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Acrophialophora fusispora brain abscess in a child with acute lymphoblastic leukemia: review of cases and taxonomy. Al-Mohsen IZ, Sutton DA, Sigler L, Almodovar E, Mahgoub N, Frayha H, Al-Hajjar S, Rinaldi MG, Walsh TJ. J Clin Microbiol. 2000 Dec;38(12):4569-76.

Dermatophytosis caused by Aphanoascus fulvescens] Marín G, Campos R

Sabouraudia. 1984;22(4):311-4.

The course of the destruction of human hair in vitro by three species of the genus Aphanoascus (A. keratinophilus, A. fulvescens and A. verrucosus) was studied with light microscopy, and transmission and scanning electron microscopy. The results obtained show that all the three species develop keratinolytic activity. A. fulvescens and A. verrucosus have similar sequences of degradation, invading the hair through the cuticula, but without the presence of specialized erosive organs. A. keratinophilus, however, shows a different way of invasion, and the keratinolytic activity was mainly located in the cortex and from that point on expanded to the cuticula.

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Experimental pathogenicity of Aphanoascus spp. Cano J, Mayayo E, Guarro J.

Mycoses. 1990 Jan;33(1):41-5.

Immunodepressed mice were inoculated intraperitonealy with a suspension of conidia and micelia macerate of four species of Aphanoascus (A. keratinophilus, A. fulvescens, A. reticulisporus and A. verrucosus). All produced nodular lesions in the peritoneal cavity, especially in the liver, spleen, diaphragm and peritoneum. The recovery rate of the fungi on phytone-yeast extract agar after one month varied approximately from 20 to 80% depending on the organs. Sections of these revealed the presence of ascospores and hyphal fragments though only in the centre of the nodules. Fungal elements were not detected in organs which were apparently not affected, nor intravascularly.

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Rhinocerebral mucormycosis caused by Apophysomyces elegans. Brown SR, Shah IA, Grinstead M. Am J Rhinol. 1998 Jul-Aug;12(4):289-92.

Mucormycosis is an uncommon fungal disease and one of the most fulminant infections known. This is the second report of rhinocerebral mucormycosis caused by Apophysomyces elegans, a newly recognized genus and species classified in the family Mucoraceae. The patient was a 54-year-old man being treated for a severe sinus infection with antibiotics and oral steroids. Recovery occurred in our patient after prompt surgical debridement and drainage of his maxillary sinuses. This case fits the reported characteristics of other A. elegans infections including warm climate, intimate contact with the soil, and an incubation period measured in days. Several reported cases indicate A. elegans can cause mucormycosis in immunocompetent individuals with no underlying medical problems.

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Necrotizing cellulitis caused by Apophysomyces elegans at a patch test site. Lesueur BW, Warschaw K, Fredrikson L. Am J Contact Dermat. 2002 Sep;13(3):140-2.

Plant material occasionally is used in patch testing to diagnose contact dermatitis. Serious adverse reactions to this practice are extremely uncommon. The authors report on a 68-year-old non-insulin-dependent diabetic gentleman with hand dermatitis in whom severe necrotizing cellulitis developed caused by Apophysomyces elegans, a subtype of mucormycosis, at the site of a patch test to a snapdragon plant from his garden.

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Systemic zygomycosis caused by Apophysomyces elegans. Lawrence RM, Snodgrass WT, Reichel GW, Padhye AA, Ajello L, Chandler FW. J Med Vet Mycol. 1986 Feb;24(1):57-65.

A case of systemic zygomycosis caused by Apophysomyces elegans in a 56-year-old man is described. The left kidney and the bladder showed presence of broad, nonseptate-to-infrequently septate hyphae in both the bladder lesion and in the septic kidney. Surgical debridement and treatment with amphotericin B cured the infection. No underlying immune defect was ever demonstrated, and the patient was not hyperglycemic or acidotic at any time. This zygomycetous fungus closely resembles Absidia corymbifera, but is distinguished by its distinctive morphological features.

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Keratitis due to Arthrobotrys oligospora Fres. 1850. Thomas PA, Kuriakose T.J Med Vet Mycol. 1990;28(1):47-50.

Mycotic keratitis caused by Arthrobotrys oligospora is reported in a 62-year-old Indian male patient. The diagnosis was made by direct microscopic examination, isolation of large quantities of the fungus on multiple media and the response of the lesion to an antifungal compound. This is believed to be the first documented case of keratitis due to an Arthrobotrys species.

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First report of mycetoma caused by Arthrographis kalrae: successful treatment with itraconazole. Degavre B, Joujoux JM, Dandurand M, Guillot B. J Am Acad Dermatol. 1997 Aug;37(2 Pt 2):318-20.

We report the first case of eumycetoma of the hand caused by Arthrographis kalrae. Cure was obtained with a 4-month course of itraconazole.

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Invasive fungal sinusitis and meningitis due to Arthrographis kalrae in a patient with AIDS. Chin-Hong PV, Sutton DA, Roemer M, Jacobson MA, Aberg JA. J Clin Microbiol. 2001 Feb;39(2):804-7.

We report the first described case of Arthrographis kalrae pansinusitis and meningitis in a patient with AIDS. The patient was initially diagnosed with Arthrographis kalrae pansinusitis by endoscopic biopsy and culture. The patient was treated with itraconazole for approximately 5 months and then died secondary to Pneumocytis carinii pneumonia. Postmortem examination revealed invasive fungal sinusitis that involved the sphenoid sinus and that extended through the cribiform plate into the inferior surfaces of the bilateral frontal lobes. There was also an associated fungal meningitis and vasculitis with fungal thrombosis and multiple recent infarcts that involved the frontal lobes, right caudate nucleus, and putamen. Post mortem cultures were positive for A. kalrae.

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Lethality of yeasts with low pathogenicity in mice immunocompromised by cyclophosphamide treatment. Okawa Y, Yamada Y. Biol Pharm Bull. 2002 Jul;25(7):940-2.

One strain each of Arxiozyma telluris, Saccharomyces cerevisiae, and S. kluyveri showed lethal activity in cyclophosphamide (CY)-treated mice. Accumulation of these yeast cells in the kidneys and elevation of the levels of cytokines, tumor necrosis factor-alpha, and interleukin-1alpha in the sera were recognized in the CY-treated infected-debilitated mice.

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Maxillary sinusitis caused by Ascotricha chartarum Berk. (anamorph Dicyma ampullifera Boul.): a new phaeoid opportunistic human pathogen. Singh SM, Naidu J, Jain S, Nawange SR, Dhindsa MK. J Med Vet Mycol. 1996 Jun-Jul;34(3):215-8.

The first human infection caused by Ascotricha chartarum of the maxillary sinus is described. The patient, a 35-year-old woman, developed a hard bony swelling on the right cheek. Her maxillary X-ray showed complete opacity of the right maxillary antrum with a shadow of erosion. C.T. scan revealed a radio opaque mass having vacuolated appearance in the antrum. The debris removed from the antrum contained phaeoid fungal elements. At places, softening of the bone was observed. The mucoperiosteum exhibited acute inflammatory reaction and invasion by the pathogen. The pale brown to subhyaline fungal elements in biopsy tissue grew Ascotricha chartarum, a phaeoid ascomycetous fungus in culture. The patient had a smooth recovery when treated with betadine lavage and itraconazole after surgical intervention.

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Mycosis in man due to Arthrinium phaeospermum var. indicum. First case report. Rai MK. Mycoses. 1989 Sep;32(9):472-5.

Arthrinium phaeospermum var. indicum Kan & Sullia was repeatedly isolated from erythematous nodules of a patient. Scrapings of the experimental infection developed on rabbits revealed fungal filaments and few spores similar to those of A. phaeospermum var. indicum. The identity of the pathogen is discussed and it is being reported for the first time from human being. In vitro sensitivity of A. phaeospermum var. indicum to miconazole nitrate exhibited a minimum inhibition concentration of 6.25 micrograms/ml.

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Aspergillus clavatus endocarditis involving a normal aortic valve following coronary artery surgery. Opal SM, Reller LB, Harrington G, Cannady P Jr. Rev Infect Dis. 1986 Sep-Oct;8(5):781-5.

Aspergillus species causing endocarditis on a native heart valve is a rare occurrence with an exceedingly high mortality. This report describes a 60-year-old man who developed Aspergillus clavatus endocarditis of the aortic valve 18 months after coronary artery bypass surgery. The aortic valve was angiographically normal on cardiac catheterization performed before coronary artery surgery. Despite aortic valve replacement and amphotericin B therapy, the patient died as a result of Aspergillus species aortitis with occlusion of the coronary ostia and bypass grafts. Coronary artery surgery may be complicated by this highly lethal infection, which is difficult to diagnose and treat.

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[A case of bronchopulmonary aspergillosis recurring in a residual tuberculous cavity] Yokoyama S, Taniguchi H, Kondo Y, Matsumoto K, Okada A. Kekkaku. 1989 Sep;64(9):579-84.

A 52-year-old man, who had undergone right upper lobectomy because of active tuberculosis 29 years before, was admitted with complaints of severe cough and expectation. Two years ago, he had pulmonary aspergillosis and was successfully treated with some anti-mycotic agents. This time his chest X-P showed fungus ball in a residual tuberculous cavity in the right upper field and he was diagnosed as pulmonary aspergilloma from the results of radiological findings, sputum culture, and serologic test. By bronchofiberscopy fungus ball was observed. With transbronchial infusion of Amphotericin B, intravenous administration of Miconazole and oral administration of Flucytosine, clinical symptoms have improved and lysis of fungus ball was observed. Sputum culture revealed Aspergillus flavipes group. Bronchopulmonary aspergillosis, which was incurable by surgical treatment because of underlying disease, was successfully treated with transbronchial infusion of Amphotericin B and administration of some anti-mycotic agents.

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Aspergillus flavipes group osteomyelitis. Roselle GA, Baird IM.

Arch Intern Med. 1979 May;139(5):590-2.

Lumbar vertebral osteomyelitis caused by Aspergillus Flavipes group organisms developed in a nonchronically immunosuppressed patient. Diagnosis was confirmed morphologically and culturally from both closed needle biopsy of the vertebrae and subsequent lumbar laminectomy. The patient was treated with 3 g of amphotericin B with apparent eradication of the organism.

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Systemic aspergillosis caused by an aflatoxin-producing strain of Aspergillus flavus.Mori T, Matsumura M, Yamada K, Irie S, Oshimi K, Suda K, Oguri T, Ichinoe M. Med Mycol. 1998 Apr;36(2):107-12.

The first case of human systemic infection by an Aspergillus flavus isolate demonstrated to produce aflatoxins in vitro and in vivo is described. The patient, a 41-year-old man with acute myelogenous leukaemia, developed a complication of suspected pulmonary Aspergillus infection during remission induction therapy. Antifungal chemotherapy brought about a considerable degree of improvement, but remission of the underlying disease was not attained. Bone marrow transplantation was also not effective. The patient showed recovery from neutropenia but died despite aggressive antifungal chemotherapy. The autopsy revealed lesions in the lungs, myocardium, kidneys, brain, thyroid gland and skin due to a suspected Aspergillus sp. A fungus isolated from the right lung and the skin lesions was identified as A. flavus. Aflatoxins B1, B2 and M1 were detected in culture filtrates of the isolated A. flavus, and in an extract of lung lesions. These aflatoxins are considered to have played an important role in damaging the immune system of the patient through their toxic effects.

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Otomycosis in Nigeria: treatment with mercurochrome. Mgbor N, Gugnani HC.

Mycoses. 2001 Nov;44(9-10):395-7.

Seventy-two mycologically proven cases of otomycosis (38 males, 34 females) aged 8-80 years were investigated. Aspergillus niger was the commonest aetiological agent (43.1%) followed by Candida spp. (22.2%), A. flavus (19.4%) and A. fumigatus (15.3%). Three topical drugs, namely mercurochrome, clotrimazole and locacorten-vioform, were evaluated for otomycosis therapy in separate groups of 24 patients each. Mercurochrome was found to be the most efficacious in terms of healing, relief from symptoms of the disease and production of negative fungal cultures. Mercurochrome is recommended as a safe and economical drug for the topical treatment of otomycosis in developing countries like Nigeria.

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Primary cutaneous aspergillosis associated with Hickman intravenous catheters. Allo MD, Miller J, Townsend T, Tan C. N Engl J Med. 1987 Oct 29;317(18):1105-8.

We describe nine patients with underlying hematologic cancer in whom primary cutaneous aspergillosis developed at the sites of Hickman intravenous catheters. Our patients, 17 to 74 years of age, were all immunocompromised either from their primary disease or from chemotherapy, and the Hickman catheters had been placed to provide venous access for chemotherapy or hyperalimentation or both. Clinical signs of infection included erythema, induration, and cutaneous or subcutaneous necrosis at the point of entry into the subclavian vein, in the subcutaneous tunnel, or at the exit site from the skin. Diagnosis was confirmed by positive wound culture for Aspergillus flavus in all but one patient. Treatment consisted of intravenous amphotericin B, oral flucytosine, and local wound care. Three patients recovered completely without operative débridement; three others recovered after operative débridement and delayed grafting. Two patients died of disseminated aspergillosis, and one died of unrelated causes while recovering from primary cutaneous aspergillosis. Successful treatment required resolution of aplasia or leukopenia, catheter removal, systemic treatment with amphotericin B, and local wound care. We conclude that primary cutaneous aspergillosis, a rare infection, may occur at the sites of Hickman catheters in immunocompromised patients, and that it is a serious complication requiring prompt diagnosis and treatment.

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[Systemic aspergillosis caused by an aflatoxin-producing strain of Aspergillus in a post-bone marrow transplant patient with acute myeloid leukemia] Yamada K, Mori T, Irie S, Matsumura M, Nakayama M, Hirano T, Suda K, Oshimi K. Rinsho Ketsueki. 1998 Nov;39(11):1103-8.

We report a case in which an aflatoxin-producing strain of Aspergillus flavus (A. flavus) caused systemic aspergillosis in a post-transplant 41-year-old man with acute myeloid leukemia. The leukemia was initially resistant to two courses of induction chemotherapy. The third course of chemotherapy, however, induced complete remission. Thereafter, the patient underwent bone marrow transplantation from his HLA identical brother. Pulmonary aspergillosis was suspected as a complication during induction chemotherapy. Twenty days after the transplant, the patient's absolute neutrophil count had increased to 500/microliter. However, the symptoms of pulmonary aspergillosis were aggravated following neutrophil and monocyte recovery. The patient died of sinus arrest due to complete atrioventricular block 31 days after his transplant. At autopsy, we found that the fungus had invaded the brain, lungs, spleen, kidneys, skin, and myocardium, including the sinoatrial conduction system. There was no sign of acute graft-versus-host disease. A strain of A. flavus was isolated from cultured tissue samples of fungal lesions and shown by thin-layer chromatography to produce aflatoxins. To our knowledge, this is the first case report describing an infection by an aflatoxin-producing A. flavus.

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Chronic invasive aspergillosis of the paranasal sinuses in immunocompetent hosts from Saudi Arabia. Alrajhi AA, Enani M, Mahasin Z, Al-Omran K. Am J Trop Med Hyg. 2001 Jul;65(1):83-6.

In immunocompetent patients, paranasal invasive aspergillosis is rare and has a high recurrence rate. Twenty-three cases of paranasal invasive aspergillosis, involving 14 male and nine female immunocompetent patients were reviewed. All patients were cancer-free, HIV-negative, with normal WBC, and none of the patients had received immunosuppressive therapy or corticosteroids. Mean duration of symptoms before diagnosis was 18 months. Aspergillus flavus was the species most frequently isolated. Surgical debridement was performed in all patients followed by antifungal therapy in 18 patients. Mean follow-up duration was 30 months. Fourteen patients relapsed after a mean of 13 months and required an average of 4.3 admissions for repeat surgical evacuation. In a logistic regression model, relapse was not associated with age, duration of symptoms, clinical findings, extent of disease, or mode of therapy. However, patients who were relapse-free tended to have had complete surgical evacuation followed by antifungal therapy.

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Invasive mold sinusitis: 17 cases in immunocompromised patients and review of the literature. Clin Infect Dis. 1997 Jun;24(6):1178-84.

A 10-year retrospective analysis of invasive mold infections in hospitalized patients was performed to characterize the epidemiology and clinical features of invasive fungal sinusitis. Seventeen cases of invasive mold sinusitis were identified. Eleven cases were caused by Aspergillus flavus, three were caused by unspecified species, and one each was caused by Aspergillus fumigatus, Rhizopus species, and Alternaria species, respectively. Fifteen patients had hematologic malignancies, and two had end-stage liver disease. The most common presenting symptom was periorbital swelling (seven patients). Sinusitis was diagnosed a median of 19 days after admission. Eight patients (47%) survived; six of these patients were treated with both amphotericin B and surgery. Postmortem examination of six patients showed evidence of disseminated disease; the brain was the most common extrapulmonary site (four patients). To our knowledge, this is the largest currently reported series on invasive mold sinusitis; our report extends the information on 
invasive mold sinusitis and shows that aggressive therapeutic and surgical interventions are needed to prevent rapid progression of disease in immunocompromised patients.

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Recurrent aspergilloma of the frontoethmoid sinus in a nonmmunocompromised patient. Tierney P, Thomas M, Samuel D, Patel KS, Stafford N.

J R Soc Med. 1996 Mar;89(3):165P-6P.

Management of invasive aspergillosis of the paranasal sinuses requires sufficient experience to initiate appropriate investigations and then utilize the correct treatment protocol. Computed tomography (CT) or magnetic resonance imaging (MRI) is essential to show the extent of the disease and diagnosis is confirmed by histological analysis. Aspergillus flavus is a ubiquitous soil saprophyte in the Sudan and is responsible for many cases originating from this area. The literature is reviewed and treatment options discussed.

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Invasive Aspergillus stomatitis in patients with acute leukemia: report of 12 cases. Myoken Y, Sugata T, Kyo T, Fujihara M, Kohara T, Katsu M, Tamura M, Mikami Y. Clin Infect Dis. 2001 Dec 15;33(12):1975-80.

Comment in: Clin Infect Dis. 2002 Jul 1;35(1):105-6; discussion 106-7 PMID: 12060886

An 8-year retrospective analysis of invasive Aspergillus stomatitis in neutropenic patients with acute leukemia was performed to characterize the epidemiology and clinical features of the infection. Twelve cases of invasive Aspergillus stomatitis were identified with both clinicohistological and microbiological evidence, and the majority of cases were caused by Aspergillus flavus (10 [83%] of 12 patients). The infection was strongly suspected when a neutropenic patient developed persistent fever without a known source, symptoms of gingival pain and facial swelling, and a solitary ulcerating lesion of mucogingiva covered with a gray necrotic pseudomembrane. Aspergillus stomatitis was diagnosed a median 23 days after admission. In all 12 patients, the diagnosis was made during the period of neutropenia. Ten patients (83%) were treated with amphotericin B and surgery and survived with recovery of neutrophils. Two patients died, and disseminated aspergillosis was identified in 1 patient.

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12. Rhinocerebral invasive mycosis: occurrence in immunocompetent individuals. Hussain S, Salahuddin N, Ahmad I, Salahuddin I, Jooma R. Eur J Radiol. 1995 Jul;20(2):151-5.

We report the computed tomographic appearance of invasive fungal disease of the paranasal sinuses in 13 patients. Coronal and axial computed tomographic images were obtained in each patient and data were analysed. Eight patients had Aspergillus flavus infection, four had Mucormycosis, and one had mixed Candida and Mucor. Our experience was different from that of other workers in many respects. All of our patients were immunocompetent. On radiological imaging by computed tomography, ethmoid sinuses were involved in 85% of our patients. In previously reported series maxillary sinuses were most frequently affected. Calcification in the inflammatory mass was not encountered in any of our patients, whereas this feature was present in many reported cases. Features in our patients that were similar to other studies were contrast enhancement, extension of the disease into the orbit and cranial cavity and a high mortality. The clinical course and radiological features of invasive mycosis simulate malignancy. Certain features that may help to differentiate invasive fungal infection from malignancy are discussed. We conclude that invasive fungal infection can affect immunocompetent individuals and should be considered in the differential diagnosis in appropriate clinical settings.

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Rhinocerebral aspergillosis. Kameswaran M, al-Wadei A, Khurana P, Okafor BC. J Laryngol Otol. 1992 Nov;106(11):981-5.

Aspergillosis is increasingly being recognised as a common fungal infection of the paranasal sinuses. Although the disease is almost endemic in neighbouring Sudan, there are few reported cases from the Kingdom of Saudi Arabia. We report four cases of sinus aspergillosis with involvement of the skull bases and/or intracranial spread; a condition we have termed rhinocerebral aspergillosis. Invasive aspergillosis in our subgroup of patients occurs in otherwise healthy patients with normal immune status, quite unlike most reported cases in the western literature. The causative agent in all our patients was identified as aspergillus flavus, similar to patients reported from Sudan. This is again at variance with the case reports from other geographical locations, where aspergillus fumigatus is the commonest causative agent. Saudi Arabia would appear to represent a distinct geographical enclave, together with Sudan, where rhinocerebral aspergillosis of the sinuses and skull base may be more common than has previously been realised.

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Medical management of Aspergillus flavus endocarditis. Rao K, Saha V.

Pediatr Hematol Oncol. 2000 Jul-Aug;17(5):425-7.

An 11-year-old boy underwent a matched unrelated bone marrow transplant for refractory acute myeloid leukemia. He developed invasive aspergillus pneumonia and endocarditis post-transplant. The fungal endocarditis was successfully eradicated with liposomal amphotericin at the dose of 10 mg/kg/day. Surgical intervention was not required and no serious side effects of liposomal amphotericin were observed at this dose.

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Aspergillus flavus endocarditis in a child with neuroblastoma. Kennedy HF, Simpson EM, Wilson N, Richardson MD, Michie JR. J Infect. 1998 Jan;36(1):126-7.

We report a case of Aspergillus flavus endocarditis in a 6-year-old boy with stage IV neuroblastoma with no pre-existing cardiac disease. The infection was successfully treated with high-dose liposomal amphotericin (AmBisome) once daily. Recurrence was prevented with itraconazole oral solution once daily as maintenance therapy. Adjunctive surgery was not required. The patient's cardiac function was uncompromised, but subsequent death from progressive neuroblastoma prevented long-term follow-up.

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Case report. Fatal Aspergillus flavus pericarditis in a patient with acute myeloblastic leukaemia. Gökahmetoğlu S, Koç AN, Patiroğlu T. Mycoses. 2000;43(1-2):65-6.

We report a case of Aspergillus flavus pericarditis treated with fluconazole for oral candidosis. The patient with acute myeloblastic leukaemia developed tachypnoea after antileukaemic chemotherapy. Pericardial effusion was seen in the echocardiogram. Aspergillus flavus was isolated from the pericardial fluid. The patient died from aspergillosis, before the antimycotic treatment could be changed to amphotericin B.

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Aspergillus osteomyelitis after liver transplantation: conservative or surgical treatment? Tang TJ, Janssen HL, van der Vlies CH, de Man RA, Metselaar HJ, Tilanus HW, de Marie S. Eur J Gastroenterol Hepatol. 2000 Jan;12(1):123-6.

