Nasal Cutaneous Infection in a Healthy Boy Caused by Fusarium moniliforme

A healthy 10‐year‐old Chinese boy developed verrucous plaques on the nose. The fungus was identified as Fusarium moniliforme via culture of biopsy fragments. The patient had normal immune status and was successfully treated with oral itraconazole (100 mg/day) for 2 months and application of oral itraconazole and topical sertaconazole nitrate cream. Fusarium is a ubiquitous hyalohyphomycete isolated from food that is also widespread in the environment and is present at all latitudes. Infections due to this mold may be disseminated or localized. Fusarium species have been known to colonize the cornea, nails, and burn eschars in otherwise healthy patients. Cutaneous and disseminated infections have been reported mostly in immunocompromised hosts. Here we describe an unusual case of localized infection caused by Fusarium moniliforme in an otherwise healthy child, with significant improvement after 2 months of oral itraconazole and topical sertaconazole nitrate cream therapy.     

Onychomycosis due to Exophiala jeanselmei

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.     

Epidemiology of deep cutaneous fungal infections in Korea (2006–2010)

Deep cutaneous fungal infections (DCFI) occur worldwide and their prevalence is influenced by personal factors of the affected patients and the geographic and cultural features. Surveillance studies of DCFI with respect to the various clinical backgrounds of affected patients can ultimately help to improve their outcome. Expanding on our previous study, we performed a retrospective analysis of patients with DCFI who were treated in a group of university teaching hospitals in Korea to determine the trends within a 5‐year period. A retrospective medical record review of patients with DCFI treated between 2006 and 2010 at 16 university teaching hospitals located throughout Korea was performed. Among the 51 cases of DCFI (median patient age, 47.0 years), opportunistic infections in immunocompromised hosts accounted for half. Patients in this group included 11 who were transplant recipients and 12 with malignancies. Overall, Candida (13/51) was the most common causative organism, followed by Sporothrix (12) and Aspergillus (6). Papuloplaques and nodular lesions were the typical presentation, with maculopatches and ulcers also occurring in considerable numbers. Ten patients had systemic involvement. Eight immunocompromised patients did not recover from the disease despite systemic antifungal treatment. Our results highlight the equal involvement of opportunistic and primary pathogens in DCFI, as determined in cases from a 5‐year period. Especially in immunocompromised hosts with non‐specific skin findings, clinical suspicion is important because failure to diagnose a DCFI causes significant morbidity and possibly even death.     

The use of topical minoxidil to accelerate nail growth: a pilot study

Linear nail growth rate is affected by various conditions, one of which is the level of blood flow. Our supposition was that topical minoxidil, which has vasodilatory properties, can increase the rate of nail growth. The aim of this study was to determine the impact of topical minoxidil on nail growth. A 5% topical minoxidil solution was applied twice daily to the fingernails of 32 participants. Two groups of 16 participants were randomly chosen. In one group, the applications were made to the right index and left ring fingernails, and, in the other, the left index and right ring fingernails. During each visit (weekly during the first month and every 2 weeks during the second month), the nail length of six fingernails (index, middle, and ring of both hands) was measured using a digital caliper. Beginning in the first week, the mean nail length of the treated nails was greater than that of nails in the untreated group with statistical significance. There were no systemic or cutaneous side effects. During the first month, the mean growth of the treated nails was 4.27 mm/month compared with 3.91 mm/month in the untreated nails (P = 0.003). These findings suggest that a 5% concentration of topical minoxidil can stimulate nail growth with increased growth beginning in the first week of application. The results may have important implications for the treatment of nail disorders; however, a comparable study involving participants with nail disorders is highly recommended.     

Cold subcutaneous abscesses as the first manifestation of disseminated coccidioidomycosis in an immunocompromised host

Coccidioidomycosis is an endemic fungal infection in the southwestern USA and northern Mexico. It is caused by Coccidioides immitis and C. posadasii. This infection occurs due to the inhalation of airborne arthroconidia, causing a mild pulmonary infection, but most cases are asymptomatic. Disseminated coccidioidomycosis (DC) is a rare entity occurring in less than 1% of all cases, usually in immunocompromised patients, and it carries high risks of morbidity and mortality. The skin is one of the most frequently affected organs and in some cases cutaneous lesions may be the first or only sign of infection. A wide spectrum of clinical lesions may develop, including cold abscess. In immunocompromised hosts, DC represents a diagnostic and therapeutic challenge. Treatment is based on antifungal drugs, such as amphotericin B and azoles, administered for long periods of time and under close follow up to monitor the treatment response and to detect relapse. In the following case report, we present a 35‐year‐old male patient with systemic lupus erythematosus under immunosuppressive therapy who presented with cold subcutaneous abscesses as the first sign of DC.     

