Cutaneous alternariosis in a kidney transplantation recipient: report of a case

Phaeohyphomycoses are induced by dematiaceous or darkly pigmented fungi. Alternaria species are the most important causative agents. Factors such as immunosuppression, local wounds or systemic disease are generally present. We report a case of phaeohyphomycosis induced by Alternaria alternata in an immunocompromised patient. The main interest in this case is the rareness of the cutaneous alternariosis and of its clinical aspects and the good response to therapy. Recognition of Alternaria spp. as potential opportunistic pathogens is important for the differential diagnosis of dermatological lesions, such as granulomatous or ulcerative lesions in immunocompromised patients.     

Cutaneous Alternariosis in an Adolescent Patient

Abstract:  Cutaneous alternariosis is a rare infection typically observed only in immunocompromised adults, but we report here that the infection can occur in apparently healthy adolescents. We saw a clinically healthy adolescent boy who presented with cutaneous alternariosis 6 weeks after suffering a laceration to his right ankle. Treatment with itraconazole resulted in significant improvement after 1 month.     

Cutaneous alternariosis with chronic granulomatous disease

We report here a case of dermal cutaneous alternariosis in a 69-year-old man with X-linked chronic granulomatous disease (CGD). The lesion on the back of the right hand spread and became indurated, even though oral itraconazole 100 mg daily for 12 weeks was administered. After 28 weeks of treatment with oral fluconazole at 200 mg daily, the lesion disappeared and left only slight pigmentation. Alternaria species are common saprophytes that are not usually pathogenic in humans. However, there are some reports of cutaneous alternariosis in immunocompromised patients. To our knowledge, this is the first case of cutaneous alternariosis in CGD and the response to fluconazole, a drug not usually used for this mycosis.     

Primary cutaneous Nocardia brasiliensis infection isolated in an immunosuppressed patient: a case report

Cutaneous nocardiosis is a rare infection that may manifest as a superficial skin lesion, lymphocutaneous infection, mycetoma, or diffuse cutaneous infection from a disseminated systemic infection. We report a case of a 65-year-old immunocompromised man with persistent primary cutaneous Nocardia brasiliensis infection following a motor vehicle collision. A high degree of suspicion is needed to diagnose Nocardia infection because of its resemblance to other bacterial infections. Nocardiosis should be included in the differential diagnosis of chronic cutaneous infections, especially when the response to antibiotics is inadequate or when the patient is immunocompromised. Because Nocardia may take several weeks to grow in standard bacterial culture media, laboratories should be notified of the suspicion so that culture plates are held for longer time periods. Long-term therapy, usually with sulfonamides, often is necessary.     

Tzanck smear as an accurate and rapid diagnostic tool for cutaneous alternariosis in a renal transplant recipient

Alternaria species are becoming increasingly important opportunistic pathogens in recipients of solid organ transplant, as it has been shown that dissemination with systemic involvement is not as rare as previously reported. Therefore, rapid and accurate diagnosis is necessary for appropriate patient management. We report a patient with renal transplant who developed recurrent cutaneous alternariosis. Tzanck smear successfully and very rapidly revealed hyphae and spores in both the primary and subsequent lesions. Furthermore, Tzanck smear provided guidance for histopathological examination of the second lesion, which failed to disclose the fungal elements until additional deeper serial sections were performed. The present case emphasizes that the Tzanck smear is a useful clinical tool leading to the immediate correct diagnosis even in deep fungal infections.     

Cutaneous infection due to acremonium

We report an immunocompromised patient who developed a cutaneous infection caused by acremonium which is a rare opportunistic fungi. With the increasing number of immunocompromised patients opportunistic fungal infection can cause serious diseases and early recognition is mandatory.     

链格孢霉致播散型皮肤链格孢病3例临床分析

【摘要】 目的 分析3例链格孢霉致播散型皮肤链格孢病临床表现、组织病理、真菌病原学特征及治疗。方法 回顾分析2019—2021年西京皮肤医院诊断的3例链格孢霉致播散型皮肤链格孢病的临床特征、组织病理、真菌培养和菌株鉴定结果及治疗。结果 3例患者年龄分别为55、41和46岁,男1例、女2例。2例患有肾病综合征,1例患有系统性红斑狼疮,均有不同时间糖皮质激素及他克莫司治疗史,均为慢性病程。皮损HE染色可见双轮廓厚壁孢子及木节状厚壁有隔菌丝,均未见黑素。内转录间隔区测序显示,2例致病真菌为互隔链格孢霉,1例为侵染链格孢霉。不同温度培养显示,链格孢霉在35 ℃以上生长能力明显下降。3例患者均将他克莫司减量至标准剂量的1/3以下或改用其他免疫抑制剂,并同时给予系统抗真菌治疗,均取得较好疗效。结论 播散型皮肤链格孢病具有双侧分布的血行播散及单侧肢体的淋巴管分布特点,皮损以覆盖痂皮的疣状斑块、结节和/或窦道为特点。     