We report on a liver transplant recipient who developed coxarthritis and lumbar spondylodiscitis due to Aspergillus flavus. He was treated with high-dose liposomal amphotericin B for 2 months followed by itraconazole. Because of intractable pain and severe, irreversible damage of the left hip, a Girdlestone resection was performed. The spondylodiscitis was treated successfully with anti-fungal agents only, which indicates that, in the absence of neurological impairment, good clinical outcome can be achieved without surgery. This case demonstrates that surgical therapy, which is often proclaimed as unavoidable for the treatment of Aspergillus osteomyelitis, should be considered in particular in the case of intolerable pain due to irreversible joint damage or involvement of vital organs.

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Clinical and microbial spectrum of fungal keratitis in Singapore: a 5-year retrospective study. Wong TY, Fong KS, Tan DT.Int Ophthalmol. 1997;21(3):127-30.

BACKGROUND: The epidemiology of fungal keratitis varies geographically, but commonly occurs in warm, tropical climates. To determine the microbial and clinical characteristics of this disease in Singapore, we conducted a 5-year hospital-based retrospective study. METHODS: A retrospective review of culture-positive fungal keratitis at the Singapore National Eye Center and Singapore General Hospital, from January 1991 to December 1995. RESULTS: Twenty-nine consecutive cases of culture-positive fungal keratitis were seen over the study period. The mean age of the cases was 41 years and 23 were males. Amongst the varied occupations, 9 were construction workers. The most common cultured organisms were Fusarium sp. (52%) and Aspergillus flavus (17%). More than half had a history of ocular trauma prior to the development of keratitis, while a quarter had antecedent topical corticosteroid therapy. In contrast, only 2 patients were contact-lens wearers. Despite medical therapy, 10 patients eventually required therapeutic penetrating keratoplasties; of these, 6 were caused by Fusarium species. CONCLUSION: Fusarium is the commonest cultured organism in fungal keratitis in Singapore and is associated with significant ocular morbidity.

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Fungal keratitis in Saudi Arabia. Khairallah SH, Byrne KA, Tabbara KF.

Doc Ophthalmol. 1992;79(3):269-76.

We studied a total of 27 cases of fungal keratitis is Saudi Arabia. History of trauma was found in 9 patients, and previous use of topical steroids in 6 patients. In the majority of patients the onset of the disease was in fall and spring. The most frequent cause of fungal keratitis was found to be Aspergillus spp., and these were isolated from 11 cases (41%). Eight of the 11 isolates were Aspergillus flavus. Other causes of keratomycosis included: Fusarium, Candida, and Mycelia sterilia. All patients were treated with antifungal therapy and 18 patients required surgical intervention. Vision improved among 11 patients, remained the same in 4 patients, and deteriorated after treatment in 6 patients. (6 patients failed to return for follow-up.) Four of the 27 patients developed fungal endophthalmitis. The high prevalence of Aspergillus spp. may be due to the fact that spores of Aspergillus can survive the hot and dry weather of Saudi Arabia.

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Fungal and Parasitic Infections of the Eye. Stephen A. Klotz, Christopher C. Penn, Gerald J. Negvesky, and Salim I. Butrus . Clin. Microbiol. Rev. 2000 13: 662-685.

The unique structure of the human eye as well as exposure of the eye directly to the environment renders it vulnerable to a number of uncommon infectious diseases caused by fungi and parasites. Host defenses directed against these microorganisms, once anatomical barriers are breached, are often insufficient to prevent loss of vision. Therefore, the timely identification and treatment of the involved microorganisms are paramount. The anatomy of the eye and its surrounding structures is presented with an emphasis upon the association of the anatomy with specific infection of fungi and parasites. For example, filamentous fungal infections of the eye are usually due to penetrating trauma by objects contaminated by vegetable matter of the cornea or globe or, by extension, of infection from adjacent paranasal sinuses. Fungal endophthalmitis and chorioretinitis, on the other hand, are usually the result of antecedent fungemia seeding the ocular tissue. Candida spp. are the most common cause of endogenous endophthalmitis, although initial infection with the dimorphic fungi may lead to infection and scarring of the chorioretina. Contact lens wear is associated with keratitis caused by yeasts, filamentous fungi, and Acanthamoebae spp. Most parasitic infections of the eye, however, arise following bloodborne carriage of the microorganism to the eye or adjacent structures. 
Candida sp., Fusarium, Acremonium killense, Alternaria, A.flavus, A.niger, A.fumigatus, A.terreus, A.glaucus, A.nidulans, Pseudallesheria boydii, H. capsulatum, B. dermatitidis, Sporotrix schenskii, Coccidioides immitis, Cryptococcus neoformans, Exophiala jeanselmei, Lasiodiplodia theobromae, Pneumocystis carinii, Paecilomyces lilacinus, Penicillium chrysogenum, Curvularia, Phialophora , Malassezia, Rhodotorula, Microsporum spp. can be cause of infection of the eye after eye trauma in immunocompromised hosts.

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Isolated renoureteric aspergilloma due to Aspergillus flavus: case report and review of the literature. Pérez-Arellano JL, Angel-Moreno A, Belón E, Francès A, Santana OE, Martín-Sánchez AM. J Infect. 2001 Feb;42(2):163-5.

In this paper we describe a case in which acute renal colic was associated with elimination of multiple hyphal masses of Aspergillus flavus. Also, we reviewed the literature on similar cases and we found a similar pattern characterized by a marked male predominance, association with at least one underlying medical condition that predisposes to fungal infection, the presence of local symptoms resembling acute ureteral colic, and the absence of systemic manifestations. Moreover, our data suggest that Aspergillus balls must be suspected when a diabetic and intravenous drug user presents with acute renal colic and that non-obstructive renal aspergillosis may be initially treated with itraconazole.

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Aspergillus flavus mycetoma and epidural abscess successfully treated with itraconazole. Witzig RS, Greer DL, Hyslop NE Jr. J Med Vet Mycol. 1996 Mar-Apr;34(2):133-7.

Aspergillus spp. rarely cause mycetomata. We report a patient with diabetes and nephrotic syndrome with Aspergillus flavus mycetoma of the back, with the development of an epidural abscess, diskitis and vertebral osteomyelitis. The patient was successfully treated with decompressive laminectomy and a 14-month itraconazole regimen. Serial serum itraconazole levels and quantitative Aspergillus antigen levels were performed. This is the second reported and first extrapedal case of mycetoma caused by A. flavus.

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Pulmonary cavitation lesions in patients infected with the human immunodeficiency virus: an analysis of a series of 78 cases] Rodríguez Arrondo F, von Wichmann MA, Arrizabalaga J, Iribarren JA, Garmendia G, Idígoras P. Med Clin (Barc). 1998 Dec 5;111(19):725-30.

The unique structure of the human eye as well as exposure of the eye directly to the environment renders it vulnerable to a number of uncommon infectious diseases caused by fungi and parasites. Host defenses directed against these microorganisms, once anatomical barriers are breached, are often insufficient to prevent loss of vision. Therefore, the timely identification and treatment of the involved microorganisms are paramount. The anatomy of the eye and its surrounding structures is presented with an emphasis upon the association of the anatomy with specific infection of fungi and parasites. For example, filamentous fungal infections of the eye are usually due to penetrating trauma by objects contaminated by vegetable matter of the cornea or globe or, by extension, of infection from adjacent paranasal sinuses. Fungal endophthalmitis and chorioretinitis, on the other hand, are usually the result of antecedent fungemia seeding the ocular tissue. Candida spp. are the most common cause of endogenous endophthalmitis, although initial infection with the dimorphic fungi may lead to infection and scarring of the chorioretina. Contact lens wear is associated with keratitis caused by yeasts, filamentous fungi, and Acanthamoebae spp. Most parasitic infections of the eye, however, arise following bloodborne carriage of the microorganism to the eye or adjacent structures. 
Candida sp., Fusarium, Acremonium killense, Alternaria, A.flavus, A.niger, A.fumigatus, A.terreus, A.glaucus, A.nidulans, Pseudallesheria boydii, H. capsulatum, B. dermatitidis, Sporotrix schenskii, Coccidioides immitis, Cryptococcus neoformans, Exophiala jeanselmei, Lasiodiplodia theobromae, Pneumocystis carinii, Paecilomyces lilacinus, Penicillium chrysogenum, Curvularia, Phialophora , Malassezia, Rhodotorula, Microsporum spp. can be cause of infection of the eye after eye trauma in immunocompromised hosts.

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Cluster of cases of invasive aspergillosis in a transplant intensive care unit: evidence of person-to-person airborne transmission. Pegues DA, Lasker BA, McNeil MM, Hamm PM, Lundal JL, Kubak BM. Clin Infect Dis. 2002 Feb 1;34(3):412-6.

In October 1998, a patient developed deep surgical-site and organ-space infection with Aspergillus fumigatus 11 days after undergoing liver retransplantation; subsequently, 2 additional patients in the transplant intensive care unit had invasive pulmonary infection with A. fumigatus diagnosed. It was determined that debriding and dressing wounds infected with Aspergillus species may result in aerosolization of spores and airborne person-to-person transmission.

145

Sternal osteomyelitis caused by Aspergillus fumigatus in a patient with previously treated Hodgkin's disease. Allen D, Ng S, Beaton K, Taussig D. J Clin Pathol. 2002 Aug;55(8):616-8.

This report details the case of a 67 year old woman with sternal osteomyelitis caused by Aspergillus fumigatus. She was diagnosed with Hodgkin's disease in 1975 and was successfully treated with chemotherapy. A lobectomy for recurrence localised to the left lung was complicated nine years later by severe bronchiectasis, for which she required a total left sided pneumonectomy. At surgery, a non-invasive aspergillus was found. She presented eight years later with symptoms that were initially attributed to recurrence of Hodgkins's disease, but on investigation were found to be caused by fungal sternal osteomyelitis. Treatment with itraconazole suspension at a dose of 400 mg daily was successful.

146

Aspergillus osteomyelitis in a child who has p67-phox-deficient chronic granulomatous disease. Tsumura N, Akasu Y, Yamane H, Ikezawa S, Hirata T, Oda K, Sakata Y, Shirahama M, Inoue A, Kato H. Kurume Med J. 1999;46(1):87-90.

Here we describe Aspergillus osteomyelitis of the tibia in a 9-year-old boy who has an autosomal recessive form of chronic granulomatous disease (CGD). The patient showed a p67-phagocyte oxidase (phox) deficiency, which is rare type of CGD in Japan. The initial treatment which consisted of surgical debridement and antibiotic therapy with amphotericin B (AMPH), did not control the infection. Aspergillus fumigatus (A. fumigatus) pure isolated from drainage fluid and necrotic bone tissue demonstrated less susceptible to antifungal agents, including AMPH, fluconazole and flucytosine. Recombinant interferon gamma was then administrated, and it was effective in controlling the course of severe invasive aspergillosis. This report indicates the use of interferon gamma might be helpful in control for Aspergillus osteomyelitis of the tibia in a child with CGD demonstrated p67-phox deficiency refractory to conventional therapy with AMPH.

147

Hospital construction-associated outbreak of ocular aspergillosis after cataract surgery. Tabbara KF, al Jabarti AL. Ophthalmology. 1998 Mar;105(3):522-6.

OBJECTIVE: This study aimed to report an outbreak of Aspergillus endophthalmitis after cataract extraction during hospital construction. DESIGN: The study design is a case series of an outbreak of Aspergillus endophthalmitis. PARTICIPANTS: Five patients in whom Aspergillus endophthalmitis developed during a period of hospital construction in Jeddah, Saudi Arabia, participated. Severe postoperative uveitis occurred in all five patients and failed to subside with topical steroid therapy. The patients were referred to the King Khaled Eye Specialist Hospital for treatment. The causative organism was identified as Aspergillus fumigatus in each case. INTERVENTION: All five patients were subjected to aqueous or vitreous tap. Three patients had vitrectomy. Patients were given systemic, periocular, and intravitreous antifungal agents. MAIN OUTCOME: The final outcome in each patient was evisceration or enucleation, despite an intensive course of antifungal therapy. RESULTS: There were five patients, three females and two males, ranging in age from 51 to 65 years. Postoperative signs of infection developed in the patients 4 to 15 days after surgery. In all five cases, cultures of aqueous or vitreous grew A. fumigatus. CONCLUSION: Aspergillus endophthalmitis is a serious and devastating complication of ocular surgery. The outbreak, herewith, may have been related to hospital construction. The infection can be prevented, notably, by proper maintenance of old, "sick" buildings and by following certain procedures during hospital construction.

148

[Fungal myocarditis in acquired immunodeficiency syndrome] Hofman P, Gari-Toussaint M, Bernard E, Michiels JF, Gibelin P, Le Fichoux Y, Morand P, Loubiere R. Arch Mal Coeur Vaiss. 1992 Feb;85(2):203-8.

The authors report 8 cases of fungal myocarditis discovered at autopsy of a series of 118 patients with AIDS. The cardiac disease was symptomatic and responsible for death in 2 cases. Antemortem diagnosis of fungal infection was made on examination of bronchioloalveolar lavage, the cerebrospinal fluid or gastrointestinal biopsy. The demonstration of intramyocardial pathogens was postmortem in all cases. The organism was Candida albicans in 3 cases, Cryptococcus neoformans in 3 cases, and Aspergillus fumigatus in 2 cases. The lesions were not confined to the heart; multi-visceral fungal involvement was diagnosed at autopsy in all cases. Cryptococcal and Candida myocarditis have already been described in most autopsy series in AIDS, but Aspergillus myocarditis is very rare. These fungal myocarditis are usually clinically latent or masked by neurological or respiratory symptoms.

149

Aspergillus fumigatus endocarditis on a normal heart valve. Vishniavsky N, Sagar KB, Markowitz SM. South Med J. 1983 Apr;76(4):506-8.

We have described an elderly man with no known underlying predisposing systemic or valvular disease who had mitral valve infection and endophthalmitis due to Aspergillus fumigatus. Two-dimensional echocardiography was valuable in detecting fungal vegetations.

150

Invasive rhinosino-orbital aspergillosis with precipitous visual loss. Mauriello JA Jr, Yepez N, Mostafavi R, Barofsky J, Kapila R, Baredes S, Norris J. Can J Ophthalmol. 1995 Apr;30(3):124-30.

OBJECTIVE: To describe the clinicopathological and radiologic features in five cases of primary and secondary orbital aspergillosis. DESIGN: Case series. SETTING: Ophthalmology department of a university hospital. PATIENTS: Five patients over 65 years of age with invasive rhinosino-orbital aspergillosis. RESULTS: Presenting features were abrupt onset of proptosis, ophthalmoplegia and blepharoptosis with precipitous visual loss. All had debilitating periorbital pain or headache, but none had orbital inflammatory signs or appeared "toxic." Predisposing causes included alcoholism, low-dose prednisone therapy and insulin-dependent diabetes mellitus. One patient, suspected of having mucormycosis based on tissue biopsy and results of potassium hydroxide preparations, harboured Aspergillus fumigatus, which grew on culture. Secondary bacterial infections developed in three patients. Three patients died from their disease despite aggressive surgical treatment, including exenteration and sinus extirpation. The one patient with primary orbital aspergillosis survived after exenteration. CONCLUSIONS: Sinonasal aspergillosis with orbital extension and primary orbital aspergillosis have a precipitous clinical course that mimics that of mucormycosis and may be fatal despite early exenteration. Computed tomography and magnetic resonance imaging of the sinuses, orbit and head provide complementary diagnostic signs. While results of potassium hydroxide preparations and tissue biopsy guide treatment of fungal infection, definitive diagnosis requires fungal culture. Relatively good vision may be associated with massive orbital and secondary intracranial extension.

151

Aspergillosis of the nose and paranasal sinuses in neutropenic patients at an oncology center. Landoy Z, Rotstein C, Shedd D. Head Neck Surg. 1985 Nov-Dec;8(2):83-90.

Invasive aspergillosis of the nose and paranasal sinuses is one of the presentations of aspergillosis in granulocytopenic patients with neoplastic disorders. It is most prevalent among patients with leukemia and granulocytopenia and is associated with a high mortality rate. We report five cases of invasive aspergillosis of the nose and paranasal sinuses in profoundly neutropenic patients treated with broad spectrum antibiotics. Both Aspergillus fumigatus and Aspergillus flavus were cultured and identified in this entity. Awareness of this disease and early diagnosis made by culture and histologic examinations of biopsy material are essential. Treatment consisting of amphotericin B therapy and surgical debridement can be effective in eradicating this form of aspergillosis.

152

. Aspergillus fumigatus infection of the optic nerve with mycotic arteritis of cerebral vessels. Fernando SS, Lauer CS. Histopathology. 1982 Mar;6(2):227-34.

A 56-year-old Caucasian male, with no obvious immune deficit or systemic disease, presented with unilateral loss of vision due to A. fumigatus infection involving the right optic nerve. There was no proptosis. Despite fungal chemotherapy he developed central nervous system involvement with mycotic arteritis of the branches of the right middle cerebral artery, temporal lobe infarction and rupture of a mycotic aneurysm of the right internal carotid artery, and died. Review of the literature concerning orbital Aspergillus infection showed both this form of presentation and a rapidly fatal course to be unusual.

153

Aspergillus fumigatus keratitis with wreath pattern infiltrates.

Sridhar MS, Gopinathan U, Garg P, Rao GN. Cornea. 2001 Jul;20(5):534-5.

PURPOSE: To report a case of Aspergillus fumigatus keratitis with clinical features simulating Nocardia keratitis and to highlight the utility of microbiologic investigation in the successful management of infectious keratitis. METHOD: Case report. RESULTS: A 62-year-old man presented with complaints of pain, redness, and watering of 10 days' duration in his right eye. Direct microscopic observation of smears of corneal scrapings revealed a fungal etiology. The patient was treated with 5% natamycin eye drops and 1% atropine sulphate eye drops and was advised to visit the hospital for observation. During his visit to the hospital on day 10 after medication, the eye demonstrated a wreath pattern corneal infiltrate that simulated Nocardia keratitis. The fungus grown from culture of corneal scraping was identified as A. fumigatus. CONCLUSION: This report highlights the significance of subjecting corneal scrapings from suspected cases of infectious keratitis to microbiologic evaluation and emphasizes the fact that a complete microbiologic work-up helps in establishing a definitive etiologic diagnosis and initiating specific antimicrobial therapy.

161

Mycotic keratitis in Madras. Venugopal PL, Venugopal TL, Gomathi A, Ramakrishna ES, Ilavarasi S. Indian J Pathol Microbiol. 1989 Jul;32(3):190-7.

Corneal scrapings from 698 clinically suspected cases of mycotic keratitis were investigated for evidence of fungal infection. Of these, 322 were found to be positive by direct examination and/or culture. The infection was predominantly seen in the age group 21-50. Men were more frequently affected than women. Majority of the patients were either agricultural workers or out door manual labourers and 66.8% of them gave a definite history of antecedent corneal trauma due to vegetable or soil matter. Aspergillus flavus was the commonest causal agent isolated from 55 cases (17.1%), followed by A. niger (13.7%), A. fumigatus (10.9%), A. terreus (1.2%), A. glaucus (0.9%), and Pseudoallescheria boydii (0.6%). The order of occurrence of the genera of fungi isolated was Aspergillus, Acremonium, Curvularia, Fusarium, Candida, Syncephalastrum, Penicillium, Aureobasidium, Drechslera, Cladosporium, Rhizopus, Alternaria, Mucor, Pseudoallescheria and lastly Paecilomyces and Trichoderma from one case each.

162

Cutaneous Aspergillosis . Jo-Anne H. van Burik,1,2,* Roy Colven,3 and David H. Spach1. Journal of Clinical Microbiology, November 1998, p. 3115-3121, Vol. 36, No. 11

Although extensive investigation has clarified multiple aspects of pulmonary aspergillosis in immunocompromised patients, cutaneous aspergillosis occurs relatively less frequently and therefore remains poorly characterized. Previous reports have described cutaneous aspergillosis as either primary (2, 17, 25, 38) or secondary (15, 19) infection. Primary cutaneous aspergillosis usually involves sites of skin injury, namely, at or near intravenous access catheter sites, at sites of traumatic inoculation, and at sites associated with occlusive dressings, burns, or surgery. Secondary cutaneous lesions result either from contiguous extension to the skin from infected underlying structures or from widespread blood-borne seeding of the skin. Herein, we present a review of cutaneous aspergillosis among immunocompromised patient populations. With this review, we have attempted to better define risk factors and common clinical presentations, as well as to formulate a reasonable approach to the diagnosis and management of cutaneous aspergillosis. Numerous reports have described primary or secondary cutaneous aspergillosis in an array of non-HIV-infected immunocompromised patients, including burn victims, neonates, individuals with cancer, and bone marrow and solid-organ transplant recipients (1, 2, 4, 6-9, 11, 20, 22-24, 26, 32-38, 43-46, 48-51, 53, 55, 56, 59, 60, 62, 66, 68). In addition, otherwise healthy hosts can develop cutaneous aspergillosis in surgical wounds (3, 8, 40), by traumatic inoculation (5, 12, 13, 27, 41, 42), or by exposure to high spore counts in occupations such as farming (10, 19, 61, 64), although such infections are rare. In general, burn victims, neonates, and solid-organ transplant recipients develop cutaneous inoculation after prolonged local skin injury, whereas bone marrow transplant recipients tend to develop secondary cutaneous aspergillosis lesions either from contiguous extension from infected structures underlying the skin, such as the paranasal sinuses, nasal cavity, or orbit, or from hematogenously disseminated embolic lesions. Cancer patients, particularly leukemia patients, develop both primary and secondary infections. The different classifications of both primary and secondary cutaneous aspergillosis infections are as follows. Primary infections include those at intravenous catheter sites (cutaneous exit sites and subcutaneous tunnels), infections associated with adhesives such as occlusive dressings and tape, and infections associated with burn wounds, surgical wounds, and trauma wounds. Secondary infections include those caused by direct extension and embolic lesions. Among patients with HIV-related cutaneous aspergillosis, seven patients had A. fumigatus infection, one had A. glaucus infection, and two had aspergillosis demonstrated by histopathology alone. The reason for this high proportion of primary A. fumigatus isolates is not known. In contrast, among cases of cutaneous aspergillosis that did not involve HIV-infected or burn patients, the following organisms accounted for the indicated proportion of cases: Aspergillus flavus, 44%; A. fumigatus, 26%; Aspergillus spp. (the species of Aspergillus was not determined), 10%; Aspergillus terreus, 6% (13, 38, 45, 61); Aspergillus niger, 6% (10, 25, 32, 38, 55); A. glaucus, 4% (15, 66, 68); Aspergillus chevalieri, 3% (42); and Aspergillus ustus, 1% (59). The proportions of species differed by at-risk populations: A. flavus accounted for approximately one-half of non-burn-related primary infection, whereas A. flavus and A. fumigatus each accounted for approximately one-third of secondary or metastatic skin lesions. Determination of the species causing aspergillosis did not guide therapy in any of the reports reviewed. 

167

Aspergillus nidulans infection in chronic granulomatous disease. Segal BH, DeCarlo ES, Kwon-Chung KJ, Malech HL, Gallin JI, Holland SM. Medicine (Baltimore). 1998 Sep;77(5):345-54.