Successful use of topical vitamin E solution in the treatment of nail changes in yellow nail syndrome

A double-blind controlled study was performed on a patient with long-standing yellow nail syndrome to investigate the potential beneficial role of topical vitamin E solution for the nail changes seen in this disorder. Three nails received active solution containing DL-alpha-tocopherol in dimethyl sulfoxide; three nails received dimethyl sulfoxide only; and the remainder were untreated. After 6 months of therapy, the three nails treated with active solution showed marked clinical improvement and a corresponding increase in nail growth rates. Dimethyl sulfoxide alone produced a small increase in nail growth rate and slight clinical improvement. Active solution was then applied to all of the nails for a further 6 months, resulting in clinical improvement and increased nail growth rates in the remaining nails. These beneficial effects require further study.     

Combination Systemic Fluorouracil and Radiation for the Treatment of Recalcitrant Condyloma with Associated Squamous Cell Carcinoma in an Immunocompromised 15‐Year‐Old Girl

Condylomata acuminata (CA), or anogenital warts, are typically benign lesions caused by human papillomavirus infection. Although they are rare, immunocompromised individuals are at a higher risk of CA undergoing transformation into invasive anal squamous cell carcinoma (SCC). These patients need aggressive evaluation and management. Treatment of CA is challenging, particularly for immunocompromised hosts, in whom warts are resistant to treatment and commonly recur. Currently, there is no gold standard treatment for CA, especially in children and immunodeficient individuals. We report the case of a 15‐year‐old immunocompromised girl with severe recalcitrant condyloma that resolved after a course of systemic 5‐fluorouracil, mitomycin C, and radiation therapy for SCC.     

Trichophyton rubrum abscesses in immunocompromised patients. A case report

A 72-year-old immunocompromised man with myelodysplastic syndrome who developed multiple erythematous, scaly abscesses like lesions on his left foot and lower leg is described. He also had dry scaly lesions on his soles and lesions on several toe nails. A punch biopsy showed abscesses with fungal elements and Trichophyton rubrum was cultured from skin scales and the biopsy. A diagnosis of T. rubrum abscesses should be suspected in all immunocompromised patients with signs of superficial dermatophyte infection.     

Efficacy of amorolfine nail lacquer for the prophylaxis of onychomycosis over 3 years

Background Standard treatment for onychomycosis often results in less than half of subjects achieving disease‐free nails. Onychomycosis is even more challenging to treat as relapses and re‐infections are common. Objective To determine if a prophylactic effect exists when a treatment with amorolfine nail lacquer (ANL), with half the frequency of the standard regimen, is instituted following successful treatment of dermatophytic toenail onychomycosis with matrix involvement. Methods Efficacy and safety of a group treated with ANL (once every 2 weeks) were compared with that of an untreated group in a 36‐month (3 years), single‐centre, randomized, open‐label, comparison study. Subjects to be included in the study were required to be cured of confirmed onychomycosis with matrix involvement after an initial treatment with either ANL + oral terbinafine or oral terbinafine alone in a previous study. Prophylaxis of onychomycosis was assessed by global recurrence rate, confirmed onychomycosis, clinical recurrence and mycological recurrence. Results A total of 52 subjects were enrolled (26 in each group) in the study. Throughout the study, recurrences occurred more quickly in the untreated group compared with that in the ANL group. Statistically significant differences were observed at month 12 (ANL, 8.3%; untreated, 31.8%; P = 0.047). At endpoint, 70.8% of the subjects treated with ANL remained cured compared to 50% in the untreated group (P = 0.153). Recurrence was delayed by nearly 200 days for the ANL group compared with that of the untreated group. Amorolfine was safe and well tolerated during the study, with no treatment‐related adverse events. Conclusion These results suggest that amorolfine nail lacquer may be effective and is safe for use as a prophylactic treatment for the recurrence of onychomycosis.     

Cutaneous Fusarium solani infection in childhood acute lymphoblastic leukaemia

Cutaneous involvement is often an initial presentation of infection with Fusarium species, which occurs more commonly in immunocompromised hosts and may be either localized or widespread. Skin lesions typically appear as red or grey macules, which may develop central ulceration and black eschar. Secondary dissemination to extracutaneous organs may occur in immunocompromised hosts, especially those with prolonged and severe neutropenia. We describe a case of widespread cutaneous involvement after infection with Fusarium solani in childhood acute lymphoblastic leukaemia that responded successfully to treatment with prolonged liposomal amphotericin B.     

