpha. These 2 organisms separately rarely cause ocular infection and when present together could produce serious damage to the eye. In long-standing diseases of the cornea, mixed infection should be suspected when the infection fails to respond to conventional medical therapy. Thorough laboratory evaluation should be done. Selection of appropriate antibiotics should be based on clinical impression, initial Gram stain findings and final cultural results.

869

Exogenous Helminthosporium endophthalmitis. Das T, Gopinathan U, Sharma S. Br J Ophthalmol. 1994 Jun;78(6):492-3.

 

873

Spinal cord histoplasmoma. A case report] Rivierez M, Heyman D, Brebion A, Landau-Ossondo M, Desbois N, Vally P. Neurochirurgie. 2002 Feb;48(1):44-8.

Over a period of 2 months, a 60-year-old man, a chicken breeder, experienced low back pain, lower limb weakness predominant on the right side, and urinary difficulties, leading progressively to a flaccid paraplegia with sphincter impairment. Concomitant poor cognitive performances were noted. MRI showed enlargement of the conus terminalis, with a low-intensity signal on T1-weighted images, high-intensity signal on T2-weighted images, and areas of intramedullar contrast enhancement. A biopsy of the lesion showed macrophages containing yeast cells, with PAS and Grocott staining aspects compatible with the presence of Histoplasma capsulatum (Hc). A brain MRI showed multiple localizations in the brain stem and in both hemispheres with associated edema. Disseminated histoplasmosis was confirmed by a biopsy of a sub-maxillary ganglion demonstrating a necrotic tuberculoid lymphadenitis containing yeast cells resembling Hc. Immune tests disclosed the presence of HTLV1 anti-bodies without immunodeficiency nor HIV co-infection. An anti-micotic treatment was started 2 weeks after surgery, with intra-venous amphotericin B, for 21 days, followed by itraconazole, orally for 90 days. Cognitive functions improved significantly in 5 weeks while paraplegia and sphincter impairment remained unchanged. Seven months later, cerebral MR aspects dramatically improved while the conus medullaris lesion diminished, and the edematous component disappeared in all areas. Even though histoplasmosis is endemic in our region, CNS localization is rare, generally in disseminated forms associated with immunodeficiency. Brain granulomas are well-known, but spinal cord histoplasmomas are exceptional: only four cases have been evaluated by MRI. Unlike our case, spinal cord forms generally improve, due to surgery associated with antifungus medication, or sometimes due to specific medical treatment alone but with sufficient dosage.

874

Epidemiological investigation of Histoplasma capsulatum infection in China. Zhao B, Xia X, Yin J, Zhang X, Wu E, Shi Y, Tong M, Sun S, Gui X, Zhao Z, Ayinuer, Feng X. Chin Med J (Engl). 2001 Jul;114(7):743-6.

OBJECTIVE: To provide reliable information concerning the presence or the absence of Histoplasma capsulatum (H. capsulatum) infection in China, and data concerning this respect. METHODS: Three hundred normal people and 435 hospitalized patients, who lived in Hunan and Jiangsu provinces, and the Xinjiang Autonomous Region, were tested with yeast-phase histoplasmin (ALK/Berkerley Biologicals Laboratories, USA) and human pure protein derivative of tuberculin (PPD) on the volar surface of the forearm. Any reaction to the antigens over 5.0 mm in diameter of induration at 48-72 hours was considered positive. RESULTS: A total of 138 subjects (18.8%) in 735 patients reacted to histoplasmin with 5.0-45.0 (9.1 +/- 4.3) mm indurations. Significant differences of positive skin reaction rates in normal subjects were found in Hunan, Jiangsu and Xinjiang (8.9% vs 15.1% vs 2.1%). The overall positive rate of patients was 25.5%. Patients with tuberculosis [31.7% (78/246)] had a significantly higher positive skin reaction rate in comparison with those suffering from pneumonia [17.7% (11/62)], lung cancer [20.9% (9/43)], chronic obstructive pulmonary disease [17.3% (9/52)] and other diseases [12.5% (4/32)] (P < 0.01). Of 562 cases, 292 cases (52.0%) reacted to PPD with indurations of 5-50 (13.7 +/- 4.9) mm in diameter, 63 cases (11.2%) reacted to both histoplasmin and PPD, while 38 cases (6.9%) reacted to histoplasmin but not to PPD. CONCLUSIONS: The data suggest that there is H. capsulatum herd infection in China. The infection rate in Southeast China is higher than that in the Northwest, and the infection rate of patients with pulmonary tuberculosis is higher than that of normal persons and other pneumonopathy patients.

875

Disseminated histoplasmosis presenting as pyoderma gangrenosum-like lesions in a patient with acquired immunodeficiency syndrome. Laochumroonvorapong P, DiCostanzo DP, Wu H, Srinivasan K, Abusamieh M, Levy H. Int J Dermatol. 2001 Aug;40(8):518-21.

A 33-year-old Hispanic woman with newly diagnosed human immunodeficiency virus (HIV) infection, a CD4 T-lymphocyte count of 2, viral load of 730,000 copies/mL, candidal esophagitis, seizure disorder, a history of bacterial pneumonia, and recent weight loss was admitted with tonic clonic seizure. On admission, her vital signs were: pulse of 88, respiration rate of 18, temperature of 37.7 degrees C, and blood pressure of 126/76. Her only medication was phenytoin. On examination, the patient was found to have multiple umbilicated papules on her face, as well as painful, erythematous, large, punched-out ulcers on the nose, face, trunk, and extremities of 3 months' duration (Fig. 1). The borders of the ulcers were irregular, raised, boggy, and undermined, while the base contained hemorrhagic exudate partially covered with necrotic eschar. The largest ulcer on the left mandible was 4 cm in diameter. The oral cavity was clear. Because of her subtherapeutic phenytoin level, the medication dose was adjusted, and she was empirically treated with Unasyn for presumptive bacterial infection. Chest radiograph and head computed tomography (CT) scan were within normal limits. Sputum for acid-fast bacilli (AFB) smear was negative. Serologic studies, including Histoplasma antibodies, toxoplasmosis immunoglobulin M (IgM), rapid plasma reagin (RPR), hepatitis C virus (HCV), and hepatitis B virus (HBV) antibodies were all negative. Examination of the cerebrospinal fluid was within normal limits without the presence of cryptococcal antigen. Blood and cerebrospinal cultures for bacteria, mycobacteria, and fungi were all negative. Viral culture from one of the lesions was also negative. The analysis of her complete blood count showed: white blood count, 2300/microl; hemoglobin, 8.5 g/dL; hematocrit, 25.7%; and platelets, 114,000/microl. Two days after admission, the dermatology service was asked to evaluate the patient. Although the umbilicated papules on the patient's face resembled lesions of molluscum contagiosum, other infectious processes considered in the differential diagnosis included histoplasmosis, cryptococcosis, and Penicillium marnefei. In addition, the morphology of the ulcers, particularly that on the left mandible, resembled lesions of pyoderma gangrenosum. A skin biopsy was performed on an ulcer on the chest. Histopathologic examination revealed granulomatous dermatitis with multiple budding yeast forms, predominantly within histiocytes, with few organisms residing extracellularly. Methenamine silver stain confirmed the presence of 2-4 microm fungal spores suggestive of Histoplasma capsulatum (Fig. 2). Because of the patient's deteriorating condition, intravenous amphotericin B was initiated after tissue culture was obtained. Within the first week of treatment, the skin lesions started to resolve. Histoplasma capsulatum was later isolated by culture, confirming the diagnosis. The patient was continued on amphotericin B for a total of 10 weeks, and was started on lamivudine, stavudine, and nelfinavir for her HIV infection during hospitalization. After amphotericin B therapy, the patient was placed on life-long suppressive therapy with itraconazole. Follow-up at 9 months after the initial presentation revealed no evidence of relapse of histoplasmosis.

876

A case of Histoplasma capsulatum causing granulomatous liver disease and Addisonian crisis. Wong P, Houston S, Power B, Lalor E, Bain VG. Can J Gastroenterol. 2001 Oct;15(10):687-91.

A 56-year-old man with persistently elevated liver enzyme levels, fatigue, lethargy and a 9.0 kg weight loss over six months underwent a percutaneous liver biopsy that demonstrated multiple granulomas. Screening serologies were positive for histoplasmosis, and he was started on itraconazole treatment. He returned to hospital the same night with coffee-ground emesis and in Addisonian crisis requiring parenteral steroids and intensive care unit support. An abdominal computed tomography scan revealed bilaterally enlarged, nonenhancing adrenal glands suggestive of infarcts, presumed secondary to histoplasmosis. Treatment was initiated with amphotericin B, and Histoplasma capsulatum was cultured from his urine and cerebrospinal fluid. A serum immunodiffusion test was also positive for both H and M bands, indicating active infection with Histoplasmosis species. His serum and urine samples were also weakly positive for the antigen. Despite complications of renal failure, pneumonia and congestive heart failure, he recovered with medical therapy and was discharged home to complete a prolonged course of itraconazole therapy. While hepatic granulomas often reflect an occult disease process, the cause may remain undiscovered in 30% to 50% of patients despite exhaustive investigations. H capsulatum is an uncommon cause of granulomatous liver disease, and with its protean clinical presentation, a high index of suspicion is needed to make the diagnosis and avoid the potentially high fatality rate associated with disseminated infection.