Chronic granulomatous disease (CGD) is a rare inherited disorder of the NADPH oxidase complex in which phagocytes are defective in generating reactive oxidants. As a result, patients with CGD suffer from recurrent bacterial and fungal infections. The most common fungal infections are caused by Aspergillus species. Aspergillus nidulans is a rare pathogen in most patient populations with quantitative or qualitative neutrophil defects. We have reviewed all cases in which A. nidulans was isolated from patients at the National Institutes of Health (Bethesda, MD) between 1976 and 1997. A. nidulans infection occurred in 6 patients with CGD, but was not a pathogen in any other patient group. Aspergillus fumigatus was a more common pathogen in CGD compared with A. nidulans, but A. nidulans was more virulent. A. nidulans was significantly more likely to result in death compared with A. fumigatus, to involve adjacent bone, and to cause disseminated disease. Patients with A. nidulans received longer courses of amphotericin B therapy than patients with A. fumigatus, and were treated with surgery more often. In contrast to A. fumigatus, A. nidulans was generally refractory to intensive antifungal therapy, suggesting that early surgery may be important. These data show that A. nidulans is a distinct pathogen in CGD and its isolation carries more severe implications than that of A. fumigatus.

168

Aspergillus nidulans infection in a patient with chronic granulomatous disease. Kim M, Shin JH, Suh SP, Ryang DW, Park CS, Kim C, Kook H, Kim J. J Korean Med Sci. 1997 Jun;12(3):244-8.

Aspergillus nidulans is one of the several species of Aspergillus with low pathogenicity. The significant infections of A. nidulans in human have rarely been reported, almost exclusively in patients with chronic granulomatous disease (CGD). CGD is a primary immunodeficiency disease which results from the absence of the NADPH oxidase in the phagocytic cells, leading to recurrent pyogenic infection and granuloma and abscess formation. Here we report a fatal case A. nidulans infection in a six-year-old boy with chronic granulomatous disease. A. nidulans was isolated from the culture of a paraspinal abscess and Aspergillus was detected in the surgical tissue by in situ hybridization. The patient succumbed despite prolonged treatment with high-dose amphotericin B, itraconazole and interferon-alpha. To our knowledge, this is the first report of A. nidulans infection in Korea.

169

A case of chronic necrotizing pulmonary aspergillosis due to Aspergillus nidulans. Mizuki M, Chikuba K, Tanaka K. Mycopathologia. 1994 Nov;128(2):75-9.

A 55-year old man without immunosuppression clinically showed a coin lesion in the right lower lung on the chest radiographs. Aspergillus nidulans was isolated and identified in both trans-bronchial lung biopsy specimen and resected tissue. The specimens revealed characteristics of chronic necrotizing pulmonary aspergillosis pathologically. Very few reports on cases of pulmonary aspergillosis due to A. nidulans exist, and we were not able to find any reports of similar cases. This case may be the first reported case of chronic necrotizing pulmonary aspergillosis due to A. nidulans.

170

Chronic granulomatous disease of childhood. An unusual case of infection with Aspergillus nidulans var. echinulatus. White CJ, Kwon-Chung KJ, Gallin JI. Am J Clin Pathol. 1988 Sep;90(3):312-6.

Aspergillus nidulans var. echinulatus was the sole agent cultured from the left lung, a paraspinal abscess, left ribs, and thoracic vertebral bodies from a patient with chronic granulomatous disease. Hyphal elements were present in histologic sections of lung, vertebral bodies, and infected ribs along with granuloma formation. The patient was treated with two debridement procedures and insertion of a Harrington rod followed by a long course of amphotericin B, flucytosine, and daily white blood cell transfusions.

171

Aspergillus endocarditis in chronic granulomatous disease. Casson DH, Riordan FA, Ladusens EJ. Acta Paediatr. 1996 Jun;85(6):758-9.

Department of Paediatric Gastroenterology, Royal Free Hospital, London.

We report the first case, to our knowledge, of Aspergillus endocarditis in chronic granulomatous disease in a patient who also had an atrial septal defect. A diagnosis was made on culture of the organism from the mass despite extensive prior investigation. The presence of distinctive skin lesions as a diagnostic clue of fungaemia is highlighted. Possible advances in diagnosis by detection of fungal cell wall components and in prophylaxis by use of itraconazole are referred to. We conclude that fungal endocarditis should be considered in this condition, especially in the presence of a structural heart defect.

172

Osteomyelitis and pneumonia in a boy with chronic granulomatous disease of childhood caused by a mutant strain of Aspergillus nidulans. Bujak JS, Kwon-Chung KJ, Chusid MJ. Am J Clin Pathol. 1974 Mar;61(3):361-7.

183

Mycotic infection of the ear (otomycosis): a prospective study. Paulose KO, Al Khalifa S, Shenoy P, Sharma RK. J Laryngol Otol. 1989 Jan;103(1):30-5.

Otomycosis (fungal infection of the ear) is not uncommon clinical problem encountered in our ENT practice. It makes up to 6 per cent of all patients with symptoms of ear disease seen in the Outpatient Clinic. Of the 193 patients with a clinical diagnosis of otomycosis, 171 cases produced positive fungal isolates. In this study Aspergillus species (niger and fumigatus) have been the most common fungal pathogens. Various aetiopathological factors have been examined in detail, and the available literature reviewed. The results of the treatment by nine antifungal agents currently available in Bahrain have been analysed.

184

Pathogenic organisms in chronic suppurative otitis media in Enugu, Nigeria. Ibekwe AO, Okafor JI. Trop Geogr Med. 1983 Dec;35(4):389-91.

Pathogenic organisms in chronic suppurative otitis media from 62 patients were identified. Pseudomonas aeruginosa was responsible in 46%, Staphylococcus aureus in 29%. Proteus mirabilis in 13%, Streptococcus pyogenes in 6%, Aspergillus niger in 5% and Mucor sp. in 2%. The most prevalent organism in children was Staphylococcus aureus. The role of fungi in chronic suppurative otitis media is discussed.

185

Otomycosis in Nigeria: treatment with mercurochrome. Mgbor N, Gugnani HC. Mycoses. 2001 Nov;44(9-10):395-7.

Seventy-two mycologically proven cases of otomycosis (38 males, 34 females) aged 8-80 years were investigated. Aspergillus niger was the commonest aetiological agent (43.1%) followed by Candida spp. (22.2%), A. flavus (19.4%) and A. fumigatus (15.3%). Three topical drugs, namely mercurochrome, clotrimazole and locacorten-vioform, were evaluated for otomycosis therapy in separate groups of 24 patients each. Mercurochrome was found to be the most efficacious in terms of healing, relief from symptoms of the disease and production of negative fungal cultures. Mercurochrome is recommended as a safe and economical drug for the topical treatment of otomycosis in developing countries like Nigeria.

186

[Chronic necrotizing pulmonary aspergillosis caused by Aspergillus niger] Arévalo M, Solera J, Rodríguez F, Vizcaya M, Vercher R, Martínez-Moratalla J. Med Clin (Barc). 1991 Nov 9;97(16):620-2.

Chronic necrotizing pulmonary aspergillosis (CNPA), also known as semi-invasive pulmonary aspergillosis , is a recently defined entity. CNPA is characterized by a pulmonary infiltration with cavitation of chronic evolution in patients with chronic pulmonary disease, slight immunodeficiency or healthy patients. Good evolution is obtained with antimicotic treatment. The isolation of Aspergillus niger as a cause of CNPA is infrequent and may bear worse prognosis. A patient who presented CNPA by Aspergillus niger is described. The patient had received radiotherapy for epidermal carcinoma of the esophagus. Three other cases have been reported in the literature. The diagnostic aspects, treatment and prognostic factors of CNPA are commented upon.

187

A case of secondary invasive pulmonary aspergillosis originating from an aspergilloma, successfully treated with itraconazole] Nakagawa Y, Shimazu K, Ebihara M, Amann K. Nihon Kokyuki Gakkai Zasshi. 1998 Mar;36(3):294-8.

A 65-year-old man was admitted to our division with of productive cough and hemosputum. Chest radiographs and chest CT on admission showed old inflammatory shadows in both upper lung fields and a fungus ball in the left upper lung field. Despite antibiotic treatment, the patient's sputum volume increased and Aspergillus niger was repeatedly cultured from his sputum. Chest radiographs showed deterioration around the intracavitary fungus ball and a test for serum aspergillus antigen was positive. Secondary invasive pulmonary aspergillosis originating from aspergilloma was diagnosed based on his clinical symptoms, radiographic features and laboratory data. Administration of fluconazole failed to improve his clinical course and amphotericin B was discontinued because of hypokalemia. Oral administration of itraconazole was a successful treatment.

188

Chronic necrotising pneumonia caused by Aspergillus niger. Wiggins J, Clark TJ, Corrin B. Thorax. 1989 May;44(5):440-1.

A woman with asthma developed chronic necrotising semi-invasive pneumonia due to mixed Aspergillus niger and Candida albicans infection; though not severely immunosuppressed, she may have been predisposed by long term oral corticosteroid and recurrent oral antibiotic treatment. The diagnosis should be considered in patients with chronic airflow limitation who develop cavitating pneumonia.

189

Invasive Aspergillus niger with fatal pulmonary oxalosis in chronic obstructive pulmonary disease. Kimmerling EA, Fedrick JA, Tenholder MF. Chest. 1992 Mar;101(3):870-2.

The ubiquitous Aspergillus fungus has numerous manifestations when associated with lung disease (primary Aspergillus pneumonia, aspergilloma, allergic bronchopulmonary aspergillosis, and invasive Aspergillus). This fungus also can colonize preexisting lung disease in an indolent manner and then acutely assume a more invasive nature. Although the species Aspergillus niger is infrequently encountered, the endobronchial visualization of black necrotic debris or a fungus ball or the finding of black acidic sputum or pleural fluid suggests the presence of A niger and the destructive by-product of its fermentation, oxalic acid.

190

Invasive aspergillosis presenting as pericarditis and cardiac tamponade. Luce JM, Ostenson RC, Springmeyer SC, Hudson LD. Chest. 1979 Dec;76(6):703-5.

A 38-year-old leukemic patient developed pericarditis and cardiac tamponade due to Aspergillus niger one month after undergoing bone marrow transplantation. She failed to improve even though amphotericin B and rifampin therapy had been initiated before infection was evident. Her unique case illustrates both the unusual presentations of invasive aspergillosis and the difficulty of diagnosing and treating this increasingly common disease.

191

Nasosinus aspergillosis in Sudanese patients: clinical features, pathology, diagnosis, and treatment. Yagi HI, Gumaa SA, Shumo AI, Abdalla N, Gadir AA. J Otolaryngol. 1999 Apr;28(2):90-4.

OBJECTIVE: The objective of this study was a prospective analysis of the clinical features, pathology, diagnosis, and treatment of patients treated between 1993 and 1996 for nasosinus aspergillosis in the Sudan. METHOD: Clinical examinations and laboratory tests for serologic, mycologic, and histologic analysis were conducted on all patients, as were radiologic and computerized tomographic studies when external swelling of any of the paranasal sinuses was evident. RESULTS: The age group 11 to 50 years were predominantly affected, with a peak in those aged 21 to 30 years. Females were affected more often than were males. The clinical features were mainly nasal polyposis, external swelling of the ethmoid sinus medial to the inner canthus, or maxillary cheek swelling and/or proptosis. In the paranasal sinuses, the ethmoids were the most frequently affected. Intracranial extension of the disease occurred in two patients. Serologic examinations and mycological cultures showed more incidence of positive results than did histopathology. Aspergillus flavus was grown in all the positive mycologic cultures except one, where Aspergillus niger was grown. The treatment was mainly surgical, supplemented by an antifungal drug (itraconazole). The incidence of recurrence was 9.3%, and it was noticed that the recurrence occurred in those patients who were not taking their medicines regularly. CONCLUSION: Nasosinus aspergillosis is a common disease in Sudan. Nasal polyposis is the commonest mode of clinical presentation. Serology and mycologic cultures are quite helpful in the diagnosis. Surgical and medical treatment are complementary of each other.

197

Inhaled mycotoxins lead to acute renal failure. Di Paolo N, Guarnieri A, Garosi G, Sacchi G, Mangiarotti AM, Di Paolo M. Nephrol Dial Transplant. 1994;9 Suppl 4:116-20.

Mysterious deaths of archeologists after opening Egyptian tombs have been suspected, but never proved, to be secondary to inhalation of mycotoxin. We observed a case of acute renal failure (ARF) due to inhalation of ochratoxin A produced by a mould of the species Aspergillus ochraceus. After working 8 h in a granary closed for several months, a farmer and his wife suffered respiratory distress; the woman developed non-oliguric ARF and biopsy revealed tubulonecrosis. A strain of Aspergillus ochraceus producing ochratoxin was isolated from the wheat.

198

Ochratoxin A genotoxicity, relation to renal tumors] Maaroufi K, Pfohl-Leszkowicz A, Achour A, el May M, Grosse Y, Hammami M, Ellouz F, Creppy EE, Bacha H. Arch Inst Pasteur Tunis. 1994 Jan-Apr;71(1-2):21-31.

Ochratoxin A (OTA) is a mycotoxin which has been implicated in Balkan Endemic Nephropathy (BEN), a disease characterized by tubulonephritis and may be involved in the high incidence of urinary tract tumors associated to BEN. The prevalence of human ochratoxicosis is being determined in Tunisia. 100% of people suffering from chronic interstitial nephropathy of unknown etiology were ochratoxin A positive. These nephropathies are similar to Balkan Endemic Nephropathy. We prove an OTA genotoxic effects in patient suffering from this kind of nephropathy. OTA-DNA adducts formation has been detected in DNA of kidney tissues (biopsy). DNA adducts which are covalent complex between OTA and DNA base (Guanine), constitute first steps of the carcinogenesis process.

205

[Aspergillus restrictus and Candida parapsilosis--agents of endocarditis following heart valve replacement] Mencl K, Otcenásek M, Spacek J, Rehulová E. Mykosen. 1985 Mar;28(3):127-33.

206

[Mycotic ulcerative aortitis after replacement of the aortic valve caused by the fungus Aspergillus restrictus] Pospísil K, Straka V, Otcenásek M, Mencl K, Pospísil M, Spacek J, Hamet A, Pidrman V. Vnitr Lek. 1984 Mar;30(3):292-7.

207

[Mycotic ulcerative aortitis after replacement of the aortic valve caused by the fungus Aspergillus restrictus] Pospísil K, Straka V, Otcenásek M, Mencl K, Pospísil M, Spacek J, Hamet A, Pidrman V. Vnitr Lek. 1984 Mar;30(3):292-7.

208

[Pulmonary aspergillosis with generalized spreading caused by Aspergillus restrictus] MARSALEK E, ZIZKA Z, RIHA V, DUSEK J, DVORACEK C. Cas Lek Cesk 1960 Oct 7;99:1285-92.

219

Fatal disseminated infection with Aspergillus terreus in immunocompromised hosts. Tritz DM, Woods GL. Clin Infect Dis. 1993 Jan;16(1):118-22.

Aspergillus terreus is widespread in the environment but only uncommonly infects humans. It can cause cutaneous and subcutaneous infections, and several cases of local invasive disease have been reported; to our knowledge, however, only five cases of disseminated disease have been documented previously. We describe here four additional patients with disseminated disease caused by A. terreus. All four had an underlying hematologic or lymphoreticular malignancy, were immunocompromised secondary to prolonged neutropenia or immunosuppressive therapy, and had invasive pulmonary disease (a circumstance supporting a respiratory route of infection). Despite treatment with amphotericin B, all four patients died. When recovered from clinical specimens, A. terreus should not routinely be dismissed as a saprobe, particularly in immunocompromised hosts.

220

Endocarditis and aortal embolization caused by Aspergillus terreus in a patient with acute lymphoblastic leukemia in remission: diagnosis by peripheral-blood culture. Schett G, Casati B, Willinger B, Weinlander G, Binder T, Grabenwoger F, Sperr W, Geissler K, Jager U.J Clin Microbiol. 1998 Nov;36(11):3347-51.

221

Invasive pulmonary aspergillosis due to Aspergillus terreus: 12-year experience and review of the literature. Iwen PC, Rupp ME, Langnas AN, Reed EC, Hinrichs SH. Clin Infect Dis. 1998 May;26(5):1092-7.

A 12-year retrospective analysis was done to identify and evaluate in detail cases of invasive pulmonary aspergillosis (IPA) caused by Aspergillus terreus. We identified 13 A. terreus infections among 133 total cases of confirmed invasive aspergillosis; 11 were IPA and 2 were primary peritoneal infections. Of the 11 patients with IPA, 7 developed neutropenia during hospitalization, and the remaining four were receiving immunosuppressive agents. Ten patients with IPA died; one liver transplantation patient without neutropenia survived after treatment with amphotericin B, itraconazole, and a pulmonary lobectomy. Six patients developed disseminated disease, with the heart the most common extrapulmonary site identified (four patients). These cases demonstrate that IPA caused by A. terreus rapidly progresses in immunocompromised patients receiving amphotericin B and illustrate the need for sensitive diagnostic tests and more effective antifungal agents.

222

Aspergillus terreus infections in haematological malignancies: molecular epidemiology suggests association with in-hospital plants. Lass-Florl C, Rath P, Niederwieser D, Kofler G, Wurzner R, Krezy A, Dierich MP. J Hosp Infect. 2000 Sep;46(1):31-5.

During a three-year period nine patients with haematological diseases after myeloablative chemotherapy died from invasive fungal infections caused by Aspergillus terreus. The hospital inanimate environment was monitored and A. terreus was cultured from potted plants in the vicinity of the patients. The patients (N = 14) and the environmental isolates (N = 2) were fingerprinted by RAPD-PCR with four different primers. Based on RAPD patterns the patients' isolates were differentiated into five different types; the environmental isolates represented two types. The isolates of four patients were identical to those found in the environment. Five additional patients were infected by RAPD types not found in the environment. One patient was infected with two different types. The data indicate a hospital-acquired infection in many of the patients and underline the need for careful environmental monitoring of units in which high-risk patients are housed.

223

Nosocomial invasive aspergillosis in lymphoma patients treated with bone marrow or peripheral stem cell transplants. Iwen PC, Reed EC, Armitage JO, Bierman PJ, Kessinger A, Vose JM, Arneson MA, Winfield BA, Woods GL. Infect Control Hosp Epidemiol. 1993 Mar;14(3):131-9.

OBJECTIVES: To determine the prevalence of aspergillosis in lymphoma patients housed in a protective environment while undergoing a bone marrow transplant or peripheral stem cell transplant and its relation to lymphoma type, type of transplant, period of neutropenia, method of diagnosis, species of Aspergillus, and the use of empiric amphotericin B. DESIGN: Clinical, autopsy, and microbiology records were reviewed retrospectively to determine the presence or absence of invasive aspergillosis. All positive specimens underwent further review to determine parameters outlined above. SETTING: The review took place at the University of Nebraska Medical Center with lymphoma patients housed in the oncology/hematology special care unit, which consists of 30 single-patient rooms under positive pressure with high-efficiency particulate air filtration. PATIENTS: 417 lymphoma patients admitted to the oncology/hematology special care unit who underwent 427 courses of high-dose chemotherapy with or without total body irradiation followed by a stem cell rescue. RESULTS: Twenty-two cases (5.2%) of nosocomial invasive aspergillosis (14 caused by Aspergillus flavus, 2 by Aspergillus terreus, 2 by Aspergillus fumigatus, and 4 by characteristic histology) were diagnosed. The prevalence of disease according to transplant was 8.7% for allogeneic bone marrow transplant (2/23 treatments), 5.6% for autologous peripheral stem cell transplant (9/161), and 4.5% for autologous bone marrow transplant (11/243). Fifteen patients were presumptively diagnosed prior to death (68.2%) most commonly by histologic examination of skin biopsies. All 22 patients received amphotericin B therapy, 17 prior to aspergillosis diagnosis, and 7 (31.8%) survived. No patient with disseminated disease survived. CONCLUSIONS: Even when housing lymphoma patients undergoing myeloablative therapy in a protective environment containing high-efficiency particulate air filtration, there was a risk of developing aspergillosis. These data also showed that antemortem diagnosis with aggressive amphotericin B therapy was most effective in the management of infected lymphoma patients when engraftment occurred and the disease did not become disseminated.

228

Primary cutaneous Aspergillus ustus infection: second reported case.

Ricci RM, Evans JS, Meffert JJ, Kaufman L, Sadkowski LC. J Am Acad Dermatol. 1998 May;38(5 Pt 2):797-8.

We describe the second case of primary cutaneous Aspergillus ustus infection in an immunocompromised patient. Cutaneous aspergillosis was confirmed both by culture and positive fluorescent antibody staining. Few species of Aspergillus are pathogenic in human beings, and fewer still cause primary cutaneous disease. The only other reported case of aspergillosis from Aspergillus ustus occurred in an immunosuppressed patient who was temporally and geographically separated from ours.

229

Invasive aspergillosis caused by Aspergillus ustus: case report and review. Verweij PE, van den Bergh MF, Rath PM, de Pauw BE, Voss A, Meis JF. J Clin Microbiol. 1999 May;37(5):1606-9.

A case of invasive pulmonary aspergillosis in an allogeneic bone marrow transplant recipient caused by Aspergillus ustus is presented. A. ustus was also recovered from the hospital environment, which may indicate that the infection was nosocomially acquired. A literature review revealed seven cases of invasive infections caused by A. ustus, and three of these were primarily cutaneous infections. In vitro susceptibility testing of 12 A. ustus isolates showed that amphotericin B and terbinafine had fungicidal activity and that itraconazole and voriconazole had fungistatic activity.

230

Disseminated aspergillosis caused by Aspergillus ustus in a patient following allogeneic peripheral stem cell transplantation. Iwen PC, Rupp ME, Bishop MR, Rinaldi MG, Sutton DA, Tarantolo S, Hinrichs SH. J Clin Microbiol. 1998 Dec;36(12):3713-7.

The first case of disseminated aspergillosis caused by Aspergillus ustus in an allogeneic peripheral stem cell transplant patient is described. The patient, a 46-year-old female with a history of myelodysplastic syndrome, underwent high-dose chemotherapy and total body irradiation prior to transplantation. She was released from the hospital 49 days posttransplant (p.t.) in a stable condition with an absolute neutrophil count (ANC) of 2,700 cells per &mgr;l. Multiple antimicrobial agents, including itraconazole (ITR), were prescribed during hospitalization and at the time of discharge. Three days after discharge, the patient was readmitted with hemorrhagic cystitis, persistent thrombocytopenia, and bilateral pulmonary consolidation, although no fever was present. The ANC at the time of readmission was 3,500. Upon detection of a pulmonary nodule (day 67 p.t.), a bronchoalveolar lavage was performed; the lavage fluid was positive for both cytomegalovirus and parainfluenza virus and negative for fungus. The patient was placed on ganciclovir. A biopsy specimen from a leg lesion also noted on day 67 p.t. revealed septate hyphae consistent with Aspergillus species, and a culture subsequently yielded Aspergillus ustus. Confirmation detection of A. ustus was made by demonstration of characteristic reproductive structures with the presence of Hülle cells. On day 67 p.t., ITR was discontinued and liposomal amphotericin B (AMB) was initiated. The patient's condition worsened, and she died 79 days p.t. At the time of autopsy, septate hyphae were present in heart, thyroid, and lung tissues, with lung tissue culture positive for A. ustus. In vitro susceptibility testing indicated probable resistance to AMB but not to ITR. This case supports the need for the development of rapid methods to determine antifungal susceptibility.

241

Onychomycosis, tinea pedis and tinea manuum caused by non-dermatophytic filamentous fungi. Summerbell RC, Kane J, Krajden S. Mycoses. 1989 Dec;32(12):609-19.

