Cutaneous infection due to Scedosporium apiospermum in an immunosuppressed patient

Scedosporium apiospermum, the anamorphic form of Pseudallescheria boydii, is a filamentous fungus with low inherent virulence. Increasing numbers of cases of this infection have been reported probably related to the rising number of immunosuppressed persons. Apart from mycetoma, cutaneous and subcutaneous infection is rarely encountered in clinical practice. We describe a case of cutaneous infection caused by Scedosporium apiospermum in a subject with rheumatoid arthritis and diabetes mellitus who was submitted to long-term therapy with cyclosporin and corticosteroids. Histopathologic examination of a skin biopsy showed a granulomatous infiltrate with hyaline septate hyphae. Culture of two skin biopsies taken at two different observations of the woman, 3 weeks apart, allowed isolation of Scedosporium apiospermum. Therapy with itraconazole, 400 mg/day, for 3 months was effective in curing the infection.     

Skin infections by Mycobacterium chelonae following mesotherapy: A report of two cases and review of the literature

Mesotherapy is sometimes responsible for dermal and subcutaneous infections caused by nontuberculous mycobacteria. Mycobacterium chelonae, M abscessus, and M fortuitum are usually involved. We present two cases of deep skin infections caused by M chelonae following mesotherapy. A review of the literature is included.     

Case of cutaneous Scedosporium apiospermum infection successfully treated with voriconazole

We report a case of cutaneous infection due to Scedosporium apiospermum in a 75-year-old immunocompromised male patient who had received long-term corticosteroid and immunosuppressant therapy for the treatment of nephrotic syndrome. The patient came to our department complaining of erythema with a number of pustules on the dorsal surface of the right hand. S. apiospermum was identified from a culture taken from the pus. After unsuccessful treatment with topical ketoconazole, oral itraconazole and oral terbinafine, the lesion quickly resolved with the daily administration of 400 mg voriconazole. No recurrence was observed despite discontinuation of voriconazole due to drug-induced hepatitis. Voriconazole holds out the promise of an effective treatment for invasive Scedosporium infection.     

Concurrent pyoderma gangrenosum and infection with Scedosporium apiospermum

We present a patient with pyoderma gangrenosum (PG) following hip surgery, who developed an exacerbation of her ulceration in conjunction with new areas on her lower limbs. Clinically, features of PG and deep fungal infection were apparent. Scedosporium apiospermum was isolated from the ulcers.     

Disseminated cutaneous Mycobacterium chelonae infection in an immunocompetent host

Mycobacterium chelonae is a rare, rapidly growing, atypical acid‐fast bacillus. Disseminated cutaneous infection has been reported in immunocompromised patients. We report an immunocompetent 86‐year‐old white woman, who presented with an 8‐month history of extensive ulcerated abscess‐like nodules. Mycobacterial culture confirmed M. chelonae infection and the patient was treated with a combination of clarithromycin and tobramycin. To our knowledge, this is the first reported case of spontaneous, disseminated cutaneous disease occurring in an immunocompetent patient.     

Scedosporium apiospermum: An unreported cause of fungal sporotrichoid‐like lymphocutaneous infection in Australia and review of the literature

Scedosporium apiospermum is a fungus emerging as a rare but important cause of both localised and disseminated infections in immunocompromised patients. Most cutaneous lesions present as mycetoma, however a review of the literature revealed an increasing number of cases worldwide presenting with lymphocutaneous spread resembling sporotrichosis. An 85‐year‐old man with an extensive medical history including type II diabetes mellitus and meningioma presented with crusted haemorrhagic areas on the dorsum of his left foot and multiple crusted nodules extending proximally along his leg in a sporotrichoid‐like lymphocutaneous pattern. A mycological examination and culture of the cutaneous tissue found the fungus, Scedosporium apiospermum.     

系统性尖端赛多孢子菌感染小鼠IL-12表达的研究

建立小鼠系统性尖端赛多孢子菌感染模型,用酶联免疫吸附试验(ELISA)及逆转录-聚合酶链反应(RT-PCR)分别检测脾内IL-12蛋白质及mRNA水平,用平皿系列稀释法检测肾内菌落形成单位(CFU),并记录平均生存时间(MST)。结果,脾内IL-12蛋白质含量:致死量组均低于正常组;亚致死量组均高于正常组,且第7天显著高于第3天;地塞米松免疫抑制组均高于正常组。此外,免疫抑制组均低于相应时间亚致死量组。脾中IL-12mRNA表达水平与蛋白质水平基本一致。致死量组及免疫抑制组肾内均有大量菌生长,亚致死量组肾内菌量少。致死量感染组平均生存时间为13.6天,免疫抑制组为14.2天,对照组和亚致死量组均超过45天。结果示健康鼠大量菌感染及免疫抑制鼠小量菌感染均可引起致死性感染,而IL-12在小鼠系统性尖端赛多孢子菌感染中可能具有保护作用。     