Successful treatment of nodular lymphangitis due to Mycobacterium chelonae in two immunosuppressed patients

M. chelonae is a classical but uncommon etiology of nodular lymphangitis. We report 2 cases of nodular lymphangitis caused by M. chelonae occurring in immunocompromised hosts; both were cleared with antibiotic therapy.     

Psoriasis of the nails treated with grenz rays: a double-blind bilateral trial

The effect of grenz ray therapy in the treatment of psoriatic nails was assessed in 22 patients by randomly allocating active treatment to the psoriatic nails of one hand while the other one, which received simulated therapy, served as a control. Five Gy of grenz rays were applied on 10 occasions at intervals of 1 week. There was a significantly better response to active treatment compared with the untreated control. However, the therapeutic response was moderate. It is concluded that grenz ray therapy could be useful only when the psoriatic nails are of normal thickness.     

An assessment of factors influencing flexibility of human fingernails

A new instrument has been developed and used to determine the effect of various materials on nail flexibility. It repeatedly flexes longitudinal nail sections through 90 degrees and records the number of flexions required to fracture each section. Immersion in water or a phospholipid-water preparation (PLW) greatly increases the flexibility of untreated and lipid extracted nails; immersion in mineral oil does not. Nail flexibility is directly related to the duration of their immersion in water. During water immersion, nail weight increases by 22% of its original weight within 2 h, and then decreases. The rapid increase in nail flexibility during water immersion is related to nail water content. It is possible to prolong the flexibility of previously hydrated nails by the application of PLW or mineral oil. PLW is more effective than water alone in prolonging flexibility of nails extracted with a mixture of acetone, water and acetic acid.     

Tinea corporis in human immunodeficiency virus-positive patients: case report and assessment of oral therapy

Dermatophytosis in immunocompromised hosts is more varied and often more severe than in immunocompetent hosts. Early recognition and treatment with systemic therapy are important in human immunodeficiency virus (HIV)-positive patients in order to prevent severe infection. Potential drug resistance can occur due to chronic usage of systemic azole therapy in such patients, or the existence of atypical fungi. Although warnings have been made of possible drug interactions between certain antifungals and antiretroviral medications, only one combination has shown a clinically significant interaction. A case treated aggressively with oral terbinafine at the onset is presented. BACKGROUND: Dermatophytosis in immunocompromised hosts is more varied and often more severe than in immunocompetent hosts. Early recognition and treatment with systemic therapy are important in human immunodeficiency virus (HIV)-positive patients in order to prevent severe infection. OBJECTIVE: To analyze potential therapies for dermatophyte infections in immunocompromised patients and risk of drug resistance and interactions with antiretroviral medications. METHODS: Literature search based on MEDLINE (1966-March 2003) and additional references obtained from cross-referencing retrieved articles. All information deemed relevant by the reviewers was included. A case study was employed to exemplify the usage of this information in patient care. RESULTS: Although warnings have been made of possible drug interactions between certain antifungals and antiretroviral medications, only one combination has shown a clinically significant interaction. CONCLUSIONS: When considering drug interactions and side-effects, there are no clinically significant reasons to avoid any oral antifungal for dermatophytosis in the HIV-positive patient.     

Disseminated Fusarium solani Infection With Cutaneous Nodules in a Bone Marrow Transplant Patient

Fusarium is a ubiquitous fungus that commonly colonizes ulcerated, burned, or traumatized skin and may cause keratitis and onychomycosis in healthy hosts. Serious disseminated infection due to Fusarium has been reported with increasing frequency in immunocompromised patients. We describe a bone marrow transplant patient who developed fungal septicemia and disseminated skin nodules due to Fusarium solani. Fusarium should be recognized as a potential cause of deep fungal infection in immunocompromised patients.     

Fatal sporotrichosis

Disseminated sporotrichosis is a serious fungal infection caused by the soil inhabitant Sporothrix schenckii. It is seen in immunocompromised patients, with a substantial number of recent cases involving patients with acquired immunodeficiency syndrome (AIDS). However, individuals with other conditions that affect the immune system also are at increased risk. We report a case of fatal disseminated sporotrichosis in a patient with liver disease and a diagnosis of a granulomatous condition presumed to be sarcoidosis; the patient was receiving systemic corticosteroid therapy. The various presentations of S schenckii infection, the risk of disseminated disease in immunocompromised hosts, and the importance of making accurate histologic diagnoses are reviewed.     