Over 4000 cases of fungal nail, sole and palm infection recorded during a three-year study period were investigated to determine the prevalence and significance of etiologic agents other than dermatophytes and yeasts. Littman's oxgall agar, which permitted isolation of cycloheximide-sensitive species but restricted overgrowth by fast growing contaminants, was used to promote isolation of these disease agents. Non-dermatophytic filamentous fungi made up 2.3% of the confirmed etiologic agents obtained overall, and constituted 3.3% of the agents obtained from nail infections. The most common species were Scopulariopsis brevicaulis, Hendersonula toruloidea, and Aspergillus sydowii. Scytalidium hyalinum was recorded for the first time from Canada, and an instance of nail infection by Gymnascella dankaliensis was recorded. Only H. toruloidea and Sc. hyalinum caused palm and sole infections.

248

Aspergillus versicolor as cause of onychomycosis: report of 12 cases and susceptibility testing to antifungal drugs. Torres-Rodriguez JM, Madrenys-Brunet N, Siddat M, Lopez-Jodra O, Jimenez T. J Eur Acad Dermatol Venereol. 1998 Jul;11(1):25-31.

BACKGROUND: Onychomycoses caused by opportunistic moulds are not well understood, and many are due to Scopulariopsis brevicaulis and other species. Aspergillus versicolor is not documented as an etiological agent in most studies. We have found an increasing prevalence of this species which is involved in 5.8% of all fungal infections of toe nails. OBJECTIVE: To study the clinical and mycological characteristics of the onychomycosis caused by A. versicolor and the in vitro susceptibility of this mould to antifungal agents. RESULTS: Onychomycosis due to A. versicolor is mainly seen in people over 60 and presents with chronic involvement of the big toe nails. Predisposing factors are not always present and the infection does not respond to conventional topical antifungals. In vitro, A. versicolor has been shown to be resistant to griseofulvin and fluconazole as well as to amphotericin B, whereas MICs for itraconazole and ketoconazole are variable but within a range of 0.50-4.0 microg/ml; on the contrary, MICs for terbinafine are very low (<0.125 microg/ml). DISCUSSION: Aspergillus versicolor could be considered as an emergent pathogen causing toenail onychomycosis. Local treatment seems not to be effective. Of the various systemic antifungal agents studied terbinafine appears to be the most effective in treating onychomycosis.

249

Osteomyelitis of sacral spine caused by aspergillus versicolor with neurologic deficits. Liu Z, Hou T, Shen Q, Liao W, Xu H. Chin Med J (Engl). 1995 Jun;108(6):472-5.

250

Cerebral aspergillosis: report of two cases. Venugopal PV, Venugopal TV, Thiruneelakantan K, Subramanian S, Shetty BM. Sabouraudia. 1977 Nov;15(3):225-30.

Two cases of cerebral aspergillosis in Tamilians presenting as intracranial space-occupying lesions are reported. The first patient had a left frontal lobe abscess and a specific diagnosis was made by histopathology and isolation of Aspergillus versicolor. He responded well to excision followed by anticonvulsant therapy. In the other, the diagnosis was based on histopathology alone and she died after surgery. These are the first cases reported from Tamil Nadu and probably only one similar case has been reported from India so far.

259

Opportunistic infection of the spleen caused by Aureobasidium pullulans. Salkin IF, Martinez JA, Kemna ME. J Clin Microbiol. 1986 May;23(5):828-31.

The mold Aureobasidium pullulans was isolated on several nutrient media from a splenic abscess in a patient with disseminated lymphoma. Examination of stained smears and paraffin sections revealed fungal structures characteristic of this organism. This is the first reported association of A. pullulans with an opportunistic visceral infection.

260

Aureobasidium mansoni meningitis in a leukemia patient successfully treated with amphotericin B. Krcméry V Jr, Spánik S, Danisovicová A, Jesenská Z, Blahová M. Chemotherapy. 1994 Jan-Feb;40(1):70-1.

Aureobasidium mansoni fungal meningitis in a 30-year-old leukemic patient is reported. This is the first reported case of Aureobasidium spp. central nervous system infection. The patient was successfully treated with systemic antifungal chemotherapy with a total dose of 2.2 g of amphotericin B.

261

Prospective study of nosocomial fungal meningitis in children--report of 10 cases. Huttova M, Kralinsky K, Horn J, Marinova I, Iligova K, Fric J, Spanik S, Filka J, Uher J, Kurak J, Krcmery V Jr. Scand J Infect Dis. 1998;30(5):485-7.

Within an 8-year period, 10 cases of fungal nosocomial meningitis in children 0-13 y old were prospectively identified, 3 caused by yeasts other than Candida spp. (Rhodotorula rubra, Aureobasidium mansoni, Clavispora lusitaniae) and 7 by Candida albicans. Seven patients survived. whereas 3 neonates with fungal meningitis (all due to C. albicans) died. Risk factors for fungal nosocomial meningitis included cancer (2 children), previous neurosurgery (2 children), cranial trauma (1 case) and prematurity with low birthweight (5 cases). All patients except 1 had received broad-spectrum antibiotics before onset of meningitis. In addition to yeasts, bacteria were isolated from CSF of 4 children. One child had additional fungaemia. Univariate analysis was used to compare 10 cases of fungal to 91 cases of bacterial nosocomial meningitis. Except for concurrent bacteraemia, (60 vs 25.3%, P < 0.03), which was more frequently observed among fungal meningitis, there were no significant differences in risk factors, sequelae or outcome (mortality) between patients with fungal vs bacterial meningitis. A review of fungal meningitis reported within the last 20 y is included.

262

Systemic phaeohyphomycosis in pregnancy and the puerperium. Fletcher H, Williams NP, Nicholson A, Rainford L, Phillip H, East-Innis A. West Indian Med J. 2000 Mar;49(1):79-82.

Systemic fungal infections are rare. In pregnancy, treatment is problematic because of the risk of possible teratogenic effects of the antifungal drugs. We present the case of a 32 year-old woman who presented during pregnancy with a two-month history of painless subcutaneous nodules. Excision biopsy of one lesion showed dematiaceous fungal elements. Anti-fungal treatment was deferred and the pregnancy proceeded uneventfully. The remaining nodules were excised at the time of caesarean section delivery. Three weeks into the puerperium, she developed generalised seizures and investigations indicated systemic fungal infection with positive cultures for Aureobasidium spp which responded to appropriate antifungal therapy of flucytosine and itraconazole.

263

Systemic infection with Aureobasidium pullulans in a leukaemic patient. Kaczmarski EB, Liu Yin JA, Tooth JA, Love EM, Delamore IW. J Infect. 1986 Nov;13(3):289-91.

Aureobasidium pullulans, a conidial fungus widely distributed in the environment, was repeatedly isolated from the blood of a 28-year-old man with acute myeloid leukaemia. Amphotericin B failed to eliminate the organism.

264

Aureobasidium pullulans scleritis following keratoplasty: a case report. Gupta V, Chawla R, Sen S. Ophthalmic Surg Lasers. 2001 Nov-Dec;32(6):481-2.

Fungal scleritis is a rare entity. A 50-year-old patient with culture proven Aureobasidium pullulans corneal ulcer underwent therapeutic keratoplasty. He developed scleritis 5 days following surgery. Although the patient had symptomatic improvement after antifungal therapy, surgical debridement, and cryotherapy, visual improvement was only marginal. Aureobasidium pullulans should be looked for as a cause for keratomycosis and scleromycosis, especially in tropical countries.

265

Peritonitis by Aureobasidium pullulans in continuous ambulatory peritoneal dialysis. Ibañez Perez R, Chacón J, Fidalgo A, Martin J, Paraiso V, Muñoz-Bellido JL. Nephrol Dial Transplant. 1997 Jul;12(7):1544-5.

266

 Peritoneal catheter colonization and peritonitis with Aureobasidium pullulans. Caporale NE, Calegari L, Perez D, Gezuele E. Perit Dial Int. 1996 Jan-Feb;16(1):97-8

267

Aureobasidium pneumonia in a post liver transplant recipient: a case report. Tan HP, Wahlstrom HE, Zamora JU, Hassanein T. Hepatogastroenterology. 1997 Jul-Aug;44(16):1215-8.

Transplantation Institute Loma Linda University Medical Center California 92354, USA.
This is the first report of Aureobasidium (A.) pullulans as an opportunistic pulmonary infection in a liver transplant recipient. A 46-year-old caucasian man had an orthotopic liver transplant in 1988. His liver disease was primary sclerosing cholangitis. He required 2 subsequent liver re-transplants for primary graft non-function and acute rejection. The patient had been living in the California desert for two months prior to admission and presented with ventilator-dependent acute respiratory failure and hemodialysis-dependent acute renal failure. Imaging studies revealed severe bilateral infiltrates. His initial bronchoalveolar lavage (BAL) and brushings grew A. pullulans. Pancultures, including sputum and throat cultures, were negative for bacterial or other fungal organisms. The patient responded to pulmonary support and aggressive systemic antifungal agents while being maintained on cyclosporine and prednisone for immunosuppression. He was discharged to a skilled nursing facility 37 days after hospitalisation. Delay in discharge was primarily due to severe malnutrition and renal impairment. Opportunistic fungal infections continue to be a major problem in immunosuppressed patients including liver transplant recipients. Here we report a pulmonary infection with Coccidioides (C.) immitis and superinfection with A. pullulans. Opportunistic infections such as A. pullulans can be treated successfully with systemic fluconazole when amphotericin B is not well tolerated.

268

Basidiobolus ranarum as an etiologic agent of gastrointestinal zygomycosis. Khan ZU, Khoursheed M, Makar R, Al-Waheeb S, Al-Bader I, Al-Muzaini A, Chandy R, Mustafa AS. J Clin Microbiol. 2001 Jun;39(6):2360-3.

Basidiobolus ranarum is a known cause of subcutaneous zygomycosis. Recently, its etiologic role in gastrointestinal infections has been increasingly recognized. While the clinical presentation of the subcutaneous disease is quite characteristic and the disease is easy to diagnose, gastrointestinal basidiobolomycosis poses diagnostic difficulties; its clinical presentation is nonspecific, there are no identifiable risk factors, and all age groups are susceptible. The case of gastrointestinal basidiobolomycosis described in the present report occurred in a 41-year-old Indian male who had a history of repair of a left inguinal hernia 2 years earlier and who is native to the southern part of India, where the subcutaneous form of the disease is indigenous. Diagnosis is based on the isolation of B. ranarum from cultures of urine and demonstration of broad, sparsely septate hyphal elements in histopathologic sections of the colon, with characteristic eosinophilic infiltration and the Splendore-Hoeppli phenomenon. The titers of both immunoglobulin G (IgG) and IgM antibodies to locally produced antigen of the fungus were elevated. The patient failed to respond to 8 weeks of amphotericin B therapy, and the isolate was later found to be resistant to amphotericin B, itraconazole, fluconazole, and flucytosine but susceptible to ketoconazole and miconazole. One other noteworthy feature of the fungus was that the patient's serum showed raised levels of Th2-type cytokines (interleukins 4 and 10) and tumor necrosis factor alpha. The present report underscores the need to consider gastrointestinal basidiobolomycosis in the differential diagnosis of inflammatory bowel diseases and suggests that, perhaps, more time should be invested in developing standardized serologic reagents that can be used as part of a less invasive means of diagnosis of the disease.

269

Gastrointestinal basidiobolomycosis in Arizona: clinical and epidemiological characteristics and review of the literature. Lyon GM, Smilack JD, Komatsu KK, Pasha TM, Leighton JA, Guarner J, Colby TV, Lindsley MD, Phelan M, Warnock DW, Hajjeh RA. Clin Infect Dis. 2001 May 15;32(10):1448-55.

Gastrointestinal basidiobolomycosis (GIB) is an unusual fungal infection that is rarely reported in the medical literature. From April 1994 through May 1999, 7 cases of GIB occurred in Arizona, 4 from December 1998 through May 1999. We reviewed the clinical characteristics of the patients and conducted a case-control study to generate hypotheses about potential risk factors. All patients had histopathologic signs characteristic of basidiobolomycosis. Five patients were male (median age, 52 years; range, 37--59 years) and had a history of diabetes mellitus (in 3 patients), peptic ulcer disease (in 2), or pica (in 1). All patients underwent partial or complete surgical resection of the infected portions of their gastrointestinal tracts, and all received itraconazole postoperatively for a median of 10 months (range, 3--19 months). Potential risk factors included prior ranitidine use and longer residence in Arizona. GIB is a newly emerging infection that causes substantial morbidity and diagnostic confusion. Further studies are needed to better define its risk factors and treatment.

270

Gastrointestinal zygomycotic infection caused by Basidiobolus ranarum: case report and review. Zavasky DM, Samowitz W, Loftus T, Segal H, Carroll K. Clin Infect Dis. 1999 Jun;28(6):1244-8.

Basidiobolus species are filamentous fungi belonging to the order Entomophthorales. Unlike other zygomycetes, Basidiobolus species have been mainly associated with a tropical form of subcutaneous zygomycosis in otherwise healthy individuals. Visceral disease caused by this pathogen is rare, but cases of gastrointestinal infection with Basidiobolus ranarum have been reported worldwide. In many of these reports, the inflammatory disease of the colon has been confused with Crohn's disease. We report the third case of B. ranarum gastrointestinal infection in the United States, which was initially treated as inflammatory bowel disease.

271

Entomophthoromycosis due to Basidiobolus haptosporus. Sood S, Sethi S, Banerjee U. Mycoses. 1997 Dec;40(9-10):345-6.

This paper reports a case of entomophthoromycosis in a 40-year-old man who presented with an ulcerative wound and serosanguineous discharge after surgical removal of a fibrocystic mass. The serosanguineous discharge yielded Basidiobolus haptosporus, perhaps the first culture-proven case from a surgical wound.

272

First human culture-proven Australian case of entomophthoromycosis caused by Basidiobolus ranarum. Davis SR, Ellis DH, Goldwater P, Dimitriou S, Byard R. J Med Vet Mycol. 1994;32(3):225-30.

The first human case of entomophthoromycosis caused by Basidiobolus ranarum in Australia is described. Upon first presentation this rare disease was not recognized, but microscopy of biopsy sections and identification of the fungal isolate allowed this condition to be identified. Treatment with fluconazole was successful.

273

A review of zygomycosis due to Basidiobolus ranarum. Gugnani HC. Eur J Epidemiol. 1999 Nov;15(10):923-9.

Zygomycosis due to Basidiobolus ranarum (entomophthoromycosis basidiobolae, subcutaneous zygomycosis, subcutaneous phycomycosis, basidiobolomycosis) is a granulomatous infection of the skin and subcutaneous tissues characterized by the formation of fluctuant firm and non-tender swellings, generally on the extremities, trunk and rarely other parts of the body. The causative agent is common in soil, decaying vegetable matter, and the gastrointestinal tracts of amphibians, reptiles, fish and bats. It is presumed that infection is acquired through exposure to B. ranarum following minor trauma to skin or insect bites. The disease usually occurs in children, less often in adolescents and rarely in adults. Males are much more frequently affected than females. Laboratory diagnosis is based on histopathology and culture. The typical histopathological feature is the presence of thin-walled, broad often aseptate hyphae or hyphal fragments with an eosinophilic sheath, frequently phagocytized within giant cells. Basidiobolus ranarum is known to produce several enzymes, e.g. lipase and protease that probably play roles in the pathogenesis of infections caused by this mould. An immunological test has been developed for specific diagnosis of the disease. Though potassium iodide (KI) has been the traditional drug employed in the treatment of infections by B. ranarum, several other drugs, viz amphotericin B, cotrimoxazole, ketoconazole, itraconazole and fluconazole have been successfully tried.

277

Mycotic keratitis due to Beauveria alba. McDonnell PJ, Werblin TP, Sigler L, Green WR. Cornea. 1984-85;3(3):213-6.

A 70-year-old white man developed mycotic keratitis following phacoemulsification and intraocular lens implantation. Extensive therapeutic surgery was necessary to control the infection. Beauveria alba, a saprophytic fungus, was cultured and demonstrated in the corneal button by histopathologic examination.

278

Medical management of Beauveria bassiana keratitis. Kisla TA, Cu-Unjieng A, Sigler L, Sugar J. Cornea. 2000 May;19(3):405-6.

PURPOSE: To describe a case of Beauveria bassiana keratitis and to discuss the management of this rare condition. METHODS: An 82-year-old woman underwent surgical repair of a graft wound dehiscence. Seven months later, shortly after the removal of sutures, the patient developed a fungal keratitis. B. bassiana was identified as the infecting organism. The patient was treated with topical natamycin and oral fluconazole. RESULTS: Following antifungal therapy, the corneal ulcer was eradicated, but the patient underwent repeat penetrating keratoplasty for decreased vision due to corneal edema. The graft remains clear and visual acuity is substantially improved. CONCLUSION: The medical management of B. bassiana keratitis has previously been unsuccessful. The use of topical natamycin combined with oral fluconazole in the management of this case is discussed.

279

Human deep tissue infection with an entomopathogenic Beauveria species. Henke MO, De Hoog GS, Gross U, Zimmermann G, Kraemer D, Weig M. J Clin Microbiol. 2002 Jul;40(7):2698-702.

Beauveria spp. are ubiquitous fungal entomopathogens that are commercially distributed as biological insecticides worldwide. In this paper we describe the clinical manifestation, diagnosis, and therapy of the first documented human deep tissue infection with an entomopathogenic Beauveria species in a patient receiving immunosuppressive therapy and describe the morphological and molecular characterization of the mold.

290

Phaeohyphomycosis caused by the fungal genera Bipolaris and Exserohilum. A report of 9 cases and review of the literature. Adam RD, Paquin ML, Petersen EA, Saubolle MA, Rinaldi MG, Corcoran JG, Galgiani JN, Sobonya RE. Medicine (Baltimore). 1986 Jul;65(4):203-17.

We have reported 7 new cases of Bipolaris infection and 2 of Exserohilum infection, which demonstrate the capability of these 2 genera to cause invasive as well as "allergic" disease. As noted previously, it is likely that all of the cases of "Helminthosporium" and Drechslera infections reported in the literature were caused by Bipolaris or Exserohilum. Infections due to these 2 genera are probably more common than previously recognized. They should be included in the differential diagnosis of central nervous system and disseminated fungal disease, sinusitis, keratitis, peritonitis associated with continuous ambulatory peritoneal dialysis, and allergic bronchopulmonary disease. These various entities have distinct histopathologic characteristics. With disseminated disease in the immunocompromised patient, the most frequent findings are acute inflammation with prominent vascular invasion, thrombosis, and infarction. In contrast, granulomatous inflammation and leukocytoclastic vasculitis are seen in meningoencephalitis caused by these fungi. The histologic features of allergic bronchopulmonary disease and sinusitis are similar. A chronic inflammatory infiltrate of lymphocytes, plasma cells and eosinophils within edematous granulation tissue is found in addition to squamous metaplasia and thickening of the basement membrane. Infections caused by Bipolaris/Exserohilum and Aspergillus show many clinical and pathologic similarities despite the lack of taxonomic relationship between these fungi. Both cause disseminated disease in immunocompromised patients that is characterized by tissue necrosis and vascular invasion. Both cause central nervous system disease, osteomyelitis, and sinusitis and are associated with allergic bronchopulmonary disease. Sinusitis, the most common form of disease caused by Bipolaris and Exserohilum, occurs in otherwise healthy patients with nasal polyposis and allergic rhinitis. Although pathologic evidence of bone invasion may not be found, there frequently is radiographic evidence of invasive disease. Most patients who are treated initially with surgical debridement and amphotericin B have apparently been cured. However, longer follow-up will be necessary in these patients. Amphotericin B appears to be the treatment of choice for invasive infections caused by Bipolaris/Exserohilum species. Ketoconazole and other imidazole derivatives may also be effective in certain of the disease entities caused by these black moulds; however, their role has yet to be defined.(ABSTRACT TRUNCATED AT 400 WORDS)

291

Phaeohyphomycosis of the nasal sinuses caused by Bipolaris species. Rao A, Forgan-Smith R, Miller S, Haswell H. Pathology. 1989 Oct;21(4):280-1.

Phaeohyphomycosis of the nasal sinuses of three patients is reported. Diagnosis is based on the laboratory findings of the biopsy tissue from the sinus lesions. All cases demonstrate a localized opportunistic infection caused by the dematiaceous fungus Bipolaris spicifera.

292

Nasal phaeohyphomycosis caused by Bipolaris hawaiiensis. Koshi G, Anandi V, Kurien M, Kirubakaran MG, Padhye AA, Ajello L. J Med Vet Mycol. 1987 Dec;25(6):397-402.

A bilateral nasal phaeohyphomycotic infection caused by Bipolaris hawaiiensis in an immunocompromised woman from India is described. Repeated direct microscopic examinations of the nasal scrapings revealed the presence of septate, branched, pigmented hyphal fragments intermingled with cells that divided internally by one transverse septum and a few cells that were chestnut brown dividing internally by septa in different planes to become muriform. Cultures of the scrapings yielded B. hawaiiensis. Local excision of the crusted lesion followed by application of 0.03% nystatin solution four times a day for 3 weeks cured the infection.

293

Cutaneous Bipolaris spicifera infection. Straka BF, Cooper PH, Body BA. Arch Dermatol. 1989 Oct;125(10):1383-6.

Bipolaris spicifera is a dematiaceous fungus that has rarely been reported to cause cutaneous infection in humans. A patient with leukemia was examined for a non-healing ulcer on her leg that developed following minor trauma. Histopathologic study revealed groups of nonpigmented, septate fungal hyphae located predominantly in the necrotic ulcer base. Cultures of a biopsy specimen yielded colonies that were gray to black with a black reverse. Microscopic examination revealed dematiaceous, straight, oblong conidia consistent with B spicifera. The ulcer was successfully treated with surgical excision, skin graft, and amphotericin B.

294

Subcutaneous phaeohyphomycosis caused by Exserohilum rostratum in an immunocompetent host. Burges GE, Walls CT, Maize JC. Arch Dermatol. 1987 Oct;123(10):1346-50.

A healthy, 55-year-old woman developed a subcutaneous abscess and systemic symptoms of nausea, dizziness, and chills following minor trauma to her leg. Histopathologic examination of a skin biopsy specimen revealed golden-brown colored mycelial elements, and culture resulted in growth of a dematiaceous fungus identified as Exserohilum rostratum. Surgical excision of the abscess and concomitant oral therapy with ketoconazole resulted in resolution of symptoms. In previously reported cases of human phaeohyphomycosis caused by Exserohilum and related Bipolaris species in both immunocompromised and immunocompetent hosts, treatment has varied from topical antimicrobial therapy to combined surgery and intravenous antifungal chemotherapy. Our experience leads us to believe that surgical débridement of an accessible focus of infection along with orally administered ketoconazole may provide adequate therapy in an immunocompetent host.

295

Fatal fungal endarteritis caused by Bipolaris spicifera following replacement of the aortic valve. Ogden PE, Hurley DL, Cain PT. Clin Infect Dis. 1992 Feb;14(2):596-8.

A 73-year-old man presented to our hospital 5 months after a porcine replacement of an aortic valve with persistent fevers, meningoencephalopathy, and progressive renal failure; evidence of systemic emboli was found subsequently. The results of an exhaustive evaluation were negative except for two of 23 blood cultures that were performed; each of these two cultures yielded one colony of Drechslera species (now known as Bipolaris) on one plate. Autopsy revealed a fungal vegetation (9.5 x 3.2 x 3.0 cm) in the ascending aorta that arose from suture material 1.0 cm distal to the aortic valve. Mycologic evaluation of the isolate revealed that it was Bipolaris spicifera.

