Skin infection with Fusarium in an immunocompetent patient

Fusarium spp. are fungi found throughout the world and can cause a great variety of skin infections, mainly in immunodepressed individuals. We present a case of skin infection with Fusarium sp. which manifested as painful superficial ulcers on the legs of an immunocompetent female patient, who had applied as a for leg pain. The condition was cured with oral itraconazole and local treatments.     

Extensive cutaneous anthrax in an immunocompetent patient

Bacillus anthracis disease constitutes an extremely important worldwide epidemiological problem. Interest in cutaneous anthrax resides in its skin manifestations, course, diagnostic methods and management. An extensive cutaneous anthrax of the whole left upper arm, accompanied by lymphadenopathy and high fever, in a 60 year-old male patient, a shepherd by profession, is reported. He was treated effectively by intravenously administered ciprofloxacin and clindamycin. In the event of clinical suspicion of cutaneous anthrax, the patient has to be treated by the recommended regimen of antibiotics because of the possibility of evolvution to an extensive or severe systemic disease, even in the absence of immuno-depressant factors.     

Primay cutaneous cryptococcosis in an immunocompetent patient

The authors report a primary cutaneous cryptococcosis, caused by Cryptococcus neoformans in immunocompetent patient, a farmer who developed extensive lesions at the site of an injury caused by one of the chickens on his right forearm, while he was cleaning out his barn. Oral treatment with fluconazole was totally successful. A review of the literature showed the rarity of cutaneous cryptococcosis in immunocompetent patients and in contrast, that skin lesions frequently occur in immunocompromised 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.     

Superficial cutaneous Trichosporon asahii infection in an immunocompetent host

A 16‐year‐old schoolgirl presented with a complaint of enlarging erythematous and mildly pruritic patches located on the buttocks of 2 years’ duration. She had been treated with a potent topical corticosteroid for many months without apparent benefit. She was in otherwise good health. She denied a history of hair infection, previous eruptions, asthma, or hay fever. No one in her family or friends had similar lesions. She had no pets in her house. Examination revealed the presence of two erythematous and slightly indurated plaques measuring approximately 16 cm × 9 cm and 6 cm × 11 cm in diameter on her right and left buttocks, respectively ( Fig. 1 ). Similar progressively enlarging lesions were present on the dorsum of her right hand, extending to the extensor aspect of the forearm and to the lateral, inner, palmar, and extensor aspects of the second, third, and fourth fingers, and on the dorsum of her left hand up to the flexor aspect of the wrist. A few erythematous papules clustering around these plaques in a satellite fashion were also detectable. Her scalp, pubic, axillary, eyebrow, and eyelash hair appeared normal with no concretions or soft, lightly pigmented, white to light‐brown, loosely attached, irregularly spaced nodules. There was no regional or generalized lymphadenopathy or hepatosplenomegaly. Routine laboratory investigations, human immunodeficiency virus (HIV) testing, and standard patch tests were negative.

Figure 1 Open in figure viewer PowerPoint Erythematous and slightly indurated plaques on the right and left buttocks     

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.     

Systemic cryptococcosis with solitary cutaneous lesion in an immunocompetent patient

A 55-year-old white farmer from north-east Brazil presented with a 1-month history of headache and a solitary nodular lesion on his face. He was a smoker and had reported contact with pigeons. He did not complain of any other systemic symptom such as cough or pain. Physical examination of the skin lesion revealed a nodule measuring approximately 3 cm in diameter with central ulceration and overlying crust ( Fig. 1 ). The lesion clinically resembled a keratoacanthoma.