877

Pathogenesis of Histoplasma capsulatum. Woods JP, Heinecke EL, Luecke JW, Maldonado E, Ng JZ, Retallack DM, Timmerman MM. Semin Respir Infect. 2001 Jun;16(2):91-101.

Histoplasma capsulatum is well adapted to be infectious and pathogenic for humans. As a soil fungus with no known requirement for interacting with a mammalian host as part of an obligate lifecycle, its plethora of strategies for successful pathogenesis is particularly remarkable. These features include the dimorphic mold-yeast transition, entry into host macrophages, subcellular localization, intracellular survival and proliferation during active infection, and persistence during clinically inapparent infection with the capacity for reactivation. To thrive within the harsh environment of a professionally phagocytic and antimicrobial host cell, H. capsulatum displays mechanisms for modulating its microenvironmental pH level, resisting host reactive oxygen and nitrogen intermediates and degradative enzymes, and withstanding nutrient starvation conditions, including acquisition of iron and calcium and biosynthesis of nucleic acid precursors. Attention has been focused on identifying virulence-associated phenotypic traits and genes that are differentially expressed under relevant conditions, such as yeast morphotype-specific genes and genes that are up-regulated during infection. These studies, together with the increasing ability to perform molecular genetic manipulations in this fungus, may yield novel antifungal drug or vaccine targets as well as elucidating pathogenic mechanisms.

878

Histoplasmosis capsulatum as a cause of lower gastrointestinal bleeding in common variable immunodeficiency. Kane S, Brasitus T. Dig Dis Sci. 2000 Nov;45(11):2133-5.

Infection with Histoplasma capsulatum is the most common systemic fungal infection in the United States, but symptomatic gastrointestinal disease is rare. Gastrointestinal involvement is seen in patients with an established immunosuppressed state that predates any infection. We report a patient presenting with gastrointestinal bleeding ultimately diagnosed with disseminated histoplasmosis. Work-up led to the diagnosis of common variable immunodeficiency, a diagnosis not previously described as associated with gastrointestinal histoplasmosis. Resolution of the colonic ulcer was documented after appropriate antifungal therapy, underscoring the importance of including this infectious process in the differential of a patient without other risk factors for colonic ulceration.

879

Histoplasmosis: an unusual presentation. Singh SK, Bhadada SK, Singh SK, Sharma OP, Arya NC, Shukla VK, Agrawal JK. J Assoc Physicians India. 2000 Sep;48(9):923-5.

Histoplasma capsulatum (HC) infection is rare in India. We document a case of unilateral adrenal histoplasmosis in a 56 year male. The patient presented with hepatosplenomegaly, unilateral adrenal mass and significant weight loss. Since FNAC of adrenal mass was inconclusive, he underwent splenectomy, adrenalectomy and liver biopsy, histology of these specimens revealed HC only in adrenal mass. Subsequently, histoplasmin test was also performed which was also found to be positive. He responded well to parenteral amphotericin B and is under regular follow-up with no complaints now.

880

Disseminated cutaneous histoplasmosis and AIDS: case report. Kucharski LD, Dal Pizzol AS, Fillus J Neto, Guerra IR, Guimarães CC, Manfrinato LC, Mulinari Brenner FA. Braz J Infect Dis. 2000 Oct;4(5):255-61.

Histoplasmosis is caused by the dimorphic fungus Histoplasma capsulatum. It manifests by the presence of fever as the only symptom in most individuals. The disease may present as self-limited pneumonia, or as an hematogenous widespread fungal infection with a potentially fatal outcome in elderly individuals and people with compromised T-cell mediated immunity. Here, we report a case of disseminated cutaneous histoplasmosis in a patient with AIDS. The patient was a 33 year old male homosexual, intravenous drug user, who had been diagnosed with HIV infection 5 years earlier. He was in good health, but had erythematous papules and pustules in the skin of the scalp, face, back, thighs, abdomen, palms, and soles. He was placed on anti-retroviral therapy, fluconazole for mucosal candidiasis, trimethoprim/sulfamethoxazole for pneumocystis prophylaxis, and antibiotics for the skin pustules. The skin lesions improved remarkably within 14 days. He was discharged and soon lost to follow-up. After his discharge, skin biopsy and fungal culture results revealed H. capsulatum. He was seen again 1 year later. The interim history revealed that he had taken fluconazole 100 mg/day for 1 month and fluconazole 150 mg/week for 7 months. He had not continued anti-retroviral therapy, nor taken other antifungal drugs. The clinical evolution of the disease was exceptional in that there was disappearance of all the skin lesions attributed to histoplasmosis with fluconazole. Although itraconazole remains the drug of choice for histoplasmosis. Cutaneous histoplasmosis should be considered in the differential diagnosis of atypical cutaneous lesions in individuals infected with HIV.

881

Histoplasmosis of the thyroid. Goldani LZ, Klock C, Diehl A, Monteiro AC, Maia AL. J Clin Microbiol. 2000 Oct;38(10):3890-1.

Fungal infection of the thyroid is rare. Most reported cases have involved Aspergillus, Coccidioides, and Candida species in the setting of disseminated disease. Infection of the thyroid with Histoplasma capsulatum is rarely reported as part of disseminated disease, even in geographic areas where histoplasmosis is endemic. We report a 52-year-old woman with a previous Hashimoto's disease and non-Hodgkin's lymphoma in which a diffuse enlarged thyroid gland with a large nodule was the only apparent locus of histoplasmosis. Fine-needle aspiration of the thyroid was an important diagnostic tool in establishing the diagnosis of histoplasmosis of the thyroid. The patient was initially treated with itraconazole (400 mg/day) for the fungal infection and six cycles of chemotherapy for the lymphoma. At a 6-month follow-up examination, the patient was doing well on suppressive therapy of itraconazole (200 mg/day), with no symptoms and with regression of the thyroid nodule and cervical adenopathy.

882

Endogenous endophthalmitis caused by Histoplasma capsulatum var. capsulatum: a case report and literature review. Gonzales CA, Scott IU, Chaudhry NA, Luu KM, Miller D, Murray TG, Davis JL. Ophthalmology. 2000 Apr;107(4):725-9.

OBJECTIVE: We report the first case of clinically diagnosed endogenous endophthalmitis caused by Histoplasma capsulatum var. capsulatum in a patient with the acquired immune deficiency syndrome. DESIGN: Interventional case report and literature review. INTERVENTION: Pars plana vitrectomy and scleral buckling procedure in the left eye with intravenous and intravitreal amphotericin in both eyes. MAIN OUTCOME MEASURES: The clinical features, culture results, visual outcome, and complications were studied. RESULTS: This case demonstrates a bilateral endophthalmitis with severe subretinal exudation, choroidal granulomas, and intraretinal hemorrhage leading to exudative bilateral retinal detachments. Vitreous cultures grew H. capsulatum var. capsulatum. Treatment consisted of intravenous amphotericin, intravitreal amphotericin (both eyes), pars plana vitrectomy (left eye), and scleral buckling procedure (left eye) with resulting counting fingers vision (right eye) and 20/300 (left eye). Four cases of Histoplasma endophthalmitis have been reported previously, all of which had a documented history of disseminated histoplasmosis and resulted in enucleation. CONCLUSIONS: H. capsulatum should be considered a possible etiologic agent of endophthalmitis, especially in patients with a history of disseminated histoplasmosis and/or immune deficiency.

883

Disseminated histoplasmosis caused by Histoplasma capsulatum with cerebral involvement occurring 13 years after the primary infection] Bérard H, Astoul P, Frenay C, Cuguillière A, Cho K, Boutin C. Rev Mal Respir. 1999 Nov;16(5):829-31.

A 49-year-old man with disseminated histoplasmosis (pulmonary and central nervous system involvement) successfully treated with ketoconazole and fluconazole combination is reported. Histoplasma capsulatum infection of the central nervous system is extremely rare in France partly because the organism is not endemic. Oral treatment with newer triazoles may be useful for central nervous system histoplasmosis, but additional information is needed to establish their effectiveness.

884

Chronic pulmonary histoplasmosis in the State of Rio de Janeiro, Brazil. Capone D, Wanke B, Monteiro PC, Lazéra MS, de Noronha Andrade G, do Valle AC, Moreno AM, Londero AT. Mycopathologia. 1999;145(2):75-9.

Three cases of chronic pulmonary histoplasmosis affecting aged patients with chronic obstructive pulmonary disease are reported. They had a history of recurrent episodes of respiratory infection and presented radiological lung lesions inducing a misdiagnosis of chronic pulmonary tuberculosis of the adults. The diagnosis of histoplasmosis, suggested by the immunodiffusion test and the detection of yeastlike cells in smeared and stained sputum, was confirmed by the isolation and identification of Histoplasma capsulatum var. capsulatum in selective media. The treatment was carried out with amphothericin B and ketoconazole or itraconazole. Clinical, radiologic, mycologic and serologic improvement was obtained in all the patients. However, relapses occurred within a period of 1 to 18 months after the interruption of the treatment. Mycological diagnosis and the difficulties observed in the treatment were discussed. In addition data on the epidemiology of histoplasmosis in the state of Rio de Janeiro, Brazil, were presented.