296

Peritoneal dialysis complicated by Bipolaris hawaiiensis peritonitis: successful therapy with catheter removal and oral itraconazol without the use of amphotericin-B. Gadallah MF, White R, el-Shahawy MA, Abreo F, Oberle A, Work J. Am J Nephrol. 1995;15(4):348-52.

Fungi classified in the genera Bipolaris are an uncommon source of infection in human diseases. It is also a rare source of peritonitis in peritoneal dialysis (PD) patients. All cases of Bipolaris peritonitis reported in the United States have occurred in the southern states. This form of peritonitis appears to have a good prognosis, with cure achieved only after removal of the peritoneal dialysis catheter and antifungal therapy. Systemic or intraperitoneal amphotericin-B with or without oral ketoconazole has been used in all previously reported cases. However, the role of antifungal therapy is unclear. We report a case of Bipolaris hawaiiensis peritonitis in a 73-year-old female on continuous cyclic peritoneal dialysis (CCPD) for 10 months who presented with a nonfunctioning peritoneal catheter. The catheter had characteristic dark gray particles, each composing a fungal ball within the lumen of the catheter. Microscopic examination confirmed the organism attached to the inner wall of the catheter. The patient achieved cure without using either amphotericin-B or ketoconazole. She was treated with removal of the catheter and a 2-week course of oral itraconazole 100 mg twice daily. A new catheter was placed after 1 month and the patient continued to do well on CCPD 12 months later with no evidence of recurrent infection. We conclude that (1) itraconazole can effect cure following removal of the catheter without using amphotericin-B or ketoconazole; (2) peritoneal dialysis can be safely reinstituted after itraconazole therapy for this uncommon fungal infection, and (3) itraconazole therapy allows for out-patient treatment of B. hawaiiensis peritonitis in peritoneal dialysis patients.

297

Fungal pneumonias. Saubolle MA. Semin Respir Infect. 2000 Jun;15(2):162-77.

Hundreds of fungal species have been associated with pulmonary diseases in humans, but few are consistently found to cause pneumonia. This paper reviews the clinical presentations, geographic prevalence, and epidemiology of, as well as the most recent, yet readily available, diagnostic methods and general therapy for the more common fungal pneumonias. The chapter is divided into categories based on the fungi's physiological and growth characteristics, clinical presentations, and prevalence in the environment. Sections include the geographically restricted dimorphic fungi (e.g., Blastomyces, Coccidioides, Histoplasma, Paracoccidioides, Sporotrichum, and Penicillium mameffei), the more globally found yeasts (e.g., Cryptococcus neoformans and Candida), other hyaline moulds (e.g., Aspergillus, Zygomyces, Fusarium, and Trichosporon), as well as the dematiaceous fungi (e.g., Altenaria, Bipolaris, Curvularia, Pseudallescheria, and Xylohypha). Pneumocystis carinii is also discussed since it is now accepted as being more closely related to the fungi based on analysis of its 16S-like RNA sequences.

298

Bipolaris spicifera meningitis complicating a neurosurgerical procedure. Latham RH. Scand J Infect Dis. 2000;32(1):102-3.

Bipolaris spicifera, one of the darkly pigmented (dematiaceous) fungi commonly found in soil, is an uncommon cause of infection in humans and an unusual cause of meningitis and nosocomial infections. An 18-y-old boy who experienced meningitis with this microorganism after acoustic neuroma resection was successfully treated with amphotericin B.

299

Granulomatous encephalitis caused by Bipolaris hawaiiensis. Morton SJ, Midthun K, Merz WG. Arch Pathol Lab Med. 1986 Dec;110(12):1183-5.

We describe a case of granulomatous encephalitis caused by Bipolaris (Drechslera) hawaiiensis in an immunocompetent patient. An 18-year-old man with a seven-month history of seizures and right leg weakness was found by computed tomographic scan to have a left frontoparietal enhancing lesion. Biopsy of the lesion revealed granulomatous inflammation and numerous septate hyphae. Culture of the biopsy specimen yielded a pure culture of B hawaiiensis in four days. Susceptibility studies revealed the organism to be sensitive to amphotericin B (minimal inhibitory concentration [MIC] equals 0.25 mg/L) and miconazole lactate (MIC equals 0.064 mg/L), but resistant to flucytosine (MIC greater than 100 mg/L). No synergy was demonstrated with amphotericin B and flucytosine in vitro. The patient was successfully treated with surgery and systemic and intrathecal amphotericin B therapy, and a negative culture was obtained from a repeated brain biopsy six weeks later.

300

Orbital involvement in allergic fungal sinusitis. Klapper SR, Lee AG, Patrinely JR, Stewart M, Alford EL. Ophthalmology. 1997 Dec;104(12):2094-100.

BACKGROUND: Although allergic fungal sinusitis is a relatively common, noninvasive form of paranasal sinus mycosis, and despite frequent orbital involvement, there have been few reports of this condition in the ophthalmic literature. METHODS: Two cases of allergic fungal sinusitis having orbital symptoms are described. The current classification, typical presentation, and ideal management of fungal sinusitis are reviewed. RESULTS: Distinguishing radiologic and pathologic features were present in both patients. Aspergillus flavus was cultured in one case, and Bipolaris spicifera was cultured in the other. CONCLUSIONS: Allergic fungal sinusitis is a unique subset of sino-orbital disease with highly characteristic clinical, radiologic, and pathologic features. Unlike invasive forms of mycotic disease, allergic fungal sinusitis may be managed adequately with surgical debridement, aeration of the involved sinuses, and systemic and topical corticosteroids.

301

Endogenous endophthalmitis caused by Bipolaris hawaiiensis in a patient with acquired immunodeficiency syndrome. Pavan PR, Margo CE. Am J Ophthalmol. 1993 Nov 15;116(5):644-5.

302

Bipolaris-induced orbital cellulitis. Jacobson M, Galetta SL, Atlas SW, Curtis MT, Wulc AW. J Clin Neuroophthalmol. 1992 Dec;12(4):250-6.

We report a patient who rapidly developed unilateral proptosis and complete ophthalmoplegia following blunt trauma to the orbit. Computed tomography (CT) scan revealed a mass involving the sinuses and orbit with erosion of the cribriform plate. Biopsy of this suspected neoplasm revealed features consistent with allergic Aspergillus sinusitis, but cultures later grew a Bipolaris species. Our review of the literature suggests that when allergic fungal sinusitis involves the orbit, Bipolaris is a more commonly isolated organism than Aspergillus. Additionally, extraocular motility impairment and proptosis occur more frequently than visual loss. Treatment is controversial, but surgical drainage followed by corticosteroids is the most often recommended therapy.

303

Bipolaris hawaiiensis-caused phaeohyphomycotic orbitopathy. A devastating fungal sinusitis in an apparently immunocompetent host. Maskin SL, Fetchick RJ, Leone CR Jr, Sharkey PK, Rinaldi MG. Ophthalmology. 1989 Feb;96(2):175-9.

The authors present a case report of a devastating bilateral optic neuropathy and orbitopathy initiated by a contiguous fungal sinusitis, in an apparently immunocompetent young man. The causative organism, Bipolaris hawaiiensis, and other species classified in the genus Bipolaris, are being recognized with increased frequency as causes of several ophthalmic and systemic disorders in both immunocompromised and normal hosts. A literature review demonstrates the variety of clinical presentations with emphasis on those cases which may present to the ophthalmologist.

304

Ocular involvement in mycotic sinusitis caused by Bipolaris. Jay WM, Bradsher RW, LeMay B, Snyderman N, Angtuaco EJ. Am J Ophthalmol. 1988 Apr 15;105(4):366-70.

We examined two patients with unilateral ophthalmologic findings secondary to pansinusitis caused by Bipolaris. Both patients were healthy young men. One patient had a gradual visual loss, whereas the other showed proptosis. Surgical debridement was the primary treatment in both patients. One patient received antifungal therapy, whereas the other was cured with surgery alone.

305

Corneal ulcer caused by Bipolaris hawaiiensis. Anandi V, Suryawanshi NB, Koshi G, Padhye AA, Ajello L. J Med Vet Mycol. 1988;26(5):301-6.

Following an injury to the right eye, a corneal ulcer with hypopyon developed in a leprosy patient. Direct examination of the corneal scrapings on three occasions showed septate, branched, dematiaceous hyphal elements. When scrapings were cultured on Sabouraud's glucose and brain heart infusion agars. Bipolaris hawaiiensis was isolated repeatedly. The patient responded successfully to treatment with nystatin ointment, although the central opacity of the cornea remained and visual acuity did not improve.

306

Disseminated Bipolaris spicifera in a neonate. Moore ML, Collins GR, Hawk BJ, Russell TS. J Perinatol. 2001 Sep;21(6):399-401.

We report a premature infant with disseminated fungal infection identified as Bipolaris spicifera. The infant was born at 23 4/7 weeks' gestation, weighing 780 g. At day of life (DOL) 7 erythematous areas on the back were noticed that progressed to black, necrotic skin lesions. A shave biopsy showed invasive fungal organisms that were identified by culture as B. spicifera. The lesions progressed despite aggressive surgical debridement and antifungal therapy. On autopsy, fungal organisms found throughout the internal organs confirmed disseminated disease with B. spicifera. This organism is now more often recognized as a human pathogen; however, this is the first reported case in a neonate.

307

Disseminated bipolaris infection in an immunocompetent host: an atypical presentation. Khan JA, Hussain ST, Hasan S, McEvoy P, Sarwari A. J Pak Med Assoc. 2000 Feb;50(2):68-71.

308

Disseminated infection due to Bipolaris australiensis in a young immunocompetent man: case report and review. Flanagan KL, Bryceson AD. Clin Infect Dis. 1997 Aug;25(2):311-3.

We report a case of disseminated infection due to Bipolaris australiensis in a 21-year-old immunocompetent Pakistani man. He presented with fever and jaundice. Examination revealed a mass in the right lung, mediastinal lymphadenopathy, a pericardial effusion, and abdominal masses obstructing and invading the common bile duct and right ureter. Histological examination and culture of a biopsy specimen of the hilar mass yielded the fungal pathogen B. australiensis. The patient was treated successfully with amphotericin B and itraconazole.

309

Fungemia in children infected with the human immunodeficiency virus: new epidemiologic patterns, emerging pathogens, and improved outcome with antifungal therapy. Walsh TJ, Gonzalez C, Roilides E, Mueller BU, Ali N, Lewis LL, Whitcomb TO, Marshall DJ, Pizzo PA. Clin Infect Dis. 1995 Apr;20(4):900-6.

We characterized 27 episodes of fungemia in 22 children infected with the human immunodeficiency virus (HIV). Fungemia in these patients presented as a community-acquired infection in the setting of outpatient total parenteral nutrition or intravenous antibiotic therapy through a chronically indwelling central venous catheter (CVC). Fungemia developed only in patients with CVCs (P < .001). Non-albicans Candida species, Torulopsis glabrata, Rhodotorula rubra, and Bipolaris spicifera constituted 52% of all causes. Fungemia was detected early, within a median of 2.4 days after the onset of new fever, which permitted prompt administration of amphotericin B (mean dosage, 0.7 mg/[kg.day]; median duration, 19 days). CVCs were removed in 23 (85%) of the episodes. We conclude that fungemia in HIV-infected children often presents as a community-acquired infection, is frequently due to newly emerging opportunistic fungi, and can be managed, with a high level of success (95% survival with no posttherapeutic sequelae), by early diagnosis, prompt initiation of amphotericin B therapy, and removal of the CVC.

310

Disseminated bipolaris infection in an asthmatic patient: case report. Karim M, Sheikh H, Alam M, Sheikh Y. Clin Infect Dis. 1993 Aug;17(2):248-53.

We present the case of a patient with a history of asthma who developed cough and hemoptysis that were unresponsive to antituberculous therapy. Chest roentgenography demonstrated right-sided collapse with consolidation and a pleural effusion. Bronchial biopsy revealed fungal hyphae, and cultures later yielded Bipolaris spicifera. In addition, weight loss and intractable hypotension in association with hyponatremia and elevated potassium levels suggested addisonian crisis, which was confirmed by measurement of serum ACTH and cortisol levels. Computed tomography of the abdomen revealed bilateral adrenal involvement. Tissue obtained on biopsy of the adrenal glands yielded B. spicifera. The patient responded to treatment with 2 g of iv amphotericin B; the adrenal masses and pneumonia resolved, and he remained well until last seen in July 1992. However, he requires replacement therapy with prednisone and fludrocortisone. On review of the available literature, we were unable to find a previously reported case.

311

In vitro activities of approved and investigational antifungal agents against 44 clinical isolates of basidiomycetous fungi. González GM, Sutton DA, Thompson E, Tijerina R, Rinaldi MG. Antimicrob Agents Chemother. 2001 Feb;45(2):633-5.

The in vitro activity of amphotericin B, fluconazole, flucytosine, itraconazole, voriconazole, and posaconazole was evaluated against 44 clinical isolates of filamentous basidiomycetous fungi. No statistically significant differences were noted between Schizophyllum commune (n = 5), Coprinus species (n = 8), Bjerkandera adusta (n = 14), and sterile, uncharacterized basidiomycetes (n = 17).

312

Detection of antibodies and delayed dermal hypersensitivity with different lots of Blastomyces dermatitidis yeast lysate antigen: stability and specificity evaluations. Wakamoto A, Fryer BM, Fisher MA, Johnson TJ, Lundgren DK, Knickerbocker JD, Rounds SL, Scalarone GM. Mycoses. 1997 Nov;40(7-8):303-8.

Comparative evaluations were performed to assess the stability, sensitivity and specificity of eight lots of yeast lysate antigen prepared from a Blastomyces dermatitidis dog isolate (T-58). These antigens were prepared during the period from 1989 to 1995. The lysates were used in an ELISA for the detection of antibodies in serum specimens from dogs with blastomycosis and histoplasmosis. In order to evaluate the ability of the lysates to elicit delayed dermal hypersensitivity (DTH) responses, they were compared as skin-testing antigens in guinea pigs that were previously sensitized with B. dermatitidis or Histoplasma capsulatum killed whole yeast cells. All 8 of the lots of antigen detected antibody in the sera from dogs with blastomycosis (absorbance values ranged from 0.432 to 0.543; mean value of 0.508). The absorbance values ranged from 0.283 to 0.439 (mean value of 0.326) when the lysates were assayed against sera from dogs with histoplasmosis. All of the antigens were able to elicit a DTH response in B.

313

Detection of antibody responses and delayed dermal hypersensitivity with Blastomyces dermatitidis yeast and mycelial lysate antigens. Seawell BW, Wheeler JY, Yearsley K, Alexander KL, Legendre AM, Scalarone GM. Mycopathologia. 1991 Jun;114(3):137-44.

Yeast cell lysate and mycelial lysate antigens prepared from one strain (T-58) of Blastomyces dermatitidis were evaluated with respect to the detection of antibodies and delayed dermal hypersensitivity. Comparable ELISA sensitivity values were evidenced with the two antigens when assayed against serum specimens from dogs with blastomycosis, sera from non-infected dogs residing in endemic and non-endemic areas for blastomycosis and sera from rabbits that were hyperimmunized with B. dermatitidis antigens. Specificity determinations with anti-Histoplasma capsulatum rabbit sera indicated that both reagents exhibited only minimal cross-reactivity; the mycelial antigen was slightly more specific than the yeast phase reagent. Similar sensitivity and specificity results were experienced when the two antigens were used to detect delayed dermal hypersensitivity in guinea pigs previously sensitized with B. dermatitidis or H. capsulatum.

315

Cluster of pulmonary blastomycosis in a rural community: evidence for multiple high-risk environmental foci following a sustained period of diminished precipitation. Proctor ME, Klein BS, Jones JM, Davis JP. Mycopathologia. 2002;153(3):113-20.

Much of our understanding of the epidemiologic features of infection with Blastomyces dermatitidis has come from cluster and outbreak investigations which have established the association of human disease with recreational pursuits and the presence of infectious microfoci in areas of moist soil with high organic content. This report describes the clustering of eight cases of pulmonary blastomycosis without an apparent common source exposure which occurred during a 90 day period in a 96 square mile area (population 4,450) within Oconto County, Wisconsin. We conclude that multiple high-risk environmental foci may have existed following a sustained five-year period of diminished precipitation in the cluster area. A case-control study which included family and community controls concluded that multiple earth-disturbing activities engaged in by case-patients was statistically associated with illness. Lymphocyte-proliferation assays of whole blood samples detected previously unrecognized infection with B. dermatititidis among five of 32 family controls.

316

Blastomycosis in northeast Tennessee. Vasquez JE, Mehta JB, Agrawal R, Sarubbi FA. Chest. 1998 Aug;114(2):436-43.

STUDY OBJECTIVES: To study the epidemiologic and clinical features of blastomycosis in northeast Tennessee. DESIGN: Retrospective review of blastomycosis cases in the region from 1980 through 1995. SETTING: Hospitals located in the Tri-Cities region of northeast Tennessee. PATIENTS: Seventy-two patients with confirmed blastomycosis infection. INTERVENTIONS: None. RESULTS: During the 1980 to 1995 study period, we documented 72 cases of blastomycosis. The mean age was 52 years (range, 13 to 86 years), most were male (69.4%), and nine were immunocompromised. A possible environmental exposure was noted for 28 patients. Pulmonary involvement represented the most common site of infection (61 cases), but multiorgan involvement was common (17 cases). Most patients with pulmonary blastomycosis (66%) presented with a chronic illness, and radiologic findings usually revealed local consolidation or a mass-like lesion. Nine patients developed ARDS with an associated mortality rate of 89%, compared with a 10% mortality for non-ARDS pulmonary cases. Antifungal treatment regimens varied widely, with amphotericin B often used for sicker patients. An epidemiologic evaluation revealed that the mean yearly incidence rate for blastomycosis quadrupled between 1980 and 1987 (0.31 cases/ 100,000 population) and 1988 to 1995 (1.23 cases/100,000 population) (p=0.00001). Most new blastomycosis cases in the 1988 to 1995 period occurred in three counties in the region where significant new construction projects have been underway. CONCLUSION: Blastomycosis is endemic in northeast Tennessee and the number of cases is increasing, coinciding with major new construction in the region. Clinicians in the area must be alert to this condition.

317

Pulmonary blastomycosis with acute respiratory failure as predominant clinical feature. Mukkamala R, Mehta JB, Myers JW, Cole CP. South Med J. 1997 Aug;90(8):847-50.

Two previously healthy young adults came to our community hospital with rapidly progressive respiratory failure. Investigation confirmed Blastomyces as the responsible etiologic agent. Despite adequate antifungal chemotherapy and intensive supportive care, both patients died, one within 24 hours and the other after 14 days. Overwhelming infection with Blastomyces dermatitidis can cause acute respiratory failure, possibly the adult respiratory distress syndrome, even in immunocompetent hosts.

318

Delayed treatment of pulmonary blastomycosis causing vertebral osteomyelitis, paraspinal abscess, and spinal cord compression. Lagging LM, Breland CM, Kennedy DJ, Milligan TW, Sokol-Anderson ML, Westblom TU. Scand J Infect Dis. 1994;26(1):111-5.

A 36-year-old woman with gallbladder disease had an incidental finding of asymptomatic cavitary lung infection with Blastomyces dermatitidis. No treatment was given initially, and 2 months later she presented with vertebral osteomyelitis, paraspinal abscess, and spinal cord compression due to dissemination of the fungus. The patient recovered following surgical debridement and treatment with 1 g of amphotericin B, followed by itraconazole 400 mg QD for 6 months. In spite of previous reports of the self limiting nature of primary pulmonary blastomycosis in the normal host, antifungal therapy may be needed in cases that do not resolve spontaneously within a short period of time, or if transient immunosuppression may be anticipated as may occur following surgery or after acquisition of other infections.

319

Blastomycotic cranial osteomyelitis. Farr RC, Gardner G, Acker JD, Brint JM, Haglund LF, Land M, Schweitzer JB, West BC. Am J Otol. 1992 Nov;13(6):582-6.

This is the second case report of a temporal bone osteomyelitis caused by Blastomyces dermatitidis, which presented as a chronic serous otitis media. The presenting serous otitis media was refractory to conventional medical and surgical management and progressed to a temporal bone osteomyelitis prior to diagnosis. B. dermatitidis is a rare fungal pathogen that causes a systemic pyogranulomatous disease that primarily manifests itself in the skin, bones, pulmonary, and genitourinary systems. If left untreated it is associated with a high rate of mortality. The otologic presentation of this rare disease is emphasized, while the clinical and therapeutic features are reviewed.

320

Blastomycosis of the cervicofacial area: a review of the literature and case report] Cavalot AL, Cravero L, Valente G, Gribodo L. Acta Otorhinolaryngol Ital. 1992 Nov-Dec;12(6):605-10.

A literature review concerning blastomycosis has been conducted. The involvement of the head and neck area appears to be very unusual, on the basis of autoptic observations. The most common diagnostic and subsequent therapeutic mistakes are pointed out. A new case is described and its clinical appearance, symptoms, diagnostic work up and therapeutic approach are discussed. This case report is of interest for three reasons: the rarity of this disease in our country, the possibility of confusing a Blastomyces infection with a cryptococcal one [correction of criptococcosy] and finally the therapeutic response to a new drug, not yet commercialized in Italy.

321

Epidemic of pulmonary blastomycosis (Namekagon fever) in Wisconsin canoeists. Cockerill FR 3rd, Roberts GD, Rosenblatt JE, Utz JP, Utz DC. Chest. 1984 Nov;86(5):688-92.

Epidemics of pulmonary blastomycosis have rarely been reported. The following epidemic occurred in a Minnesota family and several of their acquaintances after a canoeing trip in northwestern Wisconsin. The common exposure area was most likely a campsite, located along the upper reaches of the Namekagon River. The Namekagon River Valley is a known endemic area of Namekagon fever (blastomycosis) in dogs. Approximately one month after returning home, five of the eight members of the group had positive direct microscopic examinations and cultures of Blastomyces dermatitidis from their sputa, as well as abnormalities on their chest roentgenograms. Among these five patients, four were symptomatic, with fever, cough, and pleuritic chest pain. Of the three others, one had pleuritic chest pain with a transient lung infiltrate, the second was asymptomatic with a transient lung infiltrate, and the third was asymptomatic with a normal chest roentgenogram. Results of acute serologic tests (complement fixation and immunodiffusion) were negative in all five patients evaluated. None of the patients received antifungal therapy. Follow-up five years after the epidemic revealed that all eight were in excellent health, and none had evidence of continuing pulmonary or extrapulmonary disease.

322

Marked polymorphonuclear pleocytosis due to blastomycotic meningitis: case report and review. Harley WB, Lomis M, Haas DW. Clin Infect Dis. 1994 May;18(5):816-8

Meningitis is an unusual manifestation of infection caused by Blastomyces dermatitidis. We describe a patient who presented with fulminant blastomycotic meningitis. Examination of the lumbar CSF demonstrated > 5,000 polymorphonuclear leukocytes/mm3. The diagnosis of B. dermatitidis meningitis was initially suggested by cytologic examination of CSF and confirmed by culture. Pleocytosis of this magnitude had not been previously described in association with blastomycosis, although review of the published literature revealed that neutrophilic pleocytosis is a common manifestation of blastomycotic meningitis and should suggest the diagnosis. This report broadens the clinical spectrum of blastomycotic meningitis and suggests that cytologic examination of CSF is a useful way to establish this diagnosis.