Mutations in the drug resistance‐determining region of Mycobacterium lepromatosis isolated from leprosy patients in Mexico

Mycobacterium lepromatosis, an independent species from Mycobacterium leprae, has been found to be a causative agent for diffuse lepromatous leprosy (DLL) in Mexico, but remains poorly studied. Here, the drug resistance‐determining regions (DRDR) of folP1, rpoB and gyrA (conferring resistance to dapsone, rifampicin and quinolone, respectively) in M. lepromatosis from leprosy patients in Mexico were characterized. No mutations or silent mutations were found at previously characterized major sites in DRDR of M. lepromatosis. However, a non‐synonymous mutation was found in codon 54 between two major sites of the folP1 DRDR in M. lepromatosis sequences. All M. lepromatosis isolates showed CAG sequence in codon 54 of folP1. Because the next codons 53 and 55 are known as major mutation sites for drug resistance, more detailed analysis using more samples is needed to determine whether it influences susceptibility to dapsone and/or efficiency of folate biosynthesis in M. lepromatosis or not.     

Disseminated cutaneous Mycobacterium kansasii infection presenting with Rosai–Dorfman disease‐like histological features in a patient carrying anti‐interferon‐γ autoantibodies

Typical cutaneous non‐tuberculous mycobacteria (NTM) infections show a histopathology pattern of granulomas with admixed Langhans giant cells, and abscesses may be observed in acute lesions. Herein, we describe a patient carrying a high titer of autoantibodies to interferon (IFN)‐γ with disseminated Mycobacterium kansasii infection presenting with emperipolesis and Rosai–Dorfman disease (RDD)‐like histopathological features characterized by remarkable, large, pale‐staining “RD cells”, which were CD68 and S100 positive and CD1a negative. The patient was misdiagnosed with RDD initially, but exhibited a poor response to all interventions. A re‐biopsy revealed Langhans‐type multinucleated giant cells; multiple definite acid‐fast bacilli were also found. M. kansasii was isolated from cultured tissues. Anti‐NTM treatment was initiated. After treatment, all lesions resolved almost completely within the following month. High‐titer anti‐IFN‐γ autoantibodies were detected during follow up, leading to the diagnosis of adult‐onset immunodeficiency syndrome. In conclusion, patients carrying high‐titer autoantibodies to IFN‐γ who also have a disseminated cutaneous M. kansasii infection may present with RDD‐like histopathological features, which may be a pitfall in the diagnosis of disseminated cutaneous NTM infections.     

波氏假阿利什菌和尖端赛多孢子菌随机扩增DNA多态性分析

目的 了解波氏假阿利什菌和尖端赛多孢子菌的基因学特征,研究DNA分型与菌种来源的关系.方法 采用随机扩增多态性DNA分析(RAPD)方法.结果 3种引物可将来自5个国家的13株波氏假阿利什菌和18株尖端赛多孢子菌分为31个基因型.多引物聚类分析所得树状图显示,除来自哥伦比亚土壤的3株波氏假阿利什菌外,其他受试菌株无地域性群集分布特点.但受试菌株中的多数波氏假阿利什菌和尖端赛多孢子菌株分别聚集成一群.结论 波氏假阿利什菌和尖端赛多孢子菌存在较大株间差异,致病菌没有明显的地域性分布趋势,RAPD分型聚类分析结果与形态学分类之间具有一定一致性.     

Mycobacterium haemophilum infection with prominent facial manifestation mimicking leprosy

Mycobacterium haemophilum is a slow‐growing non‐tuberculous mycobacterium that is rarely known to cause human skin infection, particularly in immunocompromised patients. We recently experienced a 69‐year‐old Japanese woman with this infection who had been under immunosuppressive treatment for recalcitrant rheumatoid arthritis. The patient showed disseminated erythematous plaques and subcutaneous nodules on the face and extremities, and interestingly, the face manifested with a striking “facies leontina” appearance. Biopsy revealed abscess and granulomatous dermatitis with the involvement of peripheral nerve bundles and the presence of innumerable acid‐fast bacilli, thus necessitating differentiation from lepromatous leprosy. M. haemophilum was identified by molecular characterization as well as by successful culture with iron supplements. Although drug susceptibility testing indicated responsiveness to multiple antibiotics administrated simultaneously for the treatment, it took over 6 months to achieve significant improvement, and we also employed concurrent oral potassium iodide administration and repeated surgical excision. This case highlights the importance of continuous combination therapy for successful outcome in this rare infection. Furthermore, application of potassium iodide for mycobacterial infection warrants further evaluation by accumulating more cases.     