885

Disseminated histoplasmosis presenting as bilateral adrenal masses. Giacaglia LR, Lin CJ, Lucon AM, Goldman J. Rev Hosp Clin Fac Med Sao Paulo. 1998 Sep-Oct;53(5):254-56.

Histoplasma capsulatum is a universal dimorphic fungus found mainly in soil contaminated with excrement of birds and bats. Bilateral adrenal masses with massive tissue destruction are a rare primary presentation of disseminated histoplasmosis. As it behaves as an opportunistic pathogen there is a higher susceptibility for dissemination on those patients with immunodeficiency or immunosuppression. We report a case in an elderly diabetic patient with bilateral adrenal enlargement, diagnosed as histoplasmosis only after surgical exploration, with symptoms probably occurring at least 60 years after the original infection. She was successfully treated with itraconazole.

886

Disseminated histoplasmosis causing reversible gaze palsy and optic neuropathy. Perry JD, Girkin CA, Miller NR, Mann RB. J Neuroophthalmol. 1999 Jun;19(2):140-3.

Subacute disseminated histoplasmosis is an uncommon entity. Typical neuro-ophthalmologic manifestations are usually secondary to histoplasmomas or encephalitis. A 45-year-old man noted blurred vision while receiving empiric antituberculosis therapy for fever and diffuse granulomatous disease of unknown origin. Vertical-gaze palsy, right horizontal-gaze paresis, and mild right optic neuropathy were found on neuro-ophthalmologic examination. Further questioning revealed a history of frequent contact with fighting cocks from South America. Magnetic resonance images were consistent with multiple hemorrhagic infarcts, areas of inflammation, or both, and cerebral angiography showed changes consistent with vasculitis. A previously obtained biopsy specimen from the duodenum was restained and found to be positive for fungal elements. Serum antigen titers for Histoplasma capsulatum demonstrated evidence of active infection. This case is a rare example of a supranuclear ocular motility disturbance and optic neuropathy secondary to an occlusive vascular process in a patient with subacute disseminated histoplasmosis.

887

Oral histoplasmosis: a case report. Mead GE, Wilks D, McLaren K, Fergusson RJ. J Infect. 1998 Jul;37(1):73-5.

We report a case of biopsy-proven histoplasmosis in an 81-year-old man with mouth ulcers. The initial infection was probably contracted whilst he was a prisoner of war in Sumatra, and was reactivated during intercurrent illness with congestive cardiac failure and oral corticosteroid treatment for idiopathic thrombocytopaenic purpura. Of particular note is the latent period of 50 years, and a positive cytoplasmic antineutrophil cytoplasmic antibody (cANCA) titre.

888

Cerebral histoplasmosis in an Australian patient with systemic lupus erythematosus. Sullivan AA, Benson SM, Ewart AH, Hogan PG, Whitby RM, Boyle RS. Med J Aust. 1998 Aug 17;169(4):201-2.

A 39-year-old woman with systemic lupus erythematosus suffered a prolonged neurological illness associated with very low levels of glucose in her cerebrospinal fluid (CSF). Six months later, and after numerous CSF investigations, Histoplasma capsulatum was cultured. To our knowledge, this is the first report of cerebral histoplasmosis in Australia in a patient who is not HIV positive.

889

Acute pulmonary histoplasmosis: progressive pneumonia resulting from high inoculum exposure. Meals LT, McKinney WP. J Ky Med Assoc. 1998 Jul;96(7):258-60.

Histoplasmosis is endemic in certain areas of North, Central, and South America, especially within the Ohio and Mississippi River Valleys of the United States. We describe a case of histoplasmosis in a farm-dwelling resident of Kentucky who probably had multiple prior opportunities for exposure. However, during the gathering of topsoil containing chicken droppings for use as fertilizer, he was likely to have been exposed to such a high inoculum of the organism that he developed a severe pulmonary infection. He presented with a one-week history of malaise, myalgias, fever to 103 degrees F, and headaches. A chest X-ray showed bilateral reticulonodular infiltrates. He was initially treated for community-acquired pneumonia. When his symptoms did not resolve, a bronchoscopy was performed. Washings from the broncho-alveolar lavage grew Histoplasma capsulatum, and he responded well to itraconazole therapy. This case is presented to emphasize risks from high-inoculum exposure and the hazard imposed by harvesting certain types of organic material for use as fertilizer.

890

Acute pulmonary histoplasmosis: progressive pneumonia resulting from high inoculum exposure. Meals LT, McKinney WP. J Ky Med Assoc. 1998 Jul;96(7):258-60.

Histoplasmosis is endemic in certain areas of North, Central, and South America, especially within the Ohio and Mississippi River Valleys of the United States. We describe a case of histoplasmosis in a farm-dwelling resident of Kentucky who probably had multiple prior opportunities for exposure. However, during the gathering of topsoil containing chicken droppings for use as fertilizer, he was likely to have been exposed to such a high inoculum of the organism that he developed a severe pulmonary infection. He presented with a one-week history of malaise, myalgias, fever to 103 degrees F, and headaches. A chest X-ray showed bilateral reticulonodular infiltrates. He was initially treated for community-acquired pneumonia. When his symptoms did not resolve, a bronchoscopy was performed. Washings from the broncho-alveolar lavage grew Histoplasma capsulatum, and he responded well to itraconazole therapy. This case is presented to emphasize risks from high-inoculum exposure and the hazard imposed by harvesting certain types of organic material for use as fertilizer.

891

African histoplasmosis: osteomyelitis of the radius. Onwuasoigwe O, Gugnani HC. Mycoses. 1998 Mar-Apr;41(3-4):105-7.

Bone lesions in African histoplasmosis caused by Histoplasma capsulatum var, duboisii, without other signs of the infection, are often misdiagnosed as cancer. A case of isolated osteomyelitis due to this fungus in a 30-year-old woman is described. Diagnostic and therapeutic problems of isolated bone lesions in African histoplasmosis are discussed. A high diagnostic index of African histoplasmosis is advocated in isolated bone lesions in the endemic region of this disease.

892

Disseminated Histoplasma capsulatum infection presenting as genital ulcerations. Smith MB, Schnadig VJ, Zaharopoulos P, Van Hook C. Obstet Gynecol. 1997 May;89(5 Pt 2):842-4.

BACKGROUND: Histoplasma capsulatum infection in adults is most often subclinical but can result in disseminated disease with weight loss, fever, hepatosplenomegaly, and oropharyngeal ulcerations. Genital ulceration as the presenting sign of the disease has been reported rarely. CASE: A 63-year-old woman presented with multiple vaginal ulcerations due to chronic disseminated H capsulatum infection. Initial diagnosis was made by Papanicolaou and Giemsa-stained vulvar smears. Ketoconazole therapy resulted in clearing of the lesions in 5 weeks. CONCLUSION: Chronic disseminated histoplasmosis is an insidious and potentially fatal disease that can present rarely as genital mucocutaneous ulcerations in women. Prompt presumptive diagnosis can be accomplished by examination of smears obtained by ulcer abrasion, permitting institution of appropriate therapy.

893

A pulmonary infection caused by Coprinus cinereus (Hormographiella aspergillata) diagnosed after a neutropenic episode. Surmont I, Van Aelst F, Verbanck J, De Hoog GS. Med Mycol. 2002 Apr;40(2):217-9.

In a patient treated for a non-Hodgkin's lymphoma, a lung abscess caused by Hormographiella aspergillata (stat. anamorph. Coprinus cinereus) was diagnosed using an ultrasound-guided puncture of the lesion. The patient appeared to respond to amphotericin B, but at the same time was also recovering from her neutropenic episode. The extent to which each of these two factors explains the complete resolution of the infection is unclear. Expert classical morphological examination and molecular typing methods were needed to identify this filamentous basidiomycetous fungus.

894

Fatal pulmonary infection caused by the basidiomycete Hormographiella aspergillata. Verweij PE, van Kasteren M, van de Nes J, de Hoog GS, de Pauw BE, Meis JF. J Clin Microbiol. 1997 Oct;35(10):2675-8.

A fatal case of a pulmonary infection caused by Hormographiella aspergillata, the anamorph of the mushroom Coprinus cinereus, is reported for a patient receiving treatment for a second relapse of acute lymphoblastic leukemia. The filamentous basidiomycete was identified with restriction fragment length polymorphism patterns of PCR-amplified internally transcribed spacers and small subunit ribosomal DNA with four restriction enzymes. The patient failed to respond to treatment with amphotericin B and itraconazole. The fungus was cultured from the lungs at autopsy: the MIC of amphotericin B for the fungus was low (0.5 mg/liter), and that of itraconazole was high (8 mg/liter).