323

Cutaneous blastomycosis. Report of a case with diagnosis by fine needle aspiration cytology. Desai AP, Pandit AA, Gupte PD. Acta Cytol. 1997 Jul-Aug;41(4 Suppl):1317-9.

BACKGROUND: Blastomycosis is rare in India. Clinically, cutaneous blastomycosis may be mistaken for keratoacanthoma, squamous cell carcinoma, tuberculosis, tertiary syphilis, leprosy or pyoderma. CASE: A 19-year-old male presented with a soft, fluctuant swelling at the medial canthus of the eye. Fine needle aspiration biopsy (FNAB) showed many single, spherical structures with thick walls. They had basophilic protoplasm and six nuclei in the center. A few of them showed budding with a broad base. CONCLUSION: The cytomorphology of Blastomyces dermatitidis is characteristic, and the organism can be differentiated from other yeast forms. The disease is sensitive to antifungal imidazole derivatives and can be cured.

324

Peritoneal blastomycosis. Perez-Lasala G, Nolan RL, Chapman SW, Achord JL. Am J Gastroenterol. 1991 Mar;86(3):357-9.

Blastomycosis is a systemic fungal infection caused by Blastomyces dermatitidis. Involvement of the peritoneum is unusual, with only two previously reported cases that occurred in association with disseminated disease. A single case of histopathologically proven blastomycosis involving the peritoneum is presented, as well as a short overview of previously published cases on gastrointestinal and peritoneal blastomycosis. The case is unique in that chronic peritonitis was the only manifestation of disease. The diagnosis was made by laparoscopy.

325

Fungal splenic abscess. Johnson JD, Raff MJ. Arch Intern Med. 1984 Oct;144(10):1987-93.

Nineteen patients with fungal splenic abscesses included 16 with leukemia, one drug user, one patient with Cushing's syndrome, and one without predisposing causes. Fifteen had persistent fever; six had esophageal or mucocutaneous candidiasis. Abdominal pain occurred in seven patients, splenomegaly occurred in six, and left abdominal mass occurred in one. Three chest x-ray films showed left pleural effusions; two had elevated left hemidiaphragms, two had left-sided infiltrates, and one was normal. Sixteen of 17 technetium Tc 99m sulfur colloid scans were abnormal, as were 15 gallium citrate Ga 67 scans. Two computed tomographic studies revealed splenic defects. Candida was the cause in 15 cases, Aspergillus was the cause in three cases, and Blastomyces dermatitidis was the cause in one case. Sixteen patients underwent splenectomy, 12 receiving postoperative antifungal therapy. Fifteen survived regardless of underlying disease or hepatic microabscesses.

326

Otitis media due to blastomycosis: report of two cases. Istorico LJ, Sanders M, Jacobs RF, Gilleon S, Glasier C, Bradsher RW. Clin Infect Dis. 1992 Jan;14(1):355-8.

Blastomycosis as a causative agent in cases of otitis media has not previously been reported. Two patients recently presented with otitis media and head and neck masses due to Blastomyces dermatitidis. Initial evaluation suggested neoplastic disease, but biopsy confirmed a fungal etiology for the masses in both patients. Relapse after administration of ketoconazole was noted in one patient, who was an adult; the other patient was a child. Otitis media and masses of the head and neck are unusual features of blastomycosis. Blastomycosis should be considered in the differential diagnosis for patients with such mass lesions and for patients with otitis media.

327

Endophthalmitis due to Blastomyces dermatitidis. Case report and review of the literature. Safneck JR, Hogg GR, Napier LB. Ophthalmology. 1990 Feb;97(2):212-6.

Blastomycosis very rarely affects ocular structures other than the eyelid. It is even more unusual for involvement to occur in the absence of active widespread disease. The authors report a 71-year-old woman with unresponsive endophthalmitis of the right eye who underwent enucleation. Results of microscopic examination of the globe showed severe acute and chronic granulomatous and nongranulomatous endophthalmitis as well as numerous fungi having the histologic features of Blastomyces dermatitidis. Although constitutional symptoms (weight loss, fatigue, night sweats) were noted by the patient, multiple investigations failed to disclose any evidence of systemic disease.

328

Aetiology, antifungal susceptibility, risk factors and outcome in 201 fungaemic children: data from a 12-year prospective national study from Slovakia. Krcmery V, Laho L, Huttova M, Ondrusova A, Kralinsky K, Pevalova L, Dluholucky S, Pisarcíkova M, Hanzen J, Filka J, Sejnova D, Lisková A, Purgelová A, Szovenyová Z, Koren P. J Med Microbiol. 2002 Feb;51(2):110-6.

A total of 201 cases of fungaemia in children in a 12-year national survey from seven University Paediatric Clinics in Slovakia in 1990-2001 was assessed to determine risk factors, therapy and outcome, and to compare those cases with fungaemia in 130 adult cancer patients studied in a similar survey. Four univariate analyses were performed to assess differences in aetiology, antifungal susceptibility and outcome between fungaemia in neonates and paediatric intensive care unit (ICU) patients as well as between paediatric and adult cancer patients with fungaemia. There was a significant difference in aetiology and antifungal susceptibility between the subgroups of children with fungaemia: 83.3% of neonates versus 40.2% in children with cancer were due to Candida albicans. None of the non-albicans Candida spp. (NAC) in neonates but 23.5% of NAC isolates from children with cancer were resistant to fluconazole. C. albicans caused 144 (71.1%) episodes and NAC 48 (23.7%) episodes. Trichosporon beigelii, Blastoschizomyces (Trichosporon) capitatus, Rhodotorula rubra and Cryptococcus laurentii were found less frequently in neonates than in children with cancer (18.8%). There were not many differences in risk factors between paediatric fungaemia and adult cancer fungaemia except C. albicans aetiology, corticosteroid use in therapy, breakthrough fungaemia after ketoconazole prophylaxis and meningitis as a complication, which were observed significantly more frequently among children than in adults, both with cancer and fungaemia. Thirty-three of the paediatric fungaemias were breakthrough cases and appeared frequently in children with cancer. Fifty-one (25.1%) children died with fungaemia (attributable mortality) and 25 (12.7%) due to underlying disease with fungaemia; overall mortality was 37.8% and there was no significant difference in death rates between the subgroups of paediatric patients (neonates, children in ICUs and children with cancer).

329

Disseminated Blastoschizomyces capitatus infection in acute myeloblastic leukaemia. Report of three cases. Sanz MA, López F, Martínez ML, Sanz GF, Martínez JA, Martín G, Gobernado M. Support Care Cancer. 1996 Jul;4(4):291-3.

Three new cases of Blastoschizomyces capitatus infection occurring in neutropenic patients with acute myeloblastic leukaemia are reported. B. capitatus was isolated from blood cultures in all patients. All three patients were treated with amphotericin B, but only one was cured from the infection. Our study confirms the emergence of B. capitatus as an opportunistic agent of disseminated fungal infection in leukaemic patients.

330

Case report. Disseminated infection of Blastoschizomyces capitatus in a patient with acute myelocytic leukaemia. Buchta V, Zák P, Kohout A, Otcenásek M. Mycoses. 2001 Dec;44(11-12):505-12.

Blastoschizomyces capitatus infection in a 48-year-old man with acute myelocytic leukaemia is reported. A multiorgan involvement and fulminant course of the fungal infection resulted in the patient's death despite fluconazole prophylaxis, therapy with amphotericin B and administration of granulocyte colony-stimulating factor. Predisposing factors to the infection, clinical relevance of surveillance strains and in vitro antifungal susceptibility testing are discussed.

331

Overview of systemic fungal infections. Rolston K. Oncology (Huntingt). 2001 Nov;15(11 Suppl 9):11-4.

A steady increase in the frequency of invasive fungal infections has been observed in the past 2 decades, particularly in immunosuppressed patients. In recipients of bone marrow transplants, Candida albicans and Aspergillus fumigatus remain the primary pathogens. In many centers, however, Candida species other than C albicans now predominate, and many cases of aspergillosis are due to species other than A fumigatus. Additionally, heretofore unrecognized and/or uncommon fungal pathogens are beginning to emerge, including Blastoschizomyces capitatus, Fusarium species, Malassezia furfur, and Trichosporon beigelii. These opportunistic fungal pathogens are associated with various localized and disseminated clinical syndromes, and with substantial morbidity and mortality. These established, invasive mycoses, particularly in bone marrow transplant recipients, are the focus of this discussion.

332

Blastoschizomyces capitatus: an emerging cause of invasive fungal disease in leukemia patients. Martino P, Venditti M, Micozzi A, Morace G, Polonelli L, Mantovani MP, Petti MC, Burgio VL, Santini C, Serra P. Rev Infect Dis. 1990 Jul-Aug;12(4):570-82.

Blastoschizomyces capitatus (formerly named Trichosporon capitatum or Geotrichum capitatum) is a rare cause of invasive fungal disease in immunocompromised hosts. We retrospectively studied epidemiologic, clinical, pathologic, and microbiologic features of this infection during a 68-month period at the Division of Hematology of the University La Sapienza in Rome. Twenty patients with evidence of B. capitatus were identified: 12 were infected, four were possibly infected, and four had evidence of B. capitatus colonization but were not infected by this fungus. Pulmonary infiltrates were seen in seven infected patients; four of these patients eventually developed mycetomalike cavitations. Eight infected patients presented clinical and radiologic features of focal hepatitis compatible with hepatosplenic candidiasis. Of the 12 infected patients, two did not receive any antifungal treatment and died, five did not show any response to systemic antifungal therapy, and five received prolonged amphotericin B plus 5-fluorocytosine therapy. Of the last group, three patients achieved stable remission of their acute leukemia and were cured, and two improved but had an apparent relapse of B. capitatus infection after their acute leukemia recurred.

333

Mandibular osteomyelitis caused by Blastoschizomyces capitatus in a child with acute myelogenous leukemia.Cheung MY, Chiu NC, Chen SH, Liu HC, Ou CT, Liang DC. J Formos Med Assoc. 1999 Nov;98(11):787-9.

A 6-year-old girl with acute myelogenous leukemia (AML) developed fungal mandibular osteomyelitis during chemotherapy. Blastoschizomyces capitatus was recognized histologically by its yeast-like morphology and formation of annelloconidia, and was confirmed by culture. The fungal osteomyelitis of the mandible was treated successfully with prolonged antifungal medication, extensive surgical debridement and an oral care program, without interrupting leukemia chemotherapy. B. capitatus osteomyelitis of the mandible may occur during chemotherapy in AML patients with poor dental condition. Successful treatment can be achieved by careful management without interruption of antineoplastic chemotherapy.

334

Funguria in cancer patients: analysis of risk factors, clinical presentation and outcome in 50 patients. Oravcova E, Lacka J, Drgona L, Studena M, Sevcikova L, Spanik S, Svec J, Kukuckova E, Grey E, Silva J, Krcméry V. Infection. 1996 Jul-Aug;24(4):319-23.

Fifty cancer patients with funguria of > 10(5) CFU/ml, dysuria and leukocyturia were retrospectively analyzed for etiology, risk factors and outcome. In 72% of cases Candida albicans and in 28% non-albicans Candida spp. (Candida krusei, Candida tropicalis) and non-Candida spp. yeasts (Blastoschizomyces capitatus) were isolated. Torulopsis glabrata was not found among these patients. The most frequent risk factors were: antibiotic therapy with more than one antibiotic agent (96%), concomitant fungal infection in other localizations than the urinary tract (36%), colonization with the same species (48%), catheterization with urinary catheter or nephrostomy (46%), prophylaxis with quinolones (50%) and previous therapy with corticosteroids (72%). Structural or anatomic malformations of the urinary tract (26%), neutropenia (28%), antifungal prophylaxis with azoles (22%), and diabetes mellitus (12%) were less frequently seen. Thirty of 36 patients treated with systemic antifungals were cured and six were not.

335

Onychomycosis caused by Blastoschizomyces capitatus. D'Antonio D, Romano F, Iacone A, Violante B, Fazii P, Pontieri E, Staniscia T, Caracciolo C, Bianchini S, Sferra R, Vetuschi A, Gaudio E, Carruba G. J Clin Microbiol. 1999 Sep;37(9):2927-30.

Blastoschizomyces capitatus was cultured from the nail of a healthy patient with onychomycosis. The identity of the isolate was initially established by standard methods and ultrastructural analysis and was verified by molecular probing. Strains ATCC 200929, ATCC 62963, and ATCC 62964 served as reference strains for these analyses. To our knowledge, this is the first case of nail infection secondary to paronychia caused by this organism reported in the English literature.

336

Endocarditis caused by Blastoschizomyces capitatus and taxonomic review of the genus. Polacheck I, Salkin IF, Kitzes-Cohen R, Raz R. J Clin Microbiol. 1992 Sep;30(9):2318-22.

Blastoschizomyces capitatus Salkin, Gordon, Samsonoff et Rieder was found to be the etiologic agent of endocarditis in a patient with a prosthetic mitral valve. Cultures inoculated with peripheral blood and portions of the valve yielded B. capitatus. Examination of stained tissue sections revealed the presence of fungal filaments morphologically consistent with this organism. The salient characteristics of B. capitatus and the factors contributing to its recognition as a distinct taxon are described.

338

Botryomyces caespitosus as an agent of cutaneous phaeohyphomycosis. Benoldi D, Alinovi A, Polonelli L, Conti S, Gerloni M, Ajello L, Padhye AA, de Hoog GS. J Med Vet Mycol. 1991;29(1):9-13.

The second known case of a skin infection caused by Botryomyces caespitosus is reported. This case has made it possible to describe the characteristics of this fungus in vivo and to establish it as another agent of phaeohyphomycosis.

339

Actinomycosis and botryomycosis of the tonsil. Martins RH, Heshiki Z, Luchesi NR, Marques ME. Auris Nasus Larynx. 1991;18(4):377-81.

This study was carried out in 165 patients submitted to the surgery of tonsils or adenoid from 1977 to 1989 at the Botucatu Medical School Hospital. The clinical signs and histopathological findings were reviewed. All patients exhibited similar complaints with recurrent tonsillitis, sore throat, dysphasia, high temperature, and enlarged tonsils. After surgery, the tonsils was submitted to histopathological study and showed "grains" in the crypts in 6 cases. Four cases (2.4%) of Actinomyces and two (1.2%) of Botryomyces were identified. Any clinical peculiarity was identified with the presence of these "grains."

340

Dermatomycosis in plaques caused by Botryomyces caespitosus. A new causative agent] Carapeto FJ, Rubio C, Pastor JA, Grasa MP, Martín-Pascual A. Med Cutan Ibero Lat Am. 1985;13(1):71-5.

The clinical and histological features of a dermomycosis caused by a new dematiaceum fungus are described. The mycological characteristics of this fungus individualize and differentiate it from other demiataceum hyphomycetes, proposing the name of Botryomyces caespitosus for it. The submicroscopic features are commented, as well.

353

1. Onychomycosis in Joao Pessoa City, Brazil. Pontes ZB, Lima Ede O, Oliveira NM, Dos Santos JP, Ramos AL, Carvalho MF. Rev Argent Microbiol. 2002 Apr-Jun;34(2):95-9.

Onychomycosis epidemiology is a combination of various factors which include, among others, clinical presentation, etiologic agents of the infection and the patient's history background. Out of a total of 672 nail samples examined, 460 (68.4%) were microscopy positive for fungi and 306 (66.5%) of these were culture positive, including Candida (82%), dermatophytes (13.4%), Trichosporon spp (3.6%) and nondermatophyte molds (1%). Onychomycosis was more frequent in females (79.7%) than in males (20.3%). These were more common in fingernails (96.1%) than in toenails (60%) and yeasts were the most isolated etiologic agents. Among the clinical presentations, paronychia (CP) (57.2%) and onycholysis (CO) (24.8%) were the most common, caused frequently by C. albicans in 52.6% and 60.5% of the cases, respectively. T. rubrum (44.4%) and Trichosporon spp (22.2%) were the most frequent species in the case of distal lateral subungual onychomycosis (DLSO). Fusarium spp was the agent responsible for 33.3% of the cases of proximal subungual onychomycosis (PSO) and for 14.3% of white superficial onychomycosis (WSO), whereas Acremonium spp was responsible for 14.3% of the cases of WSO.

354

Incidence of Candida species isolated from human skin and nails: a survey. Jautova J, Viragova S, Ondrasovic M, Holoda E. Folia Microbiol (Praha). 2001;46(4):333-7.

Distribution of Candida species was investigated by examining 245 samples from skin lesions and nails. The isolates were identified using standard laboratory methods including germ tube test, micromorphology of colonies on rice agar, the commercial kit, saccharide assimilation and fermentation tests. Eight species of Candida were identified: C. albicans accounted for 56.4% of the isolates, C. parapsilosis 29.1, C. tropicalis 7.8, C. pulcherrima 2.9, C. guilliermondii 1.5, C. krusei and C. zeylanoides for 0.9% each, and C. robusta for 0.5%. The factors significantly associated with colonization were prolonged antibiotic therapy, parenteral nutrition, low birth body mass of infants, intubation, duration of stay in hospital, indwelling intravenous catheter, malignancies, diabetes, surgery, and obesity.

355

Candida in dermatology] Seebacher C. Mycoses. 1999;42 Suppl 1:63-7.

Regarding Candida in dermatology, two pathogenetic pathways must be taken into account: 1. on infection of the skin 2. immunological reactions with skin alterations as a result of Candida infection or colonization in the mouth and/or intestine. Case reports describe typical situations of napkin dermatitis, intertriginous candidosis, the intrauterine Candida infection of the foetus, Candida granuloma, Candida folliculitis and Candida paronychia. In the second part results of investigations of patients suffering from psoriasis, atopic dermatitis and urticaria are presented. There were no differences in the colonization with Candida albicans and in the level of Candida antibody titres between patients and a healthy control group.

Cutaneous congenital candidiasis: a case report. Gibney MD, Siegfried EC. Pediatr Dermatol. 1995 Dec;12(4):359-63.

St. Louis University Health Sciences Center, Division of Dermatology, Missouri, USA.

Candida albicans is a frequent pathogen of the female genital tract, especially during pregnancy. Congenital candidiasis can occur as cutaneous or disseminated infection. We report a case of congenital cutaneous candidiasis, which may occur more frequently than is indicated by the literature. This is followed by a discussion of the pathogenesis, clinical presentation, diagnosis, and treatment of this infection.

Onychomycosis caused by nondermatophytic molds: clinical features and response to treatment of 59 cases. Tosti A, Piraccini BM, Lorenzi S. J Am Acad Dermatol. 2000 Feb;42(2 Pt 1):217-24.

Femur osteomyelitis due to a mixed fungal infection in a previously healthy man. Cimerman M, Gunde-Cimerman N, Zalar P, Perkovic T.

J Clin Microbiol. 1999 May;37(5):1532-5.

447

Systemic mycosis caused by a new Cladophialophora species. Tintelnot K, von Hunnius P, de Hoog GS, Polak-Wyss A, Guého E, Masclaux F. J Med Vet Mycol. 1995 Sep-Oct;33(5):349-54.

A 22-year-old woman suffered from haemoptyses of unknown aetiology. A tumour in the lingula was diagnosed histologically to be a granulomatosis, most likely a sarcoidosis. Two years later, the patient returned with dyspnoea caused by a granulomatous tumour in the trachea, histologically similar to that seen earlier. After bronchoscopic laser resection, cortisone therapy was applied but without success. A fungus was subsequently discovered histologically and was cultivated from biopsy specimens. Retrospective research of primary histological slides led to the conclusion that a mycosis was the initial cause of the tumours. The mycosis was successfully treated with high-dose itraconazole for 1 year, combined with 5-fluorocytosine (5-FC) during the first few months. The causative agent was found to be a new species of Cladophialophora, and is described as C. arxii Tintelnot; its key characteristics are presented.

448

Cerebral phaeohyphomycosis due to a novel species: report of a case and review of the literature. Osiyemi OO, Dowdy LM, Mallon SM, Cleary T. Transplantation. 2001 May 15;71(9):1343-6.

Cerebral phaeohyphomycosis is a rare disease caused by dematiaceous (darkly pigmented) fungi. Cladophialophora species are highly neurotropic, and Cladophialophora bantiana (synonym=Xylohypha bantiana or C. trichoides) is the most commonly identified agent. Most reported cases of cerebral phaeohyphomycosis have occurred in immunocompetent patients; however, some case reports and experimental data have suggested that cellular immune deficiency is a risk factor. We report a case of pulmonary and cerebral phaeohyphomycosis in a cardiac transplant patient due to a newly identified species of Cladophialophora. Optimal management includes both antifungal therapy and surgery.

449

Cerebral phaeohyphomycosis caused by Cladophialophora bantiana in a Brazilian drug abuser. Walz R, Bianchin M, Chaves ML, Cerski MR, Severo LC, Londero AT. J Med Vet Mycol. 1997 Nov-Dec;35(6):427-31.

We present a case of cerebral phaeohyphomycosis caused by Cladophialophora bantiana in an apparently immunocompetent patient with a history of intravenous drug use. The diagnosis was achieved in specimens obtained at necropsy by histological and mycological examination, with subsequent identification of the isolate in culture.

450

Necrotizing cerebritis in an allogeneic bone marrow transplant recipient due to Cladophialophora bantiana. Emmens RK, Richardson D, Thomas W, Hunter S, Hennigar RA, Wingard JR, Nolte FS. J Clin Microbiol. 1996 May;34(5):1330-2.

We describe a necrotizing cerebritis in an allogeneic bone marrow transplant recipient caused by the neurotropic, dematiaceous fungus Cladophialophora bantiana. The patient presented 7 months after bone marrow transplantation with fever and sudden onset of left-sided weakness, followed shortly by cranial nerve III and VI palsies. The patient had a lesion (3.0 by 2.0 by 2.0 cm) of the right midbrain with extension to the pons, the left brain stem, and the right superior and the middle cerebellar peduncles. The diagnosis was made by microscopic examination and culture of a brain biopsy.

451

Cutaneous phaeohyphomycosis due to Cladophialophora bantiana. Patterson JW, Warren NG, Kelly LW. J Am Acad Dermatol. 1999 Feb;40(2 Pt 2):364-6.

452

Cutaneous infection due to Cladophialophora bantiana in a patient receiving immunosuppressive therapy. Jacyk WK, Du Bruyn JH, Holm N, Gryffenberg H, Karusseit VO. Br J Dermatol. 1997 Mar;136(3):428-30.

Cladophialophora bantiana (Xylohypha bantiana, Cladosporium trichoides), a dematiaceous fungus, causes mainly infections of the central nervous system. Systemic antifungal therapy is apparently unsuccessful. Extracerebral involvement is uncommon and only few cases have been reported. We describe a 63-year-old patient, a kidney transplant recipient on prolonged prednisone and cyclosporin, who developed a large single lesion on the thigh from which Cladophialophora bantiana was cultured. A 3-month course of itraconazole 200 mg daily resulted in complete healing of the lesion. To the best of our knowledge this is the first report on cutaneous infection with Cladophialophora bantiana in an organ transplant recipient and the first in whom treatment with itraconazole led to resolution.

453

Myelitis caused by Cladophialophora bantiana. Shields GS, Castillo M. AJR Am J Roentgenol. 2002 Jul;179(1):278-9.

