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 a patient with idiopathic pulmonary fibrosis

A 78-year-old farmer presented with symptomless skin lesions for evaluation. Two years prior, he had developed idiopathic pulmonary fibrosis (IPF) and had been treated thereafter with oral prednisolone 20 mg/day and occasionally with colchicine 1 mg/day. On examination, erythematoviolaceous, slightly infiltrated plaques, measuring approximately 5 x 9 cm, rubbery in consistency, intermingled with pustules, sometimes eroded, with distinctive borders, were noted on the dorsum of both hands and on the extensor surface of both forearms. The lesions had developed over a 20-day period. The skin of these areas was atrophic or eroded with multiple ecchymoses (Fig. 1). The abnormal laboratory findings included an elevated white blood cell count of 17,100/mm3, with 79% neutrophils, 16% lymphocytes, and 5% monocytes, C-reactive protein of 33.15 mg/dL (normal, <0.8 mg/dL), and immunoglobulin G of 598 mg/dL (normal, 701-1545 mg/dL). Other blood and urine tests performed were within normal limits. The diagnosis of IPF was reconfirmed through radiology, high-resolution computed tomography, and spirometry, as well as bronchoscopy and bronchoalveolar lavage fluid analysis. Coexistence of presumptive pulmonary alternariosis was excluded. Hematoxylin and eosin stained sections of the excised cutaneous specimen showed focal ulceration of the epidermis adjacent to a mainly intradermal abscess cavity. Within the latter, remnants of a partly destroyed hair follicle were seen amongst degenerating polymorphonuclear leukocytes, as well as many histiocytes and a few Langhans-type multinucleated giant cells. Minute collections of polymorphonuclear leukocytes were seen in the adjacent epidermis. Periodic acid-Schiff (PAS) and Gomori's silver methenamine stains showed a multitude of broad branching fungal hyphae and large spores within the aforementioned cavity, both free and within the cytoplasm of giant cells (Fig. 2). Immunohistochemistry was performed by means of the alkaline phosphatase anti-alkaline phosphatase (APAAP) method. Sections showed that the infiltrate consisted of an almost equal number of B and T lymphocytes, whereas histiocytes and the few giant cells were labeled with anti-CD68 antibodies. Skin smears and biopsy specimens taken twice from all lesions were used for mycologic examination. Wet mounts revealed numerous, brownish, septate hyphae and ovoid Skin smears and biopsy specimens taken twice from all lesions were used for mycologic examination. Wet mounts revealed numerous, brownish, septate hyphae and ovoid structures. Biopsy material was plated on Sabourand's dextrose agar with cloramphenicol (0.05 mg/mL). After 7 days at 27 degrees C, dark, gray-white colonies with a dark brown underside appeared. Microscopic examination of the colonies revealed hyphae with typical conidia having transverse and longitudinal septa. Based on macroscopic and microscopic examination, the isolates were identified as Alternaria alternata (Fig. 3). Treatment with prednisolone was reduced to 10 mg/day and the patient received oral itraconazole (200 mg/day). This resulted in progressive improvement of alternariosis, and the lesions healed completely within 3 months, when treatment was interrupted. Two years later, there is no evidence of recurrence.     

Cutaneous alternariosis in a cardiac transplant recipient

A 55-year-old male cardiac transplant recipient presented with cutaneous nodules on the limbs caused by Alternaria alternata. Oral fluconazole 200 mg daily for 3 weeks was ineffective. Itraconazole 100 mg oral daily was ceased when hyperglycaemia developed. Individual lesions were successfully treated with either curettage and cautery or double freeze-thaw cryotherapy. Alternaria spp. are ubiquitous fungal saprophytes which may cause cutaneous infections particularly in immunocompromised patients.     

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.     

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。     

儿童皮肤浆细胞增生症一例

患儿,女,8岁。因股部暗褐色斑块4年,于2017年1月来我院就诊。4年前,无明显诱因右股部内侧出现一蚕豆大红褐色斑块,无自觉症状,皮损渐增大至直径约4 cm的斑块。曾在当地外用多种药膏治疗,效果欠佳。现为求进一步诊治,遂来我院就诊。患者自发病以来神智清、精神可,饮食及睡眠如常。既往体健,否认系统疾病史,否认传染病史,否认药物及食物过敏史,否认家族其他人有类似病史,否认家族遗传病史。     

Cutaneous Acanthamoeba in a patient with AIDS: a case study with a review of new therapy; quiz 386

GOAL: To describe the presenting signs of an Acanthamoeba infection. OBJECTIVES: Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Discuss the clinical presentation of Acanthamoeba infection. 2. Describe the conditions that make a patient susceptible to Acanthamoeba. 3. Outline treatment options for Acanthamoeba infection. CME: This article has been peer reviewed and approved by Michael Fisher, MD, Professor of Medicine, Albert Einstein College of Medicine. Review date: April 2001. This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Albert Einstein College of Medicine and Quadrant HealthCom, Inc. The Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical education for physicians. Albert Einstein College of Medicine designates this educational activity for a maximum of 1.0 hour in category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity. This activity has been planned and produced in accordance with ACCME Essentials.     

Cutaneous melanoma in a patient with neurofibromatosis: a case report and review of the literature

We report the occurrence of a malignant melanoma in a patient with neurofibromatosis (von Recklinghausen's disease; NF 1). Neurofibromatosis, like malignant melanoma, is believed to be a disorder of neural crest origin, and is associated with a number of different malignancies, but a definite association between cutaneous malignant melanoma and neurofibromatosis has not been established. We describe a patient with a malignant melanoma and with neurofibromatosis, and review the literature pertinent to this topic. The malignant melanoma was not related to a café-aulait patch or congenital naevus. The paucity of reports of patients with neurofibromatosis associated with cutaneous malignant melanoma suggests that these diseases probably do not occur together with any greater frequency than that determined by chance alone.     

Cutaneous oxalate granulomas in a haemodialysed patient: report of a case with unique clinical features

We report a patient undergoing haemodialysis, who developed multiple subcutaneous nodules. Histology showed that the noduies were composed of deposits of crystals in the dermis, with an associated foreign-body reaction. The crystalline deposits were identified as calcium oxalate by histochemical staining, polarizing microscopy, and analytical electron microscopy.     

Cutaneous rhinosporidiosis in a patient of lepromatous leprosy--a case report

A rare coincidence of cutaneous Rhinosporidiosis and Lepromatous leprosy is reported. The clinical course of the cutaneous nodules simulated the feature of certain histoid nodule with ulceration.     

Cutaneous phaeohyphomycosis caused by Pyrenochaeta unguis-hominis in a diabetic patient: A case report

Phaeohyphomycosis, caused by opportunistic rare fungi, has increasingly been reported in diabetic and immunosuppressed patients. Pyrenochaeta unguis-hominis (P. unguis-hominis), a member of the dematiaceae group, has been identified to cause human nail infection. We report a rare case of cutaneous phaeohyphomycosis in a diabetic female caused by P. unguis-hominis.