896

Fatal Hormonema dematioides peritonitis in a patient on continuous ambulatory peritoneal dialysis: criteria for organism identification and review of other known fungal etiologic agents. Shin JH, Lee SK, Suh SP, Ryang DW, Kim NH, Rinaldi MG, Sutton DA. J Clin Microbiol. 1998 Jul;36(7):2157-63.

We report a fatal case a fungal peritonitis caused by the yeast-like dematiaceous mould Hormonema dematioides in a 45-year-old woman. The woman had a 13-year history of insulin-dependent diabetes mellitus and had been on continuous ambulatory peritoneal dialysis for chronic renal failure. H. dematioides was repeatedly isolated from the dialysate culture specimens collected on days 3, 9, 16, and 20 of her hospital stay. Preliminary culture reports on day 7 of the growth of a yeast-like fungus, a probable Candida species, prompted the administration of fluconazole (FLU). Intraperitoneal and intravenous FLU failed to eliminate the mould, and the patient expired on day 21 of her hospital stay. We use this case to present what appears to be the first report of fungal peritonitis due to H. dematioides, to provide laboratorians with criteria for differentiating this organism from the similar mould Aureobasidium pullulans and from various yeast genera, and to provide a review of known fungal taxa inciting peritonitis.

897

Cutaneous phaeohyphomycosis caused by a rare fungal pathogen, Hormonema dematioides: successful treatment with ketoconazole. Coldiron BM, Wiley EL, Rinaldi MG. J Am Acad Dermatol. 1990 Aug;23(2 Pt 2):363-7.

Annular, fungating, ulcerated lesions developed on both hands of a 64-year-old immunocompetent man 2 months after he was cut with barbed wire. A dematiaceous mold, Hormonema dematioides, heretofore not definitively associated with human disease, was grown from two separate tissue specimens during a period of 9 days. Histopathologic examination demonstrated rare small, periodic acid-Schiff-positive, hyaline, yeastlike organisms in tissue. Twelve weeks of empiric therapy with ketoconazole, 400 mg/day, was curative.

898

Fungemia due to Hormonema dematioides following intense avian exposure. Kent D, Wong T, Osgood R, Kosinski K, Coste G, Bor D. Clin Infect Dis. 1998 Mar;26(3):759-60.

 

903

Endophthalmitis after Lasiodiplodia theobromae corneal abscess. Borderie VM, Bourcier TM, Poirot JL, Baudrimont M, Prudhomme de Saint-Maur P, Laroche L. Graefes Arch Clin Exp Ophthalmol. 1997 Apr;235(4):259-61.

BACKGROUND: Lasiodiplodia theobromae is an exceptional cause of human keratomycosis. PATIENT: We treated a 53-year-old man with fungal keratitis, which had been treated with topical betamethasone and gentamicin for 1 month, and endophthalmitis due to Lasiodiplodia theobromae. Despite intensive systemic, topical and intravitreal fungicidal treatment, enucleation had to be performed. RESULTS: The vitreous aspirate cultures were negative as of the second amphotericin intravitreal injection. However, histology revealed that the fungus was present in the cornea, ciliary body, iris and retina. CONCLUSION: The use of topical steroids may worsen the outcome of the infection.

904

Intrahyphal hyphae in corneal tissue from a case of keratitis due to Lasiodiplodia theobromae. Thomas PA, Garrison RG, Jansen T. J Med Vet Mycol. 1991;29(4):263-7.

Lasiodiplodia theobromae, a recognized plant pathogen, was isolated in culture from a case of human mycotic keratitis. Chemotherapy with a variety of azoles was unsuccessful and the lesion was removed surgically. Electron microscopy of thin sections of the excised corneal tissue revealed several examples of intrahyphal hyphae, a unique process described previously in in vitro cultures of various zoopathogenic fungi. We believe this to be the first report of the presence of intrahyphal hyphae in parasitized animal or human tissue. The demonstration of this process in vivo is thought to be consistent with the hypothesis that intrahyphal hyphae might represent an attempt by the invading fungus to survive in an otherwise unfavourable environment.

905

Lasiodiplodia theobromae panophthalmitis. Slomovic AR, Forster RK, Gelender H. Can J Ophthalmol. 1985 Oct;20(6):225-8.

Lasiodiplodia theobromae is a rare ocular pathogen. We report a case of panophthalmitis caused by this fungus. The patient was a healthy 62-year-old janitor with no history of ocular trauma in whom keratitis developed. Cultures of corneal scrapings identified the fungus. Despite treatment with appropriate antimycotics the keratitis progressed to infectious scleritis and then spontaneous perforation of the globe, which necessitated enucleation. The ultrasonographic, microbiologic and histologic findings are discussed and the results of in-vitro sensitivity testing presented.

906

Lasiodiplodia theobromae as a cause of keratomycoses. Rebell G, Forster RK. Sabouraudia. 1976 Jul;14(2):155-70.

Four cases of human keratitis caused by the tropical fungus Lasiodiplodia theobromae have been encountered in Miami, Florida bringing to 8 the number of cases reported in the world literature. Two of the ulcers were mild. Three patients recovered without severe impairment of vision after topical polyene treatment, but 1 patient with a severe ulcer required therapeutic keratoplasty after 11 days of topical natamycin. Histopathology revealed fungus deep in the cornea, invading Descemet's membrane. L. theobromae appeared to have collagenase activity in vitro. Inoculation of L. theobromae into the corneas of rabbits produced progressive ulcers. The fungus was endemic in Miami on home grown and imported bananas. Polyene antimycotic antibiotics were fungicidal for L. theobromae in vitro. Thiabendazole was effectively fungistatic but varied in fungicidal effect. Clotrimazole and miconazole were only incompletely fungistatic. Of 7 strains of L. theobromae tested, 4 were relatively resistant to 5-flurocytosine.

907

Onychomycosis due to saprophytic fungi. Report of 25 cases. Vélez H, Díaz F. Mycopathologia. 1985 Aug;91(2):87-92.

Twenty five cases of onychomycosis due to filamentous saprophytic agents were diagnosed within the period 1981-1982 in two mycology laboratories in Medellín, Colombia. These cases represented 4.5% and 9.5% respectively of the total fungal nail lesions (FNL) seen at those institutions. No explanation was found for the high frequencies, which sharply contrast with the previous local experience with the disease (0.4% of FNL). The responsible agents belonged to the following genera in decreasing order of frequency: Fusarium, Aspergillus, Scopulariopsis, Penicillium and Lasiodiplodia; two patients were infected with unidentified dematiaceous fungi and two more had the association of a saprophyte and a dermatophyte. In every case direct KOH preparations revealed septate hyphae, associated in 14 patients (56%) with chlamydoconidia. The only predisposing factors that were common to all these patients were age above 20 years and the use of footwear.

908

Lasiodiplodia theobromae isolated from a subcutaneous abscess in a Cambodian immigrant to Australia. Maslen MM, Collis T, Stuart R. J Med Vet Mycol. 1996 Jul-Aug;34(4):279-83.

A patient from Cambodia presented at a hospital in Melbourne with a persistent subcutaneous abscess of the right buttock. Septate fungal hyphae were seen in biopsy tissue. Lasiodiplodia theobromae was isolated and identified by the formation of pycnidia that produced typical conidia. The abscess was managed by drainage and debridement only. We briefly review the history and importance of the fungus as a wound parasite in tropical horticulture and its relatively rare occurrence in human infections. The significance of this fungus in Australian horticulture and its potential as an opportunistic human pathogen is noted. This paper records the first isolation of L. theobromae from a human lesion in Australia and the second isolation from a subcutaneous lesion worldwide.

909

Lecythophora mutabilis endophthalmitis after long-term corneal cyanoacrylate. Marcus DM, Hull DS, Rubin RM, Newman CL. Retina. 1999;19(4):351-3.

 

910

Fungal peritonitis caused by Lecythophora mutabilis. Ahmad S, Johnson RJ, Hillier S, Shelton WR, Rinaldi MG. J Clin Microbiol. 1985 Aug;22(2):182-6.

Fungal peritonitis caused by Lecythophora mutabilis, a mold rarely isolated from humans, is described. A patient on continuous peritoneal dialysis developed clinical, microbiological, and serological evidence for peritonitis due to this fungus. In vitro susceptibility testing of the fungus revealed marked differences in the activities of various antifungal agents. Although initially responding to treatment with oral ketoconazole, intraperitoneal miconazole, and catheter replacement, the patient had a documented relapse. The patient was eventually cured following the removal of a second catheter in association with prolonged imidazole treatment.

916

Leptosphaeria tompkinsii mycetoma. Venugopal PV, Venugopal TV. Int J Dermatol. 1990 Jul-Aug;29(6):432-3.

 

917

Mycetoma in Yemen: clinicoepidemiologic and histopathologic study. Khatri ML, Al-Halali HM, Fouad Khalid M, Saif SA, Vyas MC. Int J Dermatol. 2002 Sep;41(9):586-93.