454

A Samoan case of chromoblastomycosis caused by Cladophialophora ajelloi. Goh KS, Padhye AA, Ajello L. Sabouraudia. 1982 Mar;20(1):1-7.

A case of chromoblastomycosis from American Samoa was studied. Histopathological examination of the biopsy material from the lesion revealed the presence of thick-walled, dematiaceous, muriform cells characteristic of chromoblastomycosis. Detailed mycological study of the dematiaceous mould isolated from the biopsy material disclosed that the fungus not only produced long, branched chains of holoblastic conidia similar to those of Cladosporium carrionii, but that many of the terminal and intercalary catenulate, holoblastic conidia had been converted into flask-shaped phialides with flaring collarettes that produced ovate to fusiform phialoconidia. These phialides were morphologically similar to those formed by members of the genus Phialorphora. The Samoan case is the second known case of chromoblastomycosis caused by Cladophialophora ajelloi Borelli.

455

[Natural history of chromoblastomycosis in Madagascar and the Indian Ocean] [Natural history of chromoblastomycosis in Madagascar and the [Natural history of chromoblastomycosis in Madagascar and the Indian Ocean] Esterre P, Andriantsimahavandy A, Raharisolo C. Bull Soc Pathol Exot. 1997;90(5):312-7.

The natural history of chromoblastomycosis was studied in Madagascar by analysing the characteristics of 1323 confirmed cases observed since 1955, including 45 patients receiving a new antifungic drug (terbinafine) during a multicentric study organized in 1995. The surveys data, conserved by the histopathology laboratory in the Institut Pasteur of Madagascar during 40 years, permit this retrospective analysis. The description of two ecosystems, one in the North with Fonsecaea pedrosoi evolving in the tropical rainforest and one in the South with Cladophialophora carrionii (41% of the whole sample) isolated in the spiny desert, demonstrates that the deforestation, in order to product charcoal and to build houses, is the primary factor associated with this disease. The epidemiologic (87% of patients are male and 96% are more than 16 years old, with more than 74% of the lesions located on feet and legs), mycologic (62% of the isolated strains belong to the F. pedrosoi species) and therapeutic (low efficiency of thiabendazole in long-term lesions, high efficiency of terbinafine especially on recent lesions and on Cladophialophora-infected patients) aspects of the natural history of chromomycosis confirmed that Madagascar is the most important focus in the world (global prevalence of about 1 for 8500 inhabitants), with few sporadic cases in the other islands of the Indian Ocean (La Reunion, Comoro islands and Mayotte). In the difficult context of Madagascar, the need for a non-specialized laboratory-applicable diagnostic technique that provides infection and species identification led the Institut Pasteur de Madagascar to develop an ELISA-based technique. A large-scale control throughout the country, with the assessment of effective oral chemotherapy with terbinafine, is seen as possible by the authors with the help of the manufacturer.

456

Cladophialophora bantiana isolated from an AIDS patient with pulmonary infiltrates. Brenner SA, Morgan J, Rickert PD, Rimland D. J Med Vet Mycol. 1996 Nov-Dec;34(6):427-9.

Cladophialophora bantiana causes a rare phaeohyphomycosis, usually manifested by brain abscesses but rarely by skin or pulmonary lesions. It has not been reported as a common colonizer or as a cause of pulmonary symptoms in patients with AIDS. We present a case in which C. bantiana was repeatedly isolated from the sputum of a patient with AIDS having pulmonary infiltrates.

457

Mycotic keratitis by Cladorrhinum. Zapater RC, Scattini F. Sabouraudia. 1979 Mar;17(1):65-9.

Cladorrhinum spp (strain CBS 604.75) was isolated, for the first time, from a case of keratomycosis. The patient, a 12 year-old boy, showed a soft white yellowish mycotic excrescence with clear borders which had followed the introduction of a small piece of straw into the cornea. The direct examination of corneal scrapings revealed dark-brown filaments. He was successfully treated with miconazole.

460

Case report. Subcutaneous phaeohyphomycosis due to Cladosporium cladosporioides. Gugnani HC, Sood N, Singh B, Makkar R. Mycoses. 2000;43(1-2):85-7.

A case of subcutaneous phaeohyphoymycosis caused by Cladosporium cladosporioides in a 25-year-old male is described. The clinical presentation was an elevated scaly suppurating lesion with sinuses on the right leg. The lesion healed completely with oral fluconazole therapy. The present report constitutes the first record of cutaneous or subcutaneous infection due to Cl. cladosporioides from India.

461

Cutaneous phaeohyphomycosis due to Cladosporium cladosporioides. Annessi G, Cimitan A, Zambruno G, Di Silverio A. Mycoses. 1992 Sep-Oct;35(9-10):243-6.

A 54-year-old man, affected by pemphigus vulgaris and severe steroid-induced diabetes, developed seven red-brown, firm, slightly raised 0.1-1 cm papular lesions on the anterior aspect of both knees and thighs. A cutaneous biopsy showed a granulomatous infiltrate with numerous fungal elements scattered in the dermis and also within giant cells. Cultures of cutaneous biopsy fragments on Sabouraud glucose agar in presence of chloramphenicol resulted in the growth of dark-green colonies at 25 degrees C. They were identified as typical Cladosporium cladosporioides. As far as we know, this species was previously isolated only in an HIV-seropositive patient as opportunistic pathogen in the site of skin testing.

462

Comparative study of Cladosporium isolated from various human lesions]. de Bievre C. Bull Soc Pathol Exot Filiales. 1982 Aug-Oct;75(4):390-9.

Two species C. carrionii and C. bantianum are important in medical mycology and are respectively the etiologic agents of chromomycosis and brain abcess. Other species such C. oxysporum and C. cladosporioides have been isolated from keratitis, further more the latter species has been isolated from a pulmonary ball. C. sphaerospermum has been recovered from nail scrapings. The role of C. herbarum, isolated from skin lesion is questionable.

463

Cladosporiosis in chronic herpetic encephalomyelitis] Nedz'ved' MK, Fridman MV. Arkh Patol. 2001 Jan-Feb;63(1):38-40.

One case of chronic herpetic meningoencepalitis complicated by a rare my costs of the central nervous system (CNS) and generalised viral infection is described. Cladosporiosis is considered as a lesion resulting from a immunosuppression due to chronic herpetic involvement of CNS. Morphologically this mycosis is manifested by the presence of spors and septic micelium among cells of productive inflammation an inside of giant multinuclear cells in affected areas. Viral nature of the encephalomyelitis is documented by presence of typical intranuclear inclusions and detection of herpetic antigen by means of fluorescent antibodies.

464

Phaeohyphomycosis due to Cladosporium cladosporioides. Vieira MR, Milheiro A, Pacheco FA. Med Mycol. 2001 Feb;39(1):135-7.

Phaeohyphomycosis is a clinical entity caused by dematiaceous fungi. We describe a clinical case of phaeohyphomycosis due to Cladosporium cladosporioides in a 45-year-old white male, apparently healthy, human immunodeficiency virus-negative. The patient was treated with terbinafine for 9 months, with regression of a skin lesion. Three months after discontinuation of the therapy, there was a clinical and mycological relapse. After progression of the disease with inadequate treatment, there was no response to amphotericin B and flucytosine. Finally, we obtained a clinical response with itraconazole oral solution at 600 mg day(-1) for a 6-month period.

465

[Mycetoma of the foot; a disease from the tropics] Buiting AG, Visser LG, Barge RM, van 't Wout JW. Ned Tijdschr Geneeskd. 1993 Jul 24;137(30):1513-5.

Two patients, a Surinamese man aged 50 and a Surinamese woman aged 56 exhibited a mycetoma of the foot, 30 and 28 years, respectively, after a local injury. Pathological examination revealed an aspecific chronic granulomatous inflammation. As causative agents a Fusarium species and a Cladosporium normodendrum, respectively, were cultured. The treatment consisted of curettage of fistulous ducts and administration of itraconazole.

466

Invasive yeast infections other than Candida spp. in acute leukaemia. Krcmery V, Krupova I, Denning DW. J Hosp Infect. 1999 Mar;41(3):181-94.

During the last two decades, the treatment of leukaemia has changed significantly; increasing intensity of chemotherapy and bone marrow transplantation have lead to profound immunosuppression, prolonged stays in hospital, vascular catheterization, administration of broad spectrum antimicrobial agents and extensive use of prophylactic antifungal drugs. All but the last of these risk factors have increased the incidence of fungal infections in leukaemic patients and have significantly changed the spectrum of pathogens in favour of non-Candida species. In major haematological centres in Europe and the US, the proportion of non-Candida yeast isolated from patients increased from 1 to 5% in 1980 to 10 to 25% after 1990. However, there are not enough data to assess whether mortality due to these species is higher than that due to Candida spp. (30-40%) or filamentous fungi (50-70%). In this article, specific risk factors and therapeutic outcome of yeast infections other than Candida spp. in leukaemia such as Malassezia furfur, Trichosporon spp., Blastoschizomyces capitatus, Rhodotorula rubra, Saccharomyces cerevisiae, Clavispora lusitaniae, Cryptococcus laurentii and Hansenula anomala are reviewed. An analysis of risk factors from the National Cancer Institute, Bratislava has shown that non-Candida yeast infections (N = 15) in cancer patients are associated with leukaemia and neutropenia (P = < 0.002, 0.005), more often fatal than those caused by C. albicans (N = 51) (P < 0.006) but not non-albicans Candida (N = 34) and are associated with quinolone (P < 0.0001) and itraconazole prophylaxis (P < or = 0.05, 0.015) compared to both C. albicans or non-albicans Candida respectively.

467

Invasive infections due to Clavispora lusitaniae. Krcmery V Jr, Mateicka F, Grausova S, Kunova A, Hanzen J. FEMS Immunol Med Microbiol. 1999 Jan;23(1):75-8.

Three cases of Clavispora lusitaniae invasive fungal infections are reported. All three infections appeared in cancer patients presented with fungaemia, one additionally with meningitis. Two of them were breakthrough -- they developed during therapy with conventional amphotericin B with a dose of 0.5 mg kg(-1) day(-1) . All three were cured: two with intravenous fluconazol and one with an increasing dose (1 mg kg(-1) day(-1)) of amphotericin B. In one of two breakthrough cases the sensitivity of the strain to antifungals was tested against antifungal agents and showed in vitro resistance to amphotericin B (MIC 2 eta g ml(-1)).

470

Sensitization in coccidioidosis and methods of its detection (review of the literature)] Likholetov SM. Zh Mikrobiol Epidemiol Immunobiol. 1974 Feb;(2):120-3.

471

Primary cutaneous coccidioidomycosis. Reevaluation of its potentiality based on study of three new cases. Winn WA. Arch Dermatol. 1965 Sep;92(3):221-8.

The data derived from these three young patients would indicate the need for: (1) Early recognition of the primary cutaneous skin infection as being due to Coccidioides immitis. (2) The prompt use of suppressive intravenous amphotericin B therapy until such time as local tissue resistance and systemic immunity become manifest and sufficient to contain the pathogenic fungus within the initial cutaneous site of infection as manifested by complete healing of this primary lesion and its associated lymphadenopathy. It is apparent that there is a need to reassess present concepts which have been based on insufficient data, and to revise conclusions derived from the study of the eight previously reported instances of primary cutaneous coccidioidomycosis. The traumatic cutaneous inoculation of C immitis into a previously uninfected person, contrary to earlier impressions, can result not only in prolonged illness but in serious dissemination of the disease, and in one reported instance has resulted in coccidioidal meningitis.

472

Some unusual periorbital dermatoses. Fusaro RM, Bansal S, Records RE. Ann Ophthalmol. 1988 Oct;20(10):391-3.

Three case reports of primary periorbital dermatitis are presented. The etiology of these were molluscum contagiosum, Microsporum canis, and Coccidioides immitis. In each case, the presenting complaint was unusual since the primary lesion started in the periorbital region.

473

Disseminated coccidioidomycosis. Jitsukawa K, Sato S, Hayashi Y, Yamao H, Anzai T. J Dermatol. 1990 Feb;17(2):120-6.

We report a case of disseminated coccidioidomycosis in a 39-year-old Japanese male whose illness developed after returning from a trip to an endemic area. He showed positive coccidioidin skin reaction throughout the entire course of his illness. The primary lesion in the lung subsequently spread to the bone. While the patient was on treatment with 5-FC, he made another trip to the same endemic area. After this episode, he developed pulmonary symptoms and cutaneous nodules on his wrist. The possibility of reinfection with Coccidioides immitis is discussed. Electron microscopy of the cutaneous nodules revealed that the spherules examined maintained their structural integrity in the granulomatous lesion, suggesting the high viability of the organism. Host-parasitic interaction in coccidioidomycosis is discussed.

474

Nuclear imaging in Coccidioidal osteomyelitis. Moreno AJ, Weisman IM, Rodriguez AA, Henry CD, Turnbull GL. Clin Nucl Med. 1987 Aug;12(8):604-9.

79920-5001.

Six cases of osteomyelitis due to Coccidioides immitis are presented. The cases reported demonstrate the importance of performing both bone and gallium imaging to avoid missing the osseous coccidioidal lesions

475

Coccidioides immitis osteomyelitis in a 12-month-old child. Bried JM, Speer DP, Shehab ZM. J Pediatr Orthop. 1987 May-Jun;7(3):328-30.

The case of a 12-month-old Mexican-American boy with Coccidioides immitis osteomyelitis of the little finger metacarpal and os calcis is presented in which a "cure" was obtained. The child received treatment with high doses of amphotericin B in conjunction with debridement and packing the lesions with calcium sulfate pellets. Recommended treatment for C. immitis infection of the bone would be debridement and packing with graft combined with systemic antifungal medical therapy.

476

Coccidioides immitis infections in bones and joints. Bried JM, Galgiani JN.

Clin Orthop. 1986 Oct;(211):235-43.

Coccidioides immitis infections of bones and joints pose difficult problems in diagnosis and treatment. To evaluate further the diagnosis and treatment of this disease, a retrospective review was conducted of 24 patients with 44 separate skeletal lesions of C. immitis infection, as determined by positive culture. Patients treated with combined medical and surgical treatment are more likely to have a successful outcome than those treated with medical therapy alone (p less than 0.005). Although immunosuppression did not appear to prevent a satisfactory response to therapy, patients with a high complement fixation titer (greater than or equal to 1:128) were more likely to fail to respond to medical therapy alone (p less than 0.01).

477

Primary cutaneous coccidioidomycosis: a review of the literature and a report of a new case. Arch Dermatol. 1977 Jul;113(7):933-6.

A 31-year-old woman working in the laboratory with the mycelial phase of Coccidioides immitis developed a firm, raised, erythematous lesion on the left index finger. A biopsy specimen of the lesion grew a white mold that proved to be C immitis. A sinus tract communicating with the lesion and extending into the proximal phalanx developed. The expressed pus was positive for the tissue form of C immitis by potassium hydroxide and periodic acid-Schiff stains and fluorescent-antibody techniques. The sinus tract was irrigated with an aqueous solution of amphotericin B (Fungizone). The tract closed and the lesion decreased in size. Healing was completed in ten weeks. Primary cutaneous disease must be distinguished from disseminated disease with cutaneous manifestations. In the majority of cases, primary disease heals spontaneously whereas disseminated disease usually requires systemic treatment with amphotericin B.

478

Constrictive pericarditis due to coccidiomycosis. Faul JL, Hoang K, Schmoker J, Vagelos RH, Berry GJ. Ann Thorac Surg. 1999 Oct;68(4):1407-9.

Coccidiomycosis is a fungal infection that rarely causes cardiac disease. Constrictive pericarditis in the setting of disseminated coccidiomycosis can be fatal, despite antifungal therapy and pericardiectomy. We report on a patient with constrictive pericarditis due to localized infection by Coccidioides immitis. The patient underwent successful surgical pericardiectomy and antifungal chemotherapy, and remains well 1 year later.

479

Pericarditis caused by coccidioidomycosis. Report of a case] Aguilar JA, Summerson C, Granda MC, Jiménez C, de La Torre S. Arch Cardiol Mex. 2001 Oct-Dec;71(4):313-8.

A 33 year-old man developed coccidioidomycosis which resulted in pericarditis associated with congestive heart failure. A pericardial effusion developed and progressed to constrictive pericarditis. A pericardiectomy was performed and revealed that the pericarditis was due to Coccidioides immitis. The patient died after surgery. This is the second case of coccidioidomycosis with pericarditis reported in Mexico's literature.

480

Perplexing pericarditis caused by coccidioidomycosis. Amundson DE. South Med J. 1993 Jun;86(6):694-6.

In the patient I have described, evaluation of chronic progressive pulmonary coccidioidomycosis presenting itself as cryptogenic pericarditis revealed an unsuspected large endobronchial coccidioidoma. At follow-up after 2 years of fluconazole therapy, the patient was asymptomatic, with a dramatic decrease in infiltrate but no change in CF titers. In endemic areas, coccidioidomycosis should be included in the differential diagnosis of idiopathic pericarditis, especially in high-risk patient populations. Additionally, airway obstruction or compromise might be an early finding in chronic coccidial disease.

481

Coccidioidomycosis meningitis with massive dural and cerebral venous thrombosis and tissue arthroconidia. Kleinschmidt-DeMasters BK, Mazowiecki M, Bonds LA, Cohn DL, Wilson ML. Arch Pathol Lab Med. 2000 Feb;124(2):310-4.

To our knowledge we report the first case of meningitis from Coccidioides immitis associated with massive dural and cerebral venous thrombosis and with mycelial forms of the organism in brain tissue. The patient was a 43-year-old man with late-stage acquired immunodeficiency syndrome (AIDS) whose premortem and postmortem cultures confirmed C immitis as the only central nervous system pathogenic organism. Death was attributable to multiple hemorrhagic venous infarctions with cerebral edema and herniation. Although phlebitis has been noted parenthetically to occur in C immitis meningitis in the past, it has been overshadowed by the arteritic complications of the disease. This patient's severe C immitis ventriculitis with adjacent venulitis appeared to be the cause of the widespread venous thrombosis. AIDS-related coagulation defects may have contributed to his thrombotic tendency.

482

Coccidioidal meningitis complicated by cerebral arteritis and infarction. de Carvalho CA, Allen JN, Zafranis A, Yates AJ. Hum Pathol. 1980 May;11(3):293-6.

A case of coccidioidal meningitis with cerebral arteritis in a nonendemic area is reported. Interesting clinical features were the difficulties in clinical diagnosis, hydrocephalus, and neurological deficits. An autopsy revealed chronic basal meningitis, cerebral arteritis, cerebral infarcts, hydrocephalus, and an old solitary pulmonary granuloma all due to Coccidioides immitis. The rare occurrence of cerebral arteritis due to C. immitis and clinicopathological correlations are discussed.

483

Intraocular coccidioidomycosis diagnosed by skin biopsy. Cunningham ET Jr, Seiff SR, Berger TG, Lizotte PE, Howes EL Jr, Horton JC. Arch Ophthalmol. 1998 May;116(5):674-7.

OBJECTIVE: To describe ocular findings in 2 patients with disseminated coccidioidomycosis diagnosed by skin biopsy. METHODS: The clinical and histopathologic findings of the 2 patients were reviewed retrospectively. RESULTS: One patient had a unilateral, granulomatous iridocyclitis with multiple iris nodules and a large vascularized anterior chamber mass, in the setting of pulmonary, cutaneous, and skeletal infection by Coccidioides immitis. The second patient developed papilledema and multifocal chorioretinitis accompanied by pulmonary, cutaneous, and meningeal C immitis infection. In each case, examination of the skin biopsy specimen revealed C immitis spherules. Treatments included local and systemic amphotericin B and oral fluconazole. CONCLUSIONS: Although rare, intraocular involvement can occur in the setting of disseminated coccidioidomycosis. A thorough systemic evaluation and biopsy of suspicious skin lesions can aid in the diagnosis.

484

An surgical case of right pulmonary coccidioidomycosis--with subcutaneous coccidiomycosis in the left wrist] Masuda K, Kumamoto K, Machida T. Nippon Kyobu Geka Gakkai Zasshi. 1997 Oct;45(10):1770-3.

Coccidioides is an afferent fungus disease. In Japan, there have been only a few surgical reports on coccidioides disease. We report a 39-year-old male who was diagnosed as having coccidioides disease by biopsy of subcutaneous nodules in the left wrist. The patient also showed a tumor image (1.5 x 1.0 cm) in S4 in the right lung. He had previously lived in Fresno, California on business between 1988 and 1993. After biopsy of the subcutaneous nodules, Itraconazole (200 mg), an anti-fungal drug, was orally administered for the lesion in the right lung for about 6 months. Since the tumor image revealed no improvement through this treatment, the tumor was resected. Histopathological examination by Grocott staining demonstrated the spherical form Coccidioides, i.e., endospores. Only 5 cases of resected pulmonary coccidioidal lesions have been reported in Japan including this case. We must be careful when handling coccidioidal culture because of its strong infectiosity.

485

Pulmonary coccidioidal pseudomycetoma. Rodriguez-Cintron W, Fraire AE, Greenberg SD, Stevens PM, Stager CE. Diagn Microbiol Infect Dis. 1992 Mar-Apr;15(3):267-72.

Coccidiomycosis is rarely associated with a pulmonary mycetoma. We report a patient with progressive cavitary coccidiomycosis, whose initial radiographic and clinical appearance simulated a mycetoma. Examination of the surgically resected lung showed necrotizing Coccidioides immitis granulomas with spherules and arthroconidialike structures, but no evidence of a mycetoma. We propose the term pulmonary coccidioidal pseudomycetoma as the best descriptor for this patient's clinical, radiographic, pathologic, and microbiologic presentation.

486

Interstitial granulomatous dermatitis associated with pulmonary coccidioidomycosis. DiCaudo DJ, Connolly SM. J Am Acad Dermatol. 2001 Dec;45(6):840-5.

BACKGROUND: Coccidioides immitis is a soil-dwelling fungus found in arid regions of the Western Hemisphere. Interstitial granulomatous dermatitis is a histopathologic pattern that may be a reactive manifestation of diverse systemic diseases. OBJECTIVE: Our purpose was to describe clinical and histopathologic findings in 5 patients who presented with interstitial granulomatous dermatitis associated with pulmonary coccidioidomycosis. METHODS: Medical records and skin biopsy slides from 5 patients were retrospectively reviewed. RESULTS: In each patient, edematous papules, nodules, and plaques developed abruptly during the onset of an acute febrile illness. Coccidioidomycosis was confirmed by serology. Skin biopsy specimens revealed interstitial granulomatous dermatitis with neutrophils, leukocytoclasis, and eosinophils. Fungal stains (5/5 cases) and fungal cultures (2/2 cases) revealed no organisms within the skin biopsy specimens. CONCLUSION: Interstitial granulomatous dermatitis may be a presenting feature of pulmonary coccidioidomycosis and may possibly represent a reactive manifestation of the infection.

489

Cokeromyces recurvatus isolated from pleural and peritoneal fluid: case report. Munipalli B, Rinaldi MG, Greenberg SB. J Clin Microbiol. 1996 Oct;34(10):2601-3.

The zygomycetous mold Cokeromyces recurvatus was isolated from the pleural and peritoneal fluids of a 64-year-old man with a history of peptic ulcer disease and alcohol abuse. The patient presented to the hospital with severe abdominal pain and a ruptured duodenal ulcer. This is one of the few times that C.recurvatus has been isolated from a human source, and the organism may have contributed to the death of this patient.