Pulmonary, rhino-orbital and cutaneous mucormycosis caused by Rhizomucor pusillus in an immunocompromised patient

The number of patients with haematopoietic malignancies receiving chemotherapy and stem-cell transplantation has increased the incidence of severe opportunistic infections. Systemic fungal infections are of major concern in immunocompromised patients, as these infections are often fatal. We report a case of a patient with acute myeloid leukaemia who developed multiple cutaneous plaques and necrotizing infiltrates in the lungs during chemotherapy. Using real-time PCR on a wax-embedded tissue sample, Rhizomucor pusillus was identified. We provide an overview of the literature on cutaneous mucormycosis and its diagnosis by PCR.     

Primary cutaneous granulomatous alternariosis

We report on a case of primary cutaneous granulomatous alternariosis on the forearm of a 65-year-old man who is otherwise in a good health. Histological examination revealed a predominantly histiocytic granuloma with numerous large cells containing fragments of fungi. The granuloma contained septate fungal hyphae and macroconidiospores. By means of macro- and micro-cultures the fungus was identified as an Alternaria species.     

In situ hybridization in cutaneous deep fungal infections: a valuable diagnostic adjunct to fungal morphology and tissue cultures

Dimorphic fungal infections (histoplasmosis, blastomycosis, coccidioidomycosis, and cryptococcosis) can occur in immunocompromised and healthy individuals. Cutaneous involvement is often secondary and may be the presenting sign of systemic disease. These ominous infections are frequently clinically indistinct, and patient prognosis is influenced by a timely diagnosis and treatment. Morphologic differentiation between these organisms is not definitive, and tissue cultures represent the diagnostic gold standard in current day practice. However, tissue cultures are rarely obtained and merely represent an afterthought in seemingly unsuspecting cases. Furthermore, when performed, they may take several days or weeks for completion. In situ hybridization (ISH) utilizing oligonucleotide probes directed against fungal ribosomal RNA is a rapid and accurate assay for the identification of dimorphic fungi in paraffin-embedded tissue sections. We present five patients in whom ISH both prospectively and retrospectively confirmed the presence of a cutaneous infection (histoplasmosis, blastomycosis, coccidioidomycosis, and cryptococcosis). In all of the skin sections analyzed, dimorphic fungi were morphologically apparent but not diagnostically discernible. In summary, ISH is a valuable tool in the prompt diagnosis of cutaneous deep fungal infections.     

Case of cutaneous botryomycosis in an 8-year-old immunocompetent boy with a review of the published work

Botryomycosis is a rare chronic suppurative granulomatous infection caused by several genera of non-filamentous bacteria. The clinical and histopathological findings are similar to those of mycetoma caused by true fungi or aerobic actinomycetes. Botryomycosis is divided into cutaneous and visceral disease, with the cutaneous form being more common. Histopathology shows granules of etiologic bacteria called “sulfur granules”. Botryomycosis occurs more commonly among immunocompromised patients, although some cases have also been reported in immunocompetent patients. We report the case of an 8-year-old immunocompetent boy who visited our hospital with a 4-mm diameter subcutaneous tumor with mild tenderness on his right heel for several months. We surgically removed the tumor with an initial diagnosis of epidermal cyst. Histopathology showed sulfur granules surrounded by an eosinophilic matrix, indicating the Splendore–Hoeppli phenomenon. The granules consisted of Gram-positive cocci, leading to a diagnosis of botryomycosis. The patient was successfully treated by excision and oral trimethoprim/sulfamethoxazole (240 mg b.i.d.) for 2 weeks as adjuvant therapy. No recurrence was noted following treatment. The subcutaneous tumor in this case was smaller than the typical in botryomycosis infections. We reviewed the infection duration and tumor size in reported cases of botryomycosis in immunocompetent patients. Small tumor size may suggest that the case is in an early stage; therefore, it is important to remove and investigate these lesions proactively.     

Global epidemiology of cutaneous zygomycosis

The large majority of cases reported worldwide as zygomycosis are infections caused by fungi belonging to the order Mucorales. These infections are invasive, often lethal, and they primarily affect immunocompromised patients.     

Disseminated cutaneous nocardiosis mimicking cellulitis and erythema nodosum

Infection with Nocardia asteroides is a rare, life-threatening infection, which is most commonly encountered in immunocompromised patients. Cutaneous involvement is usually seen with disseminated infection but may also occur as primary cutaneous nocardiosis. We present a case of an immunocompromised patient who presented with cellulitis of the right hand and disseminated subcutaneous nodules of the lower extremities resembling erythema nodosum. Cultures from both a skin biopsy of a subcutaneous nodule on the leg as well as a surgical specimen from the debridement of her hand grew Nocardia asteroides. The patient was treated successfully with trimethoprim-sulfamethoxazole. This case likely represents primary cutaneous nocardiosis with secondary dissemination, which has been rarely reported. It also emphasizes that nocardial infection should be considered in the differential diagnosis of lesions suggestive of cellulitis or erythema nodosum in the severely immunocompromised patient.     