BACKGROUND: Mycetoma is widespread in Yemen, but has not been fully documented. METHODS: A prospective study of 70 patients (53 male, 17 female; from different regions of Yemen) was performed. The clinical profile of the cases was recorded in a special protocol. The diagnosis was based on clinical features, examination of grains, roentgenographic studies, and histopathology (44 cases). RESULTS: Fifty cases were diagnosed as eumycetoma and 20 as actinomycetoma. The identification of the causative species was performed in 44 cases by histopathologic studies. Among the cases of eumycetoma, Madurella mycetomatis was recognized in 27 patients, Leptosphaeria senegalensis in two, and pale-grain fungi in two. Among the cases of actinomycetoma, Streptomyces somaliensis was seen in eight patients, Streptomyces madurae in one, and Nocardia species in four. The treatment of eumycetoma patients with ketoconazole and excision in selected cases controlled the disease activity in the majority. Most of the cases of actinomycetoma were better controlled with drug therapy alone, with a combination of penicillin and cotrimoxazole, or cotrimoxazole alone. CONCLUSIONS: Mycetoma is widespread in Yemen, with a higher incidence of eumycetoma and a maximum number of cases from the Hudaida region. A multicenter study is needed to evaluate the exact extent of disease.

918

Mycetomas in Mali: causative agents and geographic distribution. Mahe A, Develoux M, Lienhardt C, Keita S, Bobin P. Am J Trop Med Hyg. 1996 Jan;54(1):77-9.

Although Mali is situated in the African zone endemic for mycetomas, no report has been published on the characteristics of the disease in this country. We report a series of 54 cases observed in Bamako. The causative agents were Madurella mycetomatis in 20 patients, Leptosphaeria sp. in one patients, Actinomadura madurae in 12 patients, A. pelletieri in 15 patients, and Streptomyces somaliensis in three patients. In this series, the observed geographic distribution of the causative agents was in agreement with data on the causative agents and their geographic distribution in neighboring countries, and with those suggesting a relationship between the type of infectious agent and the annual rainfall.

919

[Mycetoma in Somalia - results of a survey done from 1959 to 1964] Destombes P, Mariat F, Rosati L, Segretain G. Acta Trop. 1977 Dec;34(4):355-73.

The Pasteur Institute studied 103 mycetoma patients in Somalia between 1959 and 1964. Grains were seen in 94 of them and this, added to cultural features, allowed the diagnosis of 60 pathogens as follows: 44 Madurella mycetomi, 1 Leptosphaeria senegalensis, 7 Pyrenochaeta romeroi (or Madurella grisea), 3 Allescheria boydii, 1 Fusarium sp., 3 Neotestudina (Zopfia) rosatii, and 1 unidentified; 34 were actinomycetes: 24 Streptomyces somaliensis, 4 Actinomadura madurae, 3 A. pelletieri and 3 Nocardia spp. The patients delayed too long in consulting their doctors and health education is vital if amputations are to be avoided. The geographical distribution is related to climate and fungal species. In central Somalia the association of M. mycetomi and S. somaliensis, organisms characteristic of desert conditions, was found; white grain mycetomata and those caused by Nocardia spp. occurred in more humid areas. The study revealed 2 new fungi. One, obtained in culture was called Neotestudina (Zopfia) rosatii. The 3 patients affected, lived in Mudugh (2 in El Bur). The other fungus was not identified. It also was recovered from El Bur and one with similar microscopic characters has been seen in Chad and also in "territoire français des Afars et des Issas". Both fungi are desert species.

920

Eumycetoma due to Madurella mycetomatis acquired in Jamaica. Fletcher CL, Moore MK, Hay RJ. Br J Dermatol. 2001 Dec;145(6):1018-21.

We report a case of eumycetoma due to Madurella mycetomatis affecting the left dorsal forefoot in a 35-year-old woman. She had spent her childhood in Jamaica, and had been resident in the U.K. for 20 years prior to her presentation. She gave a highly suggestive history for a mycetoma, having observed the intermittent discharge of black grains from the lesion. The diagnosis was confirmed by histological and mycological analysis of the grains, and a magnetic resonance imaging scan excluded osteomyelitis. She has responded very favourably to treatment with itraconazole. Mycetomas due to M. mycetomatis have not previously been reported from Jamaica.

921

Environmental occurrence of Madurella mycetomatis, the major agent of human eumycetoma in Sudan. Ahmed A, Adelmann D, Fahal A, Verbrugh H, van Belkum A, de Hoog S. J Clin Microbiol. 2002 Mar;40(3):1031-6.

Madurella mycetomatis is the main causative agent of human eumycetoma, a severe debilitating disease endemic in Sudan. It has been suggested that eumycetoma has a soil-borne or thorn prick-mediated origin. For this reason, efforts were undertaken to culture M. mycetomatis from soil samples (n = 43) and thorn collections (n = 35) derived from areas in which it is endemic. However, ribosomal sequencing data revealed that the black fungi obtained all belonged to other fungal species. In addition, we performed PCR-mediated detection followed by restriction fragment length polymorphism (RFLP) analysis for the identification of M. mycetomatis DNA from the environmental samples as well as biopsies from patients with mycetoma. In the case of the Sudanese soil samples, 17 out of 74 (23%) samples were positive for M. mycetomatis DNA. Among the thorn collections, 1 out of 22 (5%) was positive in the PCR. All PCR RFLP patterns clearly indicated the presence of M. mycetomatis. In contrast, 15 Dutch and English control soil samples were all negative. Clinically and environmentally obtained fungal PCR products share the same PCR RFLP patterns, suggesting identity, at least at the species level. These observations support the hypothesis that eumycetoma is primarily environmentally acquired and suggest that M. mycetomatis needs special conditions for growth, as direct isolation from the environment seems to be impossible.

922

Madura's foot: report of a case caused by Madurella mycetomatis. Verdolini R, Amerio P, Bugatti L, Manso E, Cataldi I, Brancorsini D, Nicolini M, Filosa G, Giangioacomi M. Eur J Dermatol. 2000 Dec;10(8):627-9.

We present a case of mycetoma by Madurella mycetomatis on the foot of a Chinese young man, living in Italy for more than ten years. Clinically the lesion closely resembled and was initially misinterpreted as a vascular neoformation. We analyze the histological and morphological features of the Madurella mycetomatis infection through which we managed to type the etiological agent. Our case is worth reporting because of the rarity of this disease in Europe and the unusual clinical presentation. It also offers the opportunity to stress the need for the clinical suspicion of this dermatosis, considering the increase of immigration towards our regions.

923

Eumycetoma by Madurella grisea. Report of the first case observed in the southern Brazilian region. Severo LC, Vetoratto G, Oliveira Fde M, Londero AT. Rev Inst Med Trop Sao Paulo. 1999 Mar-Apr;41(2):139-42.

The first case of eumycetoma by Madurella grisea occurred in Southern Brazilian Region is herein related. In addition, Brazilian literature on this subject was reviewed and, the geographic distribution of this eumycetoma is presented.

924

Mycetoma due to Madurella grisea acquired in Mexico. Southern PM Jr. Trop Doct. 1996 Oct;26(4):187-8.

Mycetomas due to Madurella grisea have been reported from South America, Central America, the Caribbean Islands, Africa and Asia, but only rarely from Mexico. We report a case of mycetoma due to M. grisea acquired in northern Mexico.

929

Epidemiology of Malassezia yeasts associated with pityriasis versicolor in Ontario, Canada. Gupta AK, Kohli Y, Faergemann J, Summerbell RC. Med Mycol. 2001 Apr;39(2):199-206.

The genus Malassezia was recently revised to include seven species, but the clinical significance of each of these species is not clearly understood. To obtain a better understanding of the contribution of individual Malassezia species to the epidemiology of pityriasis (tinea) versicolor, we used Leeming-Notman medium to culture patient skin specimens showing positive evidence of Malassezia infection in direct microscopy. Isolates were identified on the basis of recently published morphological and physiological tests for distinction of the new species. Identification using recently developed molecular criteria was also carried out for the ambiguous cases. Malassezia species were cultured from 111 cases of pityriasis versicolor in the Canadian province of Ontario. The most frequently isolated species were Malassezia sympodialis, M. globosa and M. furfur which respectively made up 59.4%, 25.2% and 10.8% of the isolated etiological agents. M. globosa was commonly isolated from a small number of pityriasis versicolor specimens obtained from investigators outside Canada. A large number of additional Ontario specimens with positive direct microscopy failed to yield a culture; however, it is suggested that this is consistent with the standard sampling practice of scraping the older portions of pityriasis lesions rather than the margins, where viable fungal cells are most likely to occur.

930

[Pityriasis versicolor and Malassezia folliculitis] Katoh T, Irimajiri J. Nippon Ishinkin Gakkai Zasshi. 1999;40(2):69-71.

Pityriasis versicolor and malassezia folliculitis were studied clinically and mycologically. The main results were as follows: 1) The average age of pityriasis versicolor patients has gradually become higher. 2) Negative rates of Malassezia furfur after treatment were very high by direct examination but relatively low by culture. 3) Patients who were negative by culture on completion of treatment seldom recurred within 2 months. 4) We can evaluate the effectiveness of antifungal application by using Malassezia furfur as normal skin flora on the volunteer's back. 5) Malassezia furfur (orbiculare or ovale type) is detected in follicular contents of steroid acne and acne vulgaris, which makes it necessary to establish criteria for diagnosis of malassezia folliculitis.