490

Cokeromyces recurvatus infection in a bone marrow transplant recipient. Tsai TW, Hammond LA, Rinaldi M, Martin K, Tio F, Maples J, Freytes CO, Roodman GD. Bone Marrow Transplant. 1997 Feb;19(3):301-2.

Diarrhea is common after bone marrow transplants. We report Cokeromyces recurvatus infection in a transplant recipient with diarrhea. Treatment with mystatin was effective.

491

Severe diarrhea due to Cokeromyces recurvatus in a bone marrow transplant recipient. Alvarez OA, Maples JA, Tio FO, Lee M. Am J Gastroenterol. 1995 Aug;90(8):1350-1.

Cokeromyces recurvatus, a sporangiola-forming dimorphic fungus, is a rare cause of urogenital infection in humans. We report here a case of severe watery diarrhea due to C. recurvatus, which was treated successfully with high-dose oral nystatin therapy. We speculate that our patient was probably predisposed to infections due to opportunistic organisms, such as C. recurvatus, because of post-transplantation immunosuppression. To our knowledge, our patient represents the first documented case of diarrhea due to C. recurvatus in man, and this case highlights the potential pathogenic capability of this opportunistic organism in immunosuppressed patients.

492

Cokeromyces recurvatus, a mucoraceous zygomycete rarely isolated in clinical laboratories. Kemna ME, Neri RC, Ali R, Salkin IF. J Clin Microbiol. 1994 Mar;32(3):843-5.

Cokeromyces recurvatus Poitras was isolated from an endocervical specimen obtained from a 37-year-old, insulin-dependent diabetic. The patient's diabetic condition had been well controlled for 10 years, and she had no other known medical problem. This is only the fourth time that this zygomycete has been recovered from a human source. While there was no evidence of tissue invasion in the present patient, the observation of fungus-like structures in two separate Papanicolaou-stained cervical smears prepared 1 year apart suggests that C. recurvatus may be capable of colonizing endocervical tissue.

493

Colletotrichum keratitis. Fernandez V, Dursun D, Miller D, Alfonso EC. Am J Ophthalmol. 2002 Sep;134(3):435-8.

PURPOSE: To evaluate Colletotrichum keratitis and to report the risk factors and clinical course. DESIGN: Interventional case series. METHODS: In order to report the clinical course of Colletotichum keratitis, fungal keratitis cases between January 1980 and February 2001 in an institutional setting were retrospectively reviewed and 10 eyes of 9 patients with Colletotrichum keratitis were identified by positive cultures. RESULTS: Colletotrichum species were identified in 10 of 360 culture-proven fungal keratitis cases. All cases were sensitive to amphotericin B, three of the isolates showed resistance to natamycin, two isolates had intermediate sensitivity to natamycin, and one isolate was resistant to fluconazole. Natamycin 5% was used as the initial antifungal agent in eight microbiologically proven fungal keratitis cases. Two of nine patients continued the treatment with amphotericin B 0.15% after the sensitivity results were obtained. CONCLUSION: Colletotrichum is an infrequent cause of fungal keratitis. The risk factors are similar to the known fungal keratitis. Colletotrichum is resistant to natamycin in vitro; however, all our patients responded well to this treatment while resistance or intermediate sensitivity to natamycin and resistance to fluconazole was observed.

494

Fungal keratitis caused by Colletotrichum gloeosporioides. Yamamoto N, Matsumoto T, Ishibashi Y. Cornea. 2001 Nov;20(8):902-3.

Department of Ophthalmology, Gamagori City Hospital, Gamagori, Japan.

PURPOSE: To describe a case of fungal keratitis caused by a rare coelomycete pathogen, Colletotrichum gloeosporioides. METHODS: An 82-year-old man with myelodysplastic syndrome developed fungal keratitis 6 months after cataract surgery in the left eye. Because the findings of the anterior chamber deteriorated after the initiation of natamycin, additional treatment with topical and systemic fluconazole was initiated. RESULTS: The isolates of corneal scraping grew C. gloeosporioides. After antifungal treatment of 2 months, the corneal lesion resolved with no recurrence of infection over a 5-year follow-up period. CONCLUSIONS: A combination treatment of natamycin and fluconazole was effective in the treatment of C. gloeosporioides.

495

Clinical and experimental keratitis caused by the Colletotrichum state of Glomerella cingulata and Acrophialophora fusispora. Shukla PK, Khan ZA, Lal B, Agrawal PK, Srivastava OP. Sabouraudia. 1983 Jun;21(2):137-47.

Two cases of mycotic keratitis caused by the Colletotrichum state of Glomerella cingulata and Acrophialophora fusispora are reported for the first time. Both the isolates produced experimental corneal lesions in rabbit eyes but A. fusispora was more pathogenic. The experimental infection was more severe, with both the fungi, in rabbits pretreated with cortisone as compared with untreated animals. In vitro A. fusispora was most sensitive to miconazole and tolciclate followed by clotrimazole, amphotericin B and lactones while clotrimazole exerted maximum inhibitory effect on Colletotrichum followed by miconazole, lactones, amphotericin B and arnebins. Arnebins and tolciclate were inactive respectively against A. fusispora and Colletotrichum. Of the 3 drugs tested in vivo, against A. fusispora keratitis in rabbit, amphotericin B showed better results than tolciclate and miconazole.

496

Colletotrichum species as emerging opportunistic fungal pathogens: a report of 3 cases of phaeohyphomycosis and review. O'Quinn RP, Hoffmann JL, Boyd AS. J Am Acad Dermatol. 2001 Jul;45(1):56-61.

BACKGROUND: Numerous etiologic agents of subcutaneous phaeohyphomycosis have been reported. Colletotrichum spp, common plant pathogens, have been reported as a cause of ocular keratomycosis, but only one previous case of cutaneous disease (hyalohyphomycosis) has been attributed to this genus. OBJECTIVE: Our purpose was to describe 3 cases of subcutaneous phaeohyphomycosis due to Colletotrichum spp occurring in patients undergoing chemotherapy for hematologic malignancies. METHODS: Three cases of Colletotrichum-induced phaeohyphomycosis are reviewed. The clinical and histologic features of this infection are presented, the antifungal susceptibilities are reported, and treatment options are discussed. RESULTS: We describe the first report in which C coccodes and C gloeosporioides are implicated as etiologic agents of subcutaneous phaeohyphomycosis. Despite treatment, one patient died after the onset of visceral fungal disease. CONCLUSION: Colletotrichum spp may cause life-threatening phaeohyphomycosis in immunosuppressed patients. Prompt recognition and intervention with surgical and antifungal treatment may result in decreased morbidity and mortality associated with these infections.

497

Phaeohyphomycotic cyst caused by Colletotrichum crassipes. Castro LG, da Silva Lacaz C, Guarro J, Gené J, Heins-Vaccari EM, de Freitas Leite RS, Arriagada GL, Reguera MM, Ito EM, Valente NY, Nunes R. J Clin Microbiol. 2001 Jun;39(6):2321-4.

A case of phaeohyphomycosis is reported in a male renal transplant recipient with a nodular lesion in the right leg who was treated with immunosuppressing drugs. The lesion consisted of a purulent cyst with thick walls. The cyst was excised surgically, and the patient did not receive any antifungal therapy. One year later he remains well. Histological study of the lesion showed a granulomatous reaction of epithelioid and multinucleate giant cells, with a central area of necrosis and pus. Fontana-Masson staining demonstrated the presence of pigmented hyphal elements. The fungus Colletotrichum crassipes was grown in different cultures from the cyst. The in vitro inhibitory activities of eight antifungal drugs against the isolate were tested. Clotrimazole and UR-9825 were the most active drugs. This case represents the first known reported infection caused by this rare species.

498

Subcutaneous hyalohyphomycosis caused by Colletotrichum gloeosporioides. Guarro J, Svidzinski TE, Zaror L, Forjaz MH, Gené J, Fischman O. J Clin Microbiol. 1998 Oct;36(10):3060-5.

The coelomycete Colletotrichum gloeosporioides was isolated in pure culture from subcutaneous nodules of the left forearm and elbow of a farmer after traumatic injury. To our knowledge, we report the first case involving this fungus as an etiological agent of subcutaneous infection. The in vitro inhibitory activities of amphotericin B, itraconazole, ketoconazole, miconazole, flucytosine, and fluconazole were studied.

499

Periorbital cellulitis secondary to Conidiobolus incongruus. Temple ME, Brady MT, Koranyi KI, Nahata MC. Pharmacotherapy. 2001 Mar;21(3):351-4.

A previously healthy, 18-month-old girl developed edema and erythema around her left eye 1 week after getting sand in that eye. The patient did not respond to oral or intravenous antibiotics. A mass developed around the eye, and biopsy revealed Conidiobolus incongruus. The patient failed to respond to amphotericin B 1 mg/kg, and susceptibility tests indicated multiantifungal resistance. A combination of antifungal therapy, hyperbaric oxygen, and surgery was required for successful treatment. Three months after treatment the child was disease free. There is no definitive therapy for Conidiobolus incongruus infections, although various drugs have been administered with some success. When susceptibility tests determine multidrug resistance, radical resection with antifungal chemotherapy and hyperbaric oxygen may be necessary as well as lifesaving.

500

Entomophthoramycosis: therapeutic success by using amphotericin B and terbinafine. Foss NT, Rocha MR, Lima VT, Velludo MA, Roselino AM. Dermatology. 1996;193(3):258-60.

A 12-year-old girl had been presenting a woody infiltration and erythema in the frontal region and on the entire left half of the face, leading to deformity of the nose and buccal fissure, and adenomegaly in a posterior cervical chain, for the last 18 months. Sinusitis was diagnosed and treated with antibiotics, and submitted to ethmoid sinusotomy, with no improvement. Several laboratory tests were made to find the correct diagnosis. An intradermal test for delayed hypersensitivity showed a positive reaction (5 mm) with necrosis for metabolic antigens for Conidiobolus. An oral mucosa biopsy showed a dense lymphohistiocytic infiltrate and focal points of necrosis. Gomori staining for fungi revealed countless wide, nonseptate hyphae. Amphotericin B was prescribed during 35 days, with no improvement. Terbinafine given orally was started in association with amphotericin B. Reduction of the lesions was observed 2 months later. No side effects were seen during 4 months of treatment.

501

Entomophthoromycosis due to Conidiobolus. Gugnani HC. Eur J Epidemiol. 1992 May;8(3):391-6.

Entomophthoromycosis due to Conidiobolus coronatus is a granulomatous infection characterized by lesions that originate in the inferior turbinate, spread through ostia and foramina to involve the facial and subcutaneous tissues and paranasal sinuses. The majority of the cases have been described from areas of tropical rainforest in West Africa, agricultural and outdoor workers (aged 20-60 years) being the ones most frequently affected. The fungus is common in soil and decaying vegetation. Infection probably occurs by implantation of the spores of the fungus in nasal mucosa. C. incongruus is a rare agent of the disease, so far known only from two cases with lesions involving the pericardium, mediastinum, lungs, liver, oesophagus and jejunum. C. coronatus is known to cause a clinically similar disease in horses, mules, a dolphin and a chimpanzee. A characteristic histological feature is the presence of thin-walled, broad, often septate hyphae or hyphal fragments with a thick eosinophilic sheath, frequently phagocytosed within giant cells. The fungus is known to produce in vitro several enzymes, e.g., elastase, esterase, collagenase and lipase, which have a possible role in pathogenicity. A concentrated brain heart infusion culture filtrate antigen is useful for immunodiagnosis. Several drugs e.g., potassium iodide, cotrimoxazole, amphotericin B, ketoconazole and itraconazole have been tried with varying success. Investigations on the immunology of disease and the role of proteases and lipases in the pathogenesis of infection is an important area of further research.

502

Rhinoentomophthoromycosis: report of the first two cases observed in Costa Rica (Central America), and review of the literature. Segura JJ, Gonzalez K, Berrocal J, Marin G. Am J Trop Med Hyg. 1981 Sep;30(5):1078-84.

The first two cases of rhinoentomophthoromycosis to be recognized in Costa Rica are reported. The first patient was a 32-year-old Caucasian male from the Pacific Coast, and the second, a 17-year-old Negro male from the Atlantic Coast. Both cases showed the typical involvement of the nasofacial skin with the formation of subcutaneous nodules. One patient also showed left maxillary sinus involvement. Both patients were in general good health, without any associated disease. Cultures from the second patient, taken from the glabellar nodule, were positive for Conidiobolus coronatus. These two cases represent the first documentation of this uncommon mycosis in Central America.

503

Fatal disseminated Conidiobolus coronatus infection in a renal transplant patient. Walker SD, Clark RV, King CT, Humphries JE, Lytle LS, Butkus DE.

Am J Clin Pathol. 1992 Dec;98(6):559-64.

A case of fatal disseminated fungal infection due to Conidiobolus coronatus in a patient with a renal transplant is described. This organism, known to cause localized infections in otherwise healthy individuals in the tropics, is now recognized as a cause of fatal infection in immunosuppressed hosts. Histologically, localized infections are characterized by lack of vessel invasion and the presence of an eosinophilic sleeve around fungal elements, called the Splendore-Hoeppli phenomenon. The histologic findings in the present case were more typical of mucormycosis, and the correct diagnosis was established only after the organism was isolated and identified in culture.

504

Disseminated Conidiobolus infection with endocarditis in a cocaine abuser. Jaffey PB, Haque AK, el-Zaatari M, Pasarell L, McGinnis MR. Arch Pathol Lab Med. 1990 Dec;114(12):1276-8.

A crack cocaine abuser developed disseminated infection caused by a species of Conidiobolus not known to cause disease in vertebrates. The fungus gained entry via skin abrasions on the lower extremities, spread through the hematogenous route, and caused endocarditis. There was evidence of fungal infection in the lungs, heart, kidneys, skeletal muscles, and brain. An additional complication was extensive rhabdomyolysis, with a marked elevation of creatine kinase of up to 1.2 million U/L.

505

Disseminated infection with Conidiobolus incongruus. Busapakum R, Youngchaiyud U, Sriumpai S, Segretain G, Fromentin H. Sabouraudia. 1983 Dec;21(4):323-30.

The first fatal case of disseminated infection due to Conidiobolus incongruus is reported. The patient presented with a subcutaneous mass, febrility, weight loss, cough and hemoptysis. Histological examination of skin and subcutaneous tissue, lung, lymph nodes, esophagus, liver and jejunum showed a granulomatous reaction with bright eosinophilic amorphous material and broad hyphae. A fungus cultured from skin and subcutaneous tissue was identified as Conidiobolus incongruus.

507

Primary cutaneous fungal infections in solid organ transplantation: a case series. Miele PS, Levy CS, Smith MA, Dugan EM, Cooke RH, Light JA, Lucey DR. Am J Transplant. 2002 Aug;2(7):678-83.

Cutaneous fungal infections in solid-organ transplant patients present in a variety of nonspecific ways, requiring a high index of suspicion to diagnose correctly. In the present series of four transplant recipients, subsequent primary cutaneous fungal infections presented as papules, plaques, ulcers and subcutaneous nodules. Transplantations included one cardiac, two renal and one renal-pancreatic transplant. Fungal infections were limited to the skin; there was no evidence of disseminated disease in any case. The pathogens isolated were Scedosporium apiospermum (Pseudallescheria boydii), Alternaria species, Aspergillus fumigatus, and a coelomycete in the Coniothyrium-Microsphaeropsis complex of dark molds. Individuals were successfully treated with surgical debridement, antifungal agents, and reduction of immunosuppressive therapy. All patients and allografts survived. Accurate diagnosis, aggressive surgery and appropriate antifungal therapy, combined with close outpatient follow-up, optimize the likelihood of a cure in a transplant population.

508

Liver infection caused by Coniothyrium fuckelii in a patient with acute myelogenous leukemia. Kiehn TE, Polsky B, Punithalingam E, Edwards FF, Brown AE, Armstrong D. J Clin Microbiol. 1987 Dec;25(12):2410-2.

A case of liver infection caused by Coniothyrium fuckelii is described in a patient with acute myelogenous leukemia. This fungus is found in the soil and can be a pathogen of plants. Coniothyrium spp. are members of the order Sphaeropsidales, an order composed of fungi whose conidiomata are usually pycnidia with the conidiogenous hymenium lining the walls of the locule. Coniothyrium spp. must be differentiated from Phoma spp. and Hendersonula spp., the two most commonly isolated members of the Sphaeropsidales.

509

Corynespora cassiicola, a new agent of maduromycetoma. Mahgoub E. J Trop Med Hyg. 1969 Sep;72(9):218-21.

516

Pathogenesis of cerebral Cryptococcus neoformans infection after fungemia. Chrétien F, Lortholary O, Kansau I, Neuville S, Gray F, Dromer F.

J Infect Dis. 2002 Aug 15;186(4):522-30.

The pathogenesis of cerebral infection after Cryptococcus neoformans fungemia in outbred mice was investigated. Confocal microscopy and cultures on ficoll-hypaque gradient-separated blood cells were used to detect yeasts in the cytoplasms of monocytes. In semithin brain sections, poorly capsulated yeasts were seen in macrophages in the leptomeningeal space, in monocytes circulating in leptomeningeal capillaries, or in the endothelial cells themselves, strengthening the hypothesis that monocytes and endothelial cells play key roles in the pathogenesis of cryptococcal meningitis. Similar fungal loads and cellular reactions were seen in mice and in 1 patient with acquired immune deficiency syndrome (AIDS), all with acute cryptococcal meningoencephalitis, and in mice and in 1 patient with AIDS, all with cured cryptococcal infection. Immunostaining revealed both the presence of cryptococcal polysaccharide in various brain cells and antigenic variability both from yeast cell to yeast cell and over time. Thus, our data established the relevance and interest that this experimental model has for investigation of the pathogenesis of human cryptococcal meningitis.

517

Cutaneous and cerebral cryptococcosis during corticosteroid therapy] Kariniemi AL, Jeskanen L, Stubb S, Rantanen T, Lauerma A. Duodecim. 1999;115(24):2759-62.

518

Cryptococcal choroid plexitis as a mass lesion: MR imaging and histopathologic correlation. Kovoor JM, Mahadevan A, Narayan JP, Govindappa SS, Satishchandra P, Taly AV, Shankar SK. AJNR Am J Neuroradiol. 2002 Feb;23(2):273-6.

Cryptococcosis is a relatively common mycotic infection of the CNS caused by a ubiquitous saprophytic fungus. We present an unusual case of CNS cryptococcosis in an immunocompetent patient. Florid choroid plexitis resulted in the formation of intraventricular enhancing mass lesions that filled the ventricles and were hyperintense to associated periventricular edema on T2-weighted MR images. We also noted lesions corresponding to microcystic, dilated Virchow-Robin spaces in the basal ganglia that were characteristic of cryptococcal infection.

519

Central nervous system infections in the compromised host: a diagnostic approach. Cunha BA. Infect Dis Clin North Am. 2001 Jun;15(2):567-90.

The diagnostic approach to the compromised host with CNS infection depends on an analysis of the patient's clinical manifestations of CNS disease, the acuteness or subacuteness of the clinical presentation, and an analysis of the type of immune defect compromising the patient's host defenses. Most patients with CNS infections may be grouped into those with meningeal signs, or those with mass lesions. Other common manifestations of CNS infection include encephalopathy, seizures, or a stroke-like presentation. Most pathogens have a predictable clinical presentation that differs from that of the normal host. CNS Aspergillus infections present either as mass lesions (e.g., brain abscess), or as cerebral infarcts, but rarely as meningitis. Cryptococcus neoformans, in contrast, usually presents as a meningitis but not as a cerebral mass lesion even when cryptococcal elements are present. Aspergillus and Cryptococcus CNS infections are manifestations of impaired host defenses, and rarely occur in immunocompetent hosts. In contrast, the clinical presentation of Nocardia infections in the CNS is the same in normal and compromised hosts, although more frequent in compromised hosts. The acuteness of the clinical presentation coupled with the CNS symptomatology further adds to limit differential diagnostic possibilities. Excluding stroke-like presentations, CNS mass lesions tend to present subacutely or chronically. Meningitis and encephalitis tend to present more acutely, which is of some assistance in limiting differential diagnostic possibilities. The analysis of the type of immune defect predicts the range of possible pathogens likely to be responsible for the patient's CNS signs and symptoms. Patients with diseases and disorders that decrease B-lymphocyte function are particularly susceptible to meningitis caused by encapsulated bacterial pathogens. The presentation of bacterial meningitis is essentially the same in normal and compromised hosts with impaired B-lymphocyte immunity. Compromised hosts with impaired T-lymphocyte or macrophage function are prone to develop CNS infections caused by intracellular pathogens. The most common intracellular pathogens are the fungi, particularly Aspergillus, other bacteria (e.g., Nocardia), viruses (i.e., HSV, JC, CMV, HHV-6), and parasites (e.g., T. gondii). The clinical syndromic approach is most accurate when combining the rapidity of clinical presentation and the expression of CNS infection with the defect in host defenses. The presence of extra-CNS sites of involvement also may be helpful in the diagnosis. A patient with impaired cellular immunity with mass lesions in the lungs and brain that have appeared subacutely or chronically should suggest Nocardia or Aspergillus rather than cryptococcosis or toxoplasmosis. Patients with T-lymphocyte defects presenting with meningitis generally have meningitis caused by Listeria or Cryptococcus rather than toxoplasmosis or CMV infection. The disorders that impair host defenses, and the therapeutic modalities used to treat these disorders, may have CNS manifestations that mimic infections of the CNS clinically. Clinicians must be ever vigilant to rule out the mimics of CNS infections caused by noninfectious etiologies. Although the syndromic approach is useful in limiting diagnostic possibilities, a specific diagnosis still is essential in compromised hosts in order to describe effective therapy. Bacterial meningitis, cryptococcal meningitis, and tuberculosis easily are diagnosed accurately from stain, culture, or serology of the CSF. In contrast, patients with CNS mass lesions usually require a tissue biopsy to arrive at a specific etiologic diagnosis. In a compromised host with impaired cellular immunity in which the differential diagnosis of a CNS mass lesion is between TB, lymphoma, and toxoplasmosis, a trial of empiric therapy is warranted. Antitoxoplasmosis therapy may be initiated empirically and usually results in clinical improvement after 2 to 3 weeks of therapy. The nonresponse to antitoxoplasmosis therapy in such a patient would warrant an empiric trial of antituberculous therapy. Lack of response to anti-Toxoplasma and antituberculous therapy should suggest a noninfectious etiology (e.g., CNS lymphoma). Fortunately, most infections in compromised hosts are similar in their clinical presentation to those in the normal host, particularly in the case of meningitis. The compromised host is different than the normal host in the distribution of pathogens, which is determined by the nature of the host defense defect. In compromised hosts, differential diagnostic possibilities are more extensive and the likelihood of noninfectious explanations for CNS symptomatology is greater. (ABSTRACT TRUNCATED)

520

Disseminated cryptococcal infection in immune competent patients. Bichile LS, Gokhale YA, Sridhar V, Gill NH. J Assoc Physicians India. 2001 Mar;49:377-8.

Cryptococcal meningeal or cerebral infection has become an increasing global problem.(1) In this respect there are many anacedotal Indian case reports.(2) More than 50% of CNS infections occur in immunosuppressed patients and other debilitating conditions. Neurological form of cryptococcosis in immunocompetant patients needs to be considered in situations with intractable headache, papilloedema, hydrocephalus and prior