皮肤链格孢病2例临床分析并文献复习

目的:探讨皮肤链格孢病的临床特征、诊断、治疗及预后。方法:对我院近两年收治的2例皮肤链格孢病进行总结,并检索国内万方数据库和中国知网数据库和近10年国外Pubmed数据库报告的皮肤链格孢病,共60例,进行文献分析。结果:共2例患者,男、女各1例,均有肾病综合症口服免疫制剂病史,通过组织病理检查和真菌培养确诊,并通过分子生物学方法确诊为链互隔孢(Alternaria alternate)引起的皮肤链格孢病。1例给予手术切除联合伊曲康唑治疗后失访,1例给予口服伊曲康唑及他克莫司减量治疗,随访1年,未复发。结论:免疫功能低下是皮肤链格孢病的危险因素,组织病理检查和真菌培养为主要确诊手段,治疗主要为系统应用伊曲康唑或联合其他治疗。     

Legionella feeleii: an unusual organism associated with cutaneous infection in an immunocompromised patient

We report a 23‐year‐old immunocompromised woman who, following cardiac transplantation, presented with an unusual cutaneous eruption. She developed a widespread pustular rash, systemic symptoms and a high temperature with raised inflammatory markers. The diagnosis was reached when a skin biopsy was cultured onto Legionella agar (buffered charcoal yeast extract) and Legionella feeleii was isolated. The patient was treated with 6 weeks of moxifloxacin and her cutaneous lesions gradually resolved. Cutaneous Legionella infections are uncommon and usually affect immunocompromised patients.     

Clinical patterns of cutaneous nontuberculous mycobacterial infections

BACKGROUND: Cutaneous nontuberculous mycobacterial infections result from external inoculation, spread of a deeper infection, or haematogenous spread of a disseminated infection. There are two species-specific infections (fish-tank or swimming-pool granuloma, due to Mycobacterium marinum, and Buruli ulcer, caused by M. ulcerans). Most infections, however, produce a nonspecific clinical picture. OBJECTIVES: To define clinical patterns of cutaneous disease in nontuberculous mycobacterial infections. METHODS: Fifty-one patients with cutaneous nontuberculous mycobacterial infections were reviewed. Clinical and histopathological features of normal hosts and immunosuppressed patients were compared. Two subgroups of immunosuppressed patients were distinguished: patients with cutaneous infection and patients with a disseminated infection and cutaneous involvement. RESULTS: In immunosuppressed patients the number of lesions was significantly higher. Abscesses and ulceration were also more frequently observed. Different species were found in normal hosts and immunosuppressed patients. Several clinical patterns of cutaneous infection were defined: lymphocutaneous or sporotrichoid lesions; nonlymphocutaneous lesions at the site of trauma; folliculitis and furunculosis involving the lower extremities; disseminated lesions on the extremities in immunosuppressed patients. Two patterns were observed in patients with a disseminated infection: localized cutaneous lesions and disseminated cutaneous and mucosal lesions. CONCLUSIONS: Cutaneous manifestations of nontuberculous mycobacterial infections may be classified according to criteria such as cutaneous lesions and immune status.     

皮肤链格孢霉病1例

报告1例皮肤链格孢毒病。患者女，27岁，右颊部出现浸润性班块，其中央形成溃疡8年，真菌学检查及扫描电镜观察，鉴定为交链链格孢，组织病理检查示：溃疡边缘伴有大量多核巨细胞肉芽肿；寄生形态苏木精—伊红染色表现为空泡样结构，棕色分隔菌丝或棕色孢子，PAS染色见大型圆形孢子和粗细不一的分隔菌丝，患者接受伊曲康唑200mg/d口服治疗，第9周溃疡结痂，愈合，复查组织病理仍见肉芽肿及真菌成分，分离培养未阴转。     

Lymphocutaneous nocardiosis and cutaneous pheohyphomycosis in a liver transplant recipient

Background  Infections are the leading cause of morbidity and mortality in transplanted patients. The increasing number of immunocompromised patients has not only augmented infections by specific pathogens, but also by opportunistic microbial agents.
Methods  A mixed cutaneous infection caused by Nocardia brasiliensis and Exophiala jeanselmei is reported in a liver transplant patient.
Results  The cutaneous lesions were painful nodules which drained purulent material. They were located on the right lower limb, with lymphadenopathies in the groin.
Conclusions  The patient was treated with itraconazole (600 mg/day) plus trimethoprim (1600 mg/day)–sulfamethoxazole (320 mg/day) for 8 weeks, with complete remission of the lesions.     

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.