931

Diagnosis and treatment of tinea versicolor. Savin R. J Fam Pract. 1996 Aug;43(2):127-32.

Tinea versicolor (pityriasis versicolor) is a common superficial fungal infection of the stratum corneum. Caused by the fungus Malassezia furfur, this chronically recurring disease is most prevalent in the tropics but is also common in temperate climates. Treatments are available and cure rates are high, although recurrences are common. Traditional topical agents such as selenium sulfide are effective, but recurrence following treatment with these agents is likely and often rapid. Currently, therapeutic interest is focused on synthetic "-azole" antifungal drugs, which interfere with the sterol metabolism of the infectious agent. Ketoconazole, an imidazole, has been used for years both orally and topically with great success, although it has not been approved by the Food and Drug Administration for the indication of tinea versicolor. Newer derivatives, such as fluconazole and itraconazole, have recently been introduced. Side effects associated with these triazoles tend to be minor and low in incidence. Except for ketoconazole, oral antifungals carry a low risk of hepatotoxicity.

932

Tinea versicolor of the scalp. el-Gothamy Z, Ghozzi M. Int J Dermatol. 1995 Aug;34(8):533-4.

BACKGROUND: Tinea versicolor (TV) is commonly described on the trunk without giving attention to involvement of the scalp. We examined cases with dandruff with and without TV on the body to see how frequent Malassezia furfur (M. furfur) is present in dandruff scales. METHODS: A total of 80 patients were examined mycologically using KOH preparation for the presence of M. furfur in dandruff scales. RESULTS: M. furfur was found in dandruff scales in 7 out of 20 men with TV (35%) and 5 out of 20 women with TV (25%), whereas it was absent in another 40 cases without clinical lesions of TV on the body. CONCLUSIONS: Attention must be paid to TV of the hairy scalp. Cases of dandruff, especially those accompanied with TV of the body, must be examined for the presence of M. furfur because of its prognostic significance. Positive cases should be treated accordingly.

933

Malignant otitis externa caused by Malassezia sympodialis. Chai FC, Auret K, Christiansen K, Yuen PW, Gardam D. Head Neck. 2000 Jan;22(1):87-9.

BACKGROUND: Malignant otitis externa caused by fungal infections is rare. A review of the literature showed only 9 cases, and the causative fungus in all cases was Aspergillus. This article reports an unusual case caused by Malassezia sympodialis. METHODS: A 53-year-old man with non-insulin dependent diabetes presented with malignant otitis externa. He deteriorated despite treatment with intravenous antipseudomonal therapy and surgical debridement. Microbiologic tests revealed M. sympodialis. He responded rapidly to intravenous amphotericin. RESULTS: Systemic human infections caused by M. sympodialis have not been reported. M. furfur systemic infection is rare and has been associated lipid hyperalimentation by means of a central catheter. Only 1 other case of M. fungemia without these associated risk factors has been reported. CONCLUSIONS: The first case of malignant otitis externa caused by M. sympodialis is presented. It highlights the difficulty of initial biologic diagnosis and the need for lipid-enriched media to grow this fastidious organism.

934

Malassezia furfur fungaemia in a ventilator-dependent patient without known risk factors. Chu CM, Lai RW. Hong Kong Med J. 2002 Jun;8(3):212-4.

Malassezia furfur is the lipophilic yeast which causes tinea versicolor and is an uncommon cause of fungaemia. It usually occurs in the context of hyperalimentation with lipid emulsion, immunosuppression, or the presence of a central venous catheter. We report a case of a ventilator-dependent patient who developed Malassezia furfur fungaemia in the absence of these known risk factors. A likely risk factor in this patient was receipt of multiple courses of broad-spectrum antibiotics. This case highlights the importance of recognising Malassezia furfur as a cause of fungaemia, as well as the need for special culture techniques to aid identification.

935

Systemic Malassezia furfur infection in an adult receiving total parenteral nutrition. Shparago NI, Bruno PP, Bennett J. J Am Osteopath Assoc. 1995 Jun;95(6):375-7.

Malassezia furfur sepsis developed in a woman with hyperemesis gravidarum while she was receiving total parenteral nutrition supplemented with lipids. Fever, chills, dyspnea, pleuritic chest pain, and multiple bilateral pulmonary nodular infiltrates were the primary clinical manifestations. Lysis-centrifugation fungal blood cultures supplemented with olive oil grew M furfur. Treatment included removal of the central venous catheter line, discontinuation of the lipid emulsion, and antifungal chemotherapy. Malassezia furfur sepsis complicating total parenteral nutrition may be more common in adults than once suspected. A high index of suspicion is required to diagnose this infection, and the addition of olive oil to the fungal culture medium will provide the necessary growth factors to isolate this fungus.

936

Malassezia furfur colonization of neonates in an intensive care unit. Ahtonen P, Lehtonen OP, Kero P, Tunnela E, Havu V. Mycoses. 1990 Nov-Dec;33(11-12):543-7.

We studied Malassezia furfur colonization of neonates in the neonatal intensive care unit (NICU) and found that the rate was astonishingly high as compared to the previous studies. In very low birth weight (less than 1,000 g) infants we recorded a colonization rate of 80%, and 4% infants with a birth weight greater than 2,000 g. Under 10 day's hospitalization the rate was 11%, and it was 70% after 20 days spent in the unit. Among the infants with the birth weight less than 1,700 g, antibiotic therapy was recorded as a significant risk factor for colonization. In the infants with a greater birth weight, the colonization rate was independent from the risk factors studied. M. furfur colonization could not be linked with occurrence of any symptoms of signs recorded and colonization by M. furfur was so common in NICU that the predictive value of surveillance cultures is poor.

937

Catheter-related infection in infants due to an unusual lipophilic yeast--Malassezia furfur. Long JG, Keyserling HL. Pediatrics. 1985 Dec;76(6):896-900.

Malassezia furfur (Pityrosporum orbiculare, P ovale), a lipophilic yeast that is part of the normal skin flora, causes tinea versicolor but has only rarely been associated with more serious infections. We report five episodes in four infants of catheter-related infection caused by this organism. All episodes occurred in infants who had survived serious neonatal disorders and were receiving prolonged therapy with intravenous fat emulsion. Sudden onset of fever without focal findings was the usual presentation; however, one afebrile patient had recurrent episodes of apnea, bradycardia, and cyanosis. Thrombocytopenia was a prominent finding. Patients were generally treated with amphotericin B. All patients recovered when the colonized catheter was removed or fat emulsion therapy was stopped. The yeast usually grew slowly in blood culture media but grew readily when subcultured onto Sabouraud's medium coated with sterile olive oil. Yeasts were readily identified in all four patients in whom a buffy coat Gram stain was obtained of blood from the central intravenous catheter. M furfur may be a fairly common but unrecognized cause of catheter-related sepsis in infants receiving long-term fat emulsion therapy. This organism should be sought whenever routine blood cultures are negative for bacteria and yeasts are observed in a buffy coat Gram stain.

938

An epidemic outbreak of Malassezia folliculitis in three adult patients in an intensive care unit: a previously unrecognized nosocomial infection. Archer-Dubon C, Icaza-Chivez ME, Orozco-Topete R, Reyes E, Baez-Martinez R, Ponce de León S. Int J Dermatol. 1999 Jun;38(6):453-6.

BACKGROUND: Malassezia is a lipophilic fungus commonly found in normal human skin. Infection of the hair follicle by Malassezia furfur occurs in patients with predisposing factors such as diabetes or immunosuppression, or who are undergoing antibiotic treatment. Malassezia furfur folliculitis is an infrequent nosocomial infection which may be associated with fomite transmission. METHODS: We reviewed the clinical files of three adult patients from an intensive care unit (ICU) who simultaneously developed folliculitis through Malassezia infection. We specifically analysed predisposing factors, possible transmission modes, characteristics of skin lesions, results of biopsies and cultures, treatment, and patient outcome. RESULTS: The three male patients were in neighboring beds and they all had factors that predisposed them to underlying immunosupression. Simultaneously, and within hours of each other, they developed erythematous follicular papules and pustules on the face and chest. The skin biopsies revealed an acute folliculitis with abundant round to oval yeasts of up to 5 microm in diameter. Stains for fungi (Schiff's peryodic acid, Grocott and silver methenamine) revealed numerous unipolar budding yeasts without hyphae, consistent with M. furfur. Conventional cultures were negative. The diagnosis of folliculitis by M. furfur was established and antifinigal treatment initiated, with adequate outcome of the dermatosis. After this outbreak, the aseptic and hygienic measures of the health care personnel of the ICU were reviewed and corrected. CONCLUSIONS: The simultaneous emergence of this superficial infection by M. furfur suggests fomite participation. This dermatomycosis is an infrequent nosocomial infection in adults, which to our knowledge has not been previously reported.