A case of cutaneous Scedosporium infection in an immunocompromised patient

Scedosporium apiospermum, the asexual stage of Pseudoallescheria boydii, is a fungus ubiquitous in soil as well as organically polluted areas, where nitrogen-containing compounds are abundant. It is an emerging opportunistic pathogen that can range from cutaneous to disseminated infection and can be fatal within months of diagnosis. Here we present a case of disseminated S. apiospermum infection with cutaneous manifestations in a 59-year-old woman with myelodysplastic syndrome, in remission from chronic lymphocytic leukemia, presented with pneumonia and deteriorating mental status. An X-ray computed tomography scan showed three non-contrast-enhancing hypodensities affecting the brain. Many erythematous, indurated skin lesions, measuring 3-5 mm in diameter, were noted on her chest, shoulders and arms. Biopsies were submitted for culture and histology. Histopathologic examination revealed superficial and deep perivascular and periadnexal inflammatory infiltrates of lymphocytes and neutrophils. Scattered collections of fungal organisms were noted near the eccrine glands. The periodic acid Schiff with diastase stain showed the presence of variable sized spores and hyphae with some acute angle branching. Both tissue and blood cultures were positive for a single Scedosporium species. Histologically, eccrine or peri-eccrine involvement by fungi may be an important finding for Scedosporium infection of the skin.     

Identification of Mycobacterium tuberculosis and non‐tuberculous mycobacteria from cutaneous sarcoidosis lesions by reverse blot hybridization assay

While the etiology of sarcoidosis remains uncertain, mycobacteria have been suggested as a causative infectious agent. To investigate the causal relationship between mycobacteria and sarcoidosis, we performed a reverse blot hybridization assay (REBA) to identify mycobacteria from the skin samples of nine patients with sarcoidosis. Six of the nine samples were shown to be positive for mycobacteria by REBA, including Mycobacterium tuberculosis and non‐tuberculous mycobacteria. This is the first study to identify mycobacteria from the skin samples of sarcoidosis patients using REBA, and our results could strengthen the etiologic association between mycobacteria and sarcoidosis.     

Mycobacterium chelonae cutaneous infection in a patient with mixed connective tissue disease

Around 50 mycobacteria species cause human disease. Immunosuppressive statespredispose to non-tuberculous mycobaterium infection, such as Mycobacterium chelonae:AFB, non-tuberculous, fast growth of low virulence and uncommon as a human pathogen.It may compromise the skin and soft tissues, lungs, lymph nodes and there is also adisseminated presentation. The diagnosis involves AFB identification and culture onAgar and Lowenstein-Jensen medium base. A 41-year-old female with MCTD (LESpredominance) is reported, presenting painless nodules in the right forearm. Shedenied local trauma. Immunosuppressed with prednisone and cyclophosphamide for 24months. Lesion biopsy has demonstrated positive bacilloscopy (Ziehl-Neelsen stain)and M.chelonae in culture (Lowenstein-Jensen medium base), therefore clarithromycintreatment has been started (best therapy choice in the literature).     

Case report of cutaneous nodule caused by Gordonia bronchialis in an immunocompetent patient after receiving acupuncture

Gordonia species were recently found to cause human infection. Most Gordonia bronchialis infections are associated with sternal wounds and foreign bodies. Here, we present a case of a firm cutaneous nodule caused by G. bronchialis on an immunocompetent patient's lower extremity after receiving acupuncture. Our present case indicates that spontaneous cutaneous infection of G. bronchialis can develop even in a healthy patient. With the popularity of complementary and alternative medicine, physicians should be aware that G. bronchialis infection can be associated with Oriental medicine similar to mycobacterial infection. Recognizing the diverse clinical features of newly emerging Gordonia species will facilitate appropriate diagnosis and management of future patients.     

Ungual hyalohyphomycosis caused by Fusarium proliferatum in an immunocompetent patient

The patient was a 73‐year‐old healthy female farmer who had been treated with terbinafine for 25.5 months by a primary physician. She exhibited a discoloration and thickening of the right big toenail. She had no concomitant paronychia. Direct microscopy revealed chlamydoconidia and hyphae, and periodic acid‐Schiff stained nail specimen showed septate hyphae. On the basis of these morphological features and gene analysis, the final diagnosis was ungual hyalohyphomycosis caused by Fusarium proliferatum. Topical application of 10% efinaconazole solution cured the disease in 10 months.     

First case of Mycobacterium haemophilum infection in an AIDS patient in Italy.

Mycobacterium haemophilum, a strongly acid- and alcohol-fast bacillus belonging to the group of non-tuberculous mycobacteria was first described in 1978 as the cause of cutaneous ulcerating lesions in a woman with Hodgkin's disease. Infection due to M. haemophilum is rare but increasing in prevalence in immnunosuppressed subjects, particularly in patients with acquired immunodeficiency syndrome (AIDS) patients. The skin is the most common site of infection with erythematous or violaceous papules and/or nodules that are usually painless at first, but some elements develop into abscesses or ulcers that can become very painful. The incidence of M. haemophilum is unknown, but cases of infection have been reported in Australia, Canada, the United States, France, Israel, the United Kingdom and Taiwan; to date no cases have been reported in Italy, thus the case reported here is apparently the first one observed in our country.