Non-tuberculous mycobacterial infections of the skin: a retrospective study of 29 cases

The incidence of infections caused by non-tuberculous mycobacteria has increased in recent years, due to a rise in dermatological procedures and a greater prevalence of immunosuppression in the general population. This study investigated the clinical and microbiological findings of non-tuberculous mycobacterial skin infections. The study population included 29 patients from whom non-tuberculous mycobacteria were cultured after isolation from skin biopsy materials, cutaneous abscesses or exudates. Clinical, microbiological and epidemiological data were collected from each patient. Eight patients were immunocompromised while 21 were not. Precipitating factors such as acupuncture, filler injection, surgical procedures and other traumatic events preceded infection in 13 (including 11 normal hosts and two immunocompromised hosts) of the 29 patients. Multiple skin lesions were present in eight patients (including three normal hosts and five immunocompromised hosts). In eight patients (including four immunocompromised hosts), symptoms were accompanied by tenosynovitis, osteomyelitis and myositis. Mycobacterium abscessus was isolated from nine patients, Mycobacterium fortuitum was isolated from nine patients, Mycobacterium chelonae was isolated from six patients, Mycobacterium marinum was isolated from two patients, a Mycobacterium avium complex member was isolated from two patients, and Mycobacterium haemophilum was isolated from one patient. Ten of the 24 cases caused by rapidly growing organisms (i.e. M. chelonae, M. abscessus and M. fortuitum groups) were precipitated by skin injuries such as acupuncture, filler infection and other medical procedures. Increases in skin medical procedures, including both acupuncture and esthetic interventions, explain the increasing incidence of these organisms. Immunocompromised patients tended to develop multiple skin lesions and deep tissue infections.     

Disseminated dermatophytic pseudomycetoma caused by Microsporum species

Background  Dermatophyte infection is almost exclusively a superficial cutaneous mycosis usually confined to the stratum corneum of nails and hairs of normal hosts. Deep cutaneous and subcutaneous infections due to dermatophytes are exceedingly rare and usually limited to immunosuppressed individuals. These infections remain chronic and persist in spite of treatment. Materials and methods  We report two clinical cases of disseminated dermatophytic pseudomycetoma caused by Microsporum gypseum and Microsporum canis in immunosuppressed patients. Results  Patient 1, in 2008, showed improvement with fluconazole, cephalothin, and terbinafine treatment for Microsporum gypseum. After suspension of the treatment, new lesions appeared and culture from material was positive. In 2009, she presented confluent papules and nodules forming plaques on her face and neck with the isolation of Microsporum canis. Clinical response to this treatment was poor. Patient 2 was affected by both tinea corporis due to Trichophyton rubrum and dermatophytic pseudomycetoma caused by Microsporum canis. The response to treatment was successful with oral itraconazole and local surgical excision. Conclusions  It is important to recognize these atypical presentations of dermatophytic infections in immunosuppressed patients, which may warrant a more aggressive treatment in order to achieve resolution.     

Leclercia adecarboxylata cellulitis in a child with acute lymphoblastic leukemia

Leclercia adecarboxylata is a rare, gram-negative rod that has been infrequently reported in the literature. The organism has been documented to cause solitary infections in immunocompromised hosts and polymicrobial wound infections in the immunocompetent. We present a case of an 8-year-old boy with significant past medical history of acute lymphoblastic leukemia who developed cellulitis due to local infection by L. adecarboxylata. This case is presented to raise awareness of this rare organism's ability to cause common cutaneous disease, especially in the immunocompromised.     

Pneumocystis carinii pneumonia in patients receiving immunosuppressive drugs for dermatological diseases

In recent years, Pneumocystis carinii pneumonia (PCP) has been increasingly reported in patients without human immunodeficiency virus (HIV) infection. The increased occurrence of PCP in non-HIV-immunocompromised subjects has been attributed to several factors: use of stronger immunosuppressive regimens, higher awareness of PCP, advanced diagnostic technology and nosocomial spread of P. carinii. Appearance of PCP subsequent to the use of immunosuppressive drugs has been noticed in many inflammatory diseases such as rheumatoid arthritis, systemic lupus erythematosus and ulcerative colitis. Dermatologists frequently use immunomodulating agents, but the occurrence of PCP in patients receiving immunosuppressive drugs for skin diseases is largely unknown. We report four cases where PCP appeared following the use of immunosuppressive drugs primarily for cutaneous diseases, namely pemphigus, cutaneous necrotizing vasculitis (two cases) and Behçet's syndrome. These cases were identified in a computerized database study (1979–95) to evaluate the occurrence of PCP among immunocompromised hosts without HIV infection.