939

11. Human infections due to Malassezia spp. Marcon MJ, Powell DA. Clin Microbiol Rev. 1992 Apr;5(2):101-19.

The genus Malassezia contains three member species: Malassezia furfur and Malassezia sympodialis, both obligatory lipophilic, skin flora yeasts of humans, and Malassezia pachydermatis, a nonobligatory lipophilic, skin flora yeast of other warm-blooded animals. Several characteristics suggest the basidiomycetous nature of these yeasts, although a perfect stage has not been identified. Classically, these organisms are associated with superficial infections of the skin and associated structures, including pityriasis versicolor and folliculitis. Recently, however, they have been reported as agents of more invasive human diseases including deep-line catheter-associated sepsis. The latter infection occurs in patients, primarily infants, receiving parenteral nutrition (including lipid emulsions) through the catheter. The lipids presumably provide growth factors required for replication of the organisms. It is unclear how deep-line catheters become colonized with Malassezia spp. Skin colonization with M. furfur is common in infants hospitalized in neonatal intensive care units, whereas colonization of newborns hospitalized in well-baby nurseries and of older infants is rarely observed. Catheter colonization, which may occur without overt clinical symptoms, probably occurs secondary to skin colonization, with the organism gaining access either via the catheter insertion site on the skin or through the external catheter hub (connecting port). There is little information on the colonization of hospitalized patients by M. sympodialis or M. pachydermatis. Diagnosis of superficial infections is best made by microscopic examination of skin scrapings following KOH, calcofluor white, or histologic staining. Treatment of these infections involves the use of topical or oral antifungal agents, and it may be prolonged. Diagnosis of Malassezia catheter-associated sepsis requires detection of the organism in whole blood smears or in buffy coat smears of blood drawn through the infected catheter or isolation of the organism from catheter or peripheral blood or the catheter tip. Culture of M. furfur from blood is best achieved with Isolator tubes and plating onto a solid medium supplemented with a lipid source. Appropriate treatment of patients requires removal of the infected catheter with or without temporary stoppage of lipid emulsions; administration of antifungal therapeutic agents does not appear to be necessary. Because many patients who develop Malassezia catheter-associated sepsis have severe underlying illnesses, caution must be exercised in attributing all clinical deterioration to Malassezia infection. Our better understanding of how these organisms cause disease awaits the development of a useful typing scheme for epidemiologic studies and further studies on microbial virulence factors and the role of the immune response in pathogenesis.

941

Malbranchea pulchella fungal sinusitis. Benda TJ Jr, Corey JP. Otolaryngol Head Neck Surg. 1994 Jun;110(6):501-4.

Fungal sinus disease is being reported with increasing frequency. We could find no previously reported cases of sinonasal infections with Malbranchea pulchella and only two previously reported cases of human infection of any kind. We now report on a case of suspected sinonasal Malbranchea pulchella in a patient with aspirin-sensitive triad asthma.

955

Fungal keratitis caused by Metarhizium anisopliae var. anisopliae. De Garcia MC, Arboleda ML, Barraquer F, Grose E.J Med Vet Mycol. 1997 Sep-Oct;35(5):361-3.

Metarhizium anisopliae var. anisopliae (Metschnikov) Sorokin 1883 to our knowledge has never been reported as an agent of human or animal mycosis. This fungus has great importance as an agent of biological control of different pests and mosquito larvae in Colombia. It has been isolated as the aetiological agent of keratomycosis for the first time from the eye of a Colombian male.

958

Suppurative cutaneous granulomata caused by Microascus cinereus in a patient with chronic granulomatous disease. Marques AR, Kwon-Chung KJ, Holland SM, Turner ML, Gallin JI. Clin Infect Dis. 1995 Jan;20(1):110-4.

We describe a patient with chronic granulomatous disease who presented with erythematous papular skin lesions on the chest, back, and arm. Examination of biopsy specimens from the lesions on the arm and back showed suppurative granulomata in association with acute and chronic inflammation. Histopathologic examination of a specimen from the lesion on the arm revealed fungal elements, and cultures yielded Microascus cinereus. The patient was treated with 2.5 g of intravenous amphotericin B, and the lesions resolved. We report what is, to our knowledge, the first case of invasive disease due solely to M. cinereus.

959

Onychomycoses due to Microascus cirrosus (syn. M. desmosporus). de Vroey C, Lasagni A, Tosi E, Schroeder F, Song M. Mycoses. 1992 Jul-Aug;35(7-8):193-6.

Microascus cirrosus is very rarely the aetiological agent of onychomycosis. We report two additional cases of toenail infections caused by this fungus.

960

Microascus desmosphorus(Lechmere)Curzi 1931 as causative agent of toe-nail mycosis] Schönborn C, Jahn H. Dermatol Monatsschr. 1970;156(6):615-26.

 

961

Microascus cinereus infection of human nail. Agarwal GP, Singh SM. Indian J Med Sci. 1980 Nov;34(11):263-5.

 

962

Maxillary sinusitis from Microascus cinereus and Aspergillus repens. Aznar C, de Bievre C, Guiguen C. Mycopathologia. 1989 Feb;105(2):93-7.

Microascus was associated with Aspergillus repens in a left maxillary sinus. Tissue contained septale filaments of two types, conidia, ostiolate perithecia containing ascospores corresponding to Microascus cinereus which was identified by culture. The abundance of sexual fructifications in the tissue indicates that pathogenicity is due to Microascus cinereus.

963

Microascus cinereus (Anamorph scopulariopsis) brain abscess in a bone marrow transplant recipient. Baddley JW, Moser SA, Sutton DA, Pappas PG. J Clin Microbiol. 2000 Jan;38(1):395-7.

We report the first documented case of brain abscess due to the dematiaceous fungus Microascus cinereus, an organism common in soil and stored grain. M. cinereus was isolated from brain abscess material from a bone marrow transplant recipient. The patient responded well to treatment by amphotericin B lipid complex, itraconazole, and a craniotomy but later died from secondary complications caused by graft-versus-host disease.

964

Early Microascus cinereus endocarditis of a prosthetic valve implanted after Staphylococcus aureus endocarditis of the native valve. Célard M, Dannaoui E, Piens MA, Guého E, Kirkorian G, Greenland T, Vandenesch F, Picot S. Clin Infect Dis. 1999 Sep;29(3):691-2.

 

969

Microsphaeropsis olivacea as an etiological agent of human skin infection. Guarro J, Mayayo E, Tapiol J, Aguilar C, Cano J. Med Mycol. 1999 Apr;37(2):133-7.

Microsphaeropsis olivacea is reported as the agent of a case of human skin infection in an otherwise healthy woman. This fungus has not been reported previously as causing disease in humans. It was identified on the basis of its production of pycnidia and conidial structures typical of the Coelomycetes, and by its light brown, ellipsoid to cylindrical and thick walled conidia. The in vitro inhibitory activity of amphotericin B, fluconazole, flucytosine, itraconazole, ketoconazole and miconazole was determined.

970

Microsphaeropsis olivacea keratitis and consecutive endophthalmitis. Shah CV, Jones DB, Holz ER. Am J Ophthalmol. 2001 Jan;131(1):142-3.

PURPOSE: To report a case of fungal keratitis with consecutive endophthalmitis caused by Microsphaeropsis olivacea. METHODS: Case report. RESULTS: A 51-year-old man developed fungal keratitis and consecutive endophthalmitis after sustaining a penetrating injury to the right eye. Cultures of the aqueous humor yielded M. olivacea. Infection resolved after intraocular fungal debridement, intravitreous amphotericin B, and aggressive topical natamycin and oral fluconazole. Persistent, low-grade smoldering corneal and intraocular inflammation required topical corticosteroid therapy. CONCLUSION: M. olivacea is an exceedingly rare ocular pathogen. The intraocular portion of the infection responded quickly to intravitreal antifungal treatment; however, the course was prolonged by smoldering corneal inflammation. Prompt recognition of intraocular spread and aggressive treatment may be beneficial in fungal infections caused by unusual organisms with uncertain virulence.

971

Microsporum langeronii dermatophytosis in a newborn infant contaminated in France] Cabon N, Moulinier C, Taieb A, Maleville J. Ann Dermatol Venereol. 1994;121(3):247-8.

Dermatophytosis due to Microsporum langeronii was observed in a 21-day neonate born in Bordeaux, France to a mother of West African origin. A typical misleading manifestations were: non alopecic squamation of the scalp with seborrhoea associated with circineous vesiculo-squamous lesions of the forehead. The source of the contamination was undoubtedly the mother who presented squamation without alopecia of the scalp. M. langeronii were observed in the scales and the hair. Epidemiological search for tinea should be carried out in the family as well as in schools attended by the brothers and sisters. Familial contamination is more frequent.

972

[Microsporum canis tinea ciliaris and blepharitis] Creach P, Auffret N, Buot G, Binet O. Ann Dermatol Venereol. 1995;122(11-12):773-4.

INTRODUCTION: The involvement of eyelashes and eyelids by dermatophytes is unfrequent. CASE REPORT: We describe such a case in a 48 year old woman, who presented with unilateral blepharitis, resistant to topical treatments with antiseptics, antibiotics and corticosteroids. Diagnosis was suspected by magnifying lens and Wood's light examination; Microsporum canis was isolated from broken eyelashes and scales of annular lesions of eyelids. CONCLUSION: This case emphasizes the interest of mycological examination of eyelashes and eyelids in front of a persisting unilateral blepharitis.