Figure 1 Open in figure viewer PowerPoint Nodular, single, keratoacanthoma-like lesion with a necrotic crust on the face     

Atypical presentation of cutaneous sporotrichosis in an alcoholic patient

Sporotrichosis is a subcutaneous mycosis with a high prevalence in Brasil. It is caused by the dimorphic fungus Sporothrix schenckii, and may lead to different clinical presentations. The disseminated cutaneous form is uncommon and corresponds to 4 percent of the total number of cases. We report a case of atypical disseminated sporotrichosis in an alcoholic patient, whose culture for fungi revealed the presence of Sporothrix schenckii. The patient was treated with itraconazole 200 mg/day for 6 months with clinical clearing.     

Atypical mycobacteria infection in an immunocompromised patient

A 61-year-old woman with systemic lupus erythematosus and Sj?gren syndrome presented with a two-month history of symptomatic nodules on the buttocks and thighs that progressed to involve the dorsal aspects of the hands. On examination, infiltrative papules, nodules, and plaques were present in these regions. Biopsy specimens demonstrated granulomatous inflammation and acid-fast bacilli with the use of a Fite stain, although a culture and polymerase chain reaction analysis were negative. The patient continues to improve on long-term clarithromycin therapy. Atypical mycobacterial infections are becoming more common, especially in immunocompromised patients. Antimicrobial therapy, either with a single agent or multiple agents, often is prolonged. A high index of suspicion is warranted in immunocompromised patients, which includes those with connective-tissue diseases that are active or that require immunosuppression. In these patients, the differential diagnosis includes infectious as well as inflammatory, reactive, or neoplastic processes.     

Indolent Acremonium strictum infection in an immunocompetent patient.

A 35‐year‐old housewife presented with an 11‐year history of a painless lesion on the right cheek, which had enlarged over the last 2 years. She had no history of travel or trauma. Various topical and systemic antimicrobial and antifungal agents, such as fluconazole, ketoconazole, sulbactam/ampicillin, and mupirocin, had been prescribed, with a probable diagnosis of pyoderma and blastomycosis, without significant benefit. Her medical history was otherwise unremarkable. Dermatologic examination revealed a well‐circumscribed, erythematous, infiltrative, 8 × 10 cm plaque covering the right cheek and a 2 × 3.5 cm vegetative, ulcerated lesion on the chin ( Fig. 1 ). There were no sinus tracts or grains.

Figure 1 Open in figure viewer PowerPoint Erythematous, infiltrative plaque covering the right cheek, and vegetative, ulcerated lesion on the chin     

Atypical molluscum contagiosum infection in an HIV-infected patient

A 43-year-old man, who was an intravenous drug abuser from 1978 to 1988, was referred to our STD & AIDS Center in October 1995 with flesh-colored nodules of the foreskin. He was confirmed to be seronegative in February 1989, and the first positive human immunodeficiency virus (HIV) serology was documented in October 1989. At that time, the CD4+ count was 114/mm³ and anti-retroviral therapy was therefore initiated and prolonged until October 1995. Within the last 4 months, the patient progressively lost weight (13 kg) and suffered from recurrent oral candidiasis, cytomegalovirus (CMV) retinitis, and severe oral herpes simplex virus (HSV) infection. Shortly afterwards the dermatologic lesions appeared. At this time, the CD4+ count had decreased to 8/mm³. Examination revealed nodules distributed over the external and internal linings of the foreskin, some isolated and some grouped, but individually well defined. These lesions, of the same color as the surrounding skin or slightly erythematous, were of varying sizes ranging from 0.5 to 1 cm in diameter, sessile, globous, coated with a keratotic epidermal layer, not shiny, hard-elastic, non-tender at compression, and without evident central umbilication, mimicking condylomata acuminata (Fig. 1). Upon squeezing, no discharge could be seen. The source of this infection was not identified as the patient denied sexual contact for the previous year.
A three-lesions biopsy showed the characteristic histologic features of molluscum contagiosum (MC). The dermis appeared indented by multiple, closely packed, lobules of proliferating epithelium (Figs 2 and 3). The infected keratinocytes contained intracytoplasmatic inclusions, the so-called molluscum bodies displacing the nucleus and enlarging the infected cells.