973

Microsporum canis infections in children: results of a new oral antifungal therapy. Ginter G. Mycoses. 1996 Jul-Aug;39(7-8):265-9.

Clinical and laboratory data from 22 children with tinea corporis and tinea capitis caused by Microsporum canis (10 tinea corporis, 12 tinea capitis), confirmed by microscopic examination and culture and partly pretreated with griseofulvin or terbinafine, are summarized. The children were treated consecutively with itraconazole in our clinic during 1994/95. The age of the children ranged between 4 and 13 years, with girls being affected much more frequently than boys. Oral, individually adapted, high-dose treatment of 5 mg itraconazole per kg body weight proved to be successful. In all 22 children, although pretreatment with griseofulvin or terbinafine was partly unsuccessful, fungal infections could be cured clinically and also were culture negative at control examinations. In 10 children with tinea corporis treatment was performed only for 4-14 (middle 11) days. In the children with tinea capitis itraconazole treatment was continued for 3-11 weeks. Among the six children without pretreatment, itraconazole solution was administered for 4-11 weeks (average 7.5 weeks). Of the patients in whom pretreatment was unsuccessful, four with griseofulvin and two with terbinafine, the duration of the subsequent oral treatment with itraconazole solution was 3-5 weeks (average 3.6 weeks). The drug seemed to be well tolerated-no significant side-effects occurred, with the exception of possible minor gastrointestinal disturbances in two patients. Laboratory values remained within normal limits.

974

Tinea capitis due to Microsporum gypseum in an adult. Offidani A, Simoncini C, Arzeni D, Cellini A, Amerio P, Scalise G. Mycoses. 1998 May-Jun;41(5-6):239-41.

A case of tinea capitis due to Microsporum gypseum in an adult is described. An otherwise healthy 69-year-old woman presented two large patches of slightly erythematous scaling alopecia localized on the vertex and on the left parietal region of the scalp. The only subjective sign was itching. A mycological culture was positive for Microsporum gypseum. Tinea capitis is uncommon in adults; furthermore, isolation of Microsporum gypseum from this type of lesion is rare.

975

Case report. Tinea corporis purpurea. Veraldi S, Gorani A, Schmitt E, Gianotti R. Mycoses. 1999;42(9-10):587-9.

We report a case of tinea corporis purpurea localized to a calf in a 36-year-old woman. The patient, who was also affected by mild superficial venous insufficiency of lower limbs, complained of intense pruritus. Microsporum canis was the aetiological agent. Clinically atypical varieties of tinea corporis were sometimes reported in the literature, particularly in HIV-positive patients, although they are uncommon in immunocompetent patients; in particular, tinea corporis purpurea is very rare.

976

Tinea faciei due to Microsporum canis abscess formation. Patel G, Mills C. Clin Exp Dermatol. 2000 Nov;25(8):608-10.

Superficial dermatophyte infections are common in children; however, complications are encountered rarely. We describe a child with tinea faciei caused by Microsporum canis, who subsequently developed an abscess. Complete resolution occurred after treatment with oral terbinafine.

977

Microsporum canis tinea capitis in an 8-month-old infant successfully treated with 2 weekly pulses of oral itraconazole. Koumantaki E, Georgala S, Rallis E, Papadavid E. Pediatr Dermatol. 2001 Jan-Feb;18(1):60-2.

We report an 8-month-old girl with tinea capitis caused by Microsporum canis which was successfully treated with two pulses of oral itraconazole 50 mg/day, each of 1 week duration with an interval of 2 weeks. M. canis tinea capitis can be a difficult therapeutic problem in an infant, as the treatment is usually long, lasting up to 4-6 weeks with griseofulvin and 6-12 weeks with terbinafine, and the desire to provide a safe systemic therapy is particularly important. With an intermittent regimen the duration of treatment with active drug can be much shorter compared to continuous therapy. We found that itraconazole pulse therapy for M. canis tinea capitis was a safe and effective treatment in an infant.

978

Subcutaneous infection by Microsporum gypseum. Fernández-Torres B, Mayayo E, Boronat J, Guarro J. Br J Dermatol. 2002 Feb;146(2):311-3.

We report a case of subcutaneous infection caused by the dermatophyte Microsporum gypseum in an immunocompetent host. The patient acquired the infection in the knee through a traumatic inoculation of a splinter. To our knowledge this is the first case of subcutaneous infection caused by this fungus.

979

Case report. Onychomycosis due to Microsporum canis. Romano C, Paccagnini E, Pelliccia L. Mycoses. 2001 May;44(3-4):119-20.

A case of distal subungual onychomycosis of the big toe due to Microsporum canis is reported in a 69-year-old male asthma patient who had been treated with systemic corticosteroids for the last 3 years. The nail infection was contracted from a cat who was a healthy carrier. The patient was treated successfully with intermittent itraconazole therapy.

980

Onychomycosis due to Microsporum gypseum. Romano C. Mycoses. 1998 Sep-Oct;41(7-8):349-51.

The first four cases of onychomycosis due to Microsporum gypseum observed in Italy between 1990 and 1997 are reported. clinical manifestation was distal subungual onychomycosis in all cases. The lesions were asymptomatic in two patients. Three patients were treated with oral itraconazole (pulsed therapy) and the other with ciclopirox 8% nail lacquer. Clinical and mycological recovery was achieved in all cases. The cases are reported because of their rarity.

981

Case of onychomycosis caused by Microsporum racemosum. García-Martos P, Gené J, Solé M, Mira J, Ruíz-Henestrosa R, Guarro J. J Clin Microbiol. 1999 Jan;37(1):258-60.

We report the case of a Spanish 60-year-old female who presented in 1997 with onychomycosis of the left thumbnail following an injury caused by a fresh fish bone. Microsporum racemosum was repeatedly cultured from nail scrapings, and its identity was confirmed by sequencing the isolate's ITS1/ITS2 and 5.8S rRNA regions. The patient was successfully treated with itraconazole, which was administered for 12 weeks. This represents the first case of onychomycosis due to M. racemosum and the first time that this species has been isolated from a human in Europe.

982

[Mycetomas caused by Microsporum canis. Report of one case] Zaror L, Moreno MI, Hering M, Siegmund I, Norambuena L. Rev Med Chil. 1997 Aug;125(8):922-6.

We report an eight years old boy presenting with a pyogenic granuloma of the scalp, generalized alopecia, descamative plates in the neck, trunk and limbs and nail involvement. Cultures for fungus of all these lesions disclosed Microspore canis. The patient was treated with oral griseofulvin, miconazole and topical tolnaftate. Five years later and after several incomplete treatments, the patient returns with a fistulous mass of 15 x 8 cm in the dorsal area whose culture revealed Microspore canis. The mass was excised and oral ketoconazole was indicated. After three months of follow up, the patient was lost from control.

983

[Microsporum canis mycetoma of the scalp] Vezon G, Desbois N, Boisseau-Garsaud AM, Helenon R, Jouannelle A, Saint-Cyr I, Cales-Quist D. Ann Dermatol Venereol. 2000 Aug-Sep;127(8-9):729-31.

BACKGROUND: Mycetoma is a chronic subcutaneous tumefaction with presence of grains or granules. Etiological agents include bacteria or filamentous fungi. Mycetoma due to dermatophytes is uncommon, mainly occurring in Africa. To our knowledge, no case has been reported in the West Indies. Only two observations of Micosporum canis mycetoma in humans have been reported in the literature. We report a third case of mycetoma of the scalp caused by this fungus. CASE REPORT: A 22-year-old woman from Martinique, French West Indies, presented with an indolent tumefaction of the scalp evolving over five years. She had mental retardation due to congenital adrenal hyperplasia with 21-hydroxylase deficiency. The lesion was extracted surgically. Pathology and mycology examinations showed features of Microsporum canis mycetoma. Two months later, the scalp lesion recurred and the patient was treated with griseofulvin after surgical extraction. DISCUSSION: Mycetoma due to dermatophytes is very uncommon, mainly observed on the scalp and nape of the neck. A history of a skin lesion is frequent, leading to transcutaneous penetration of the fungus and mycetoma formation. Several dermatophyte species have been identified as causal agents (Microsporum ferrugineum, Trichophyton rubrum, Trichophyton verrucosum, Trichophyton mentagrophytes, Microsporum audouinii, Microsporum langeronii). Microsporum canis is rarely demonstrated in humans: two cases in children in Africa and Australia. Our observation was similar to the two cases in the literature: indolent and mobile tumefaction of the scalp, in a child or young adult, suggestive of lipoma or epidermal cyst, with excision leading to diagnosis. Association with tinea capitis and skin or nail involvement can also be observed.

984

Occupational asthma caused by a natural food colorant derived from Monascus ruber. Vandenplas O, Caroyer JM, Cangh FB, Delwiche JP, Symoens F, Nolard N. J Allergy Clin Immunol. 2000 Jun;105(6 Pt 1):1241-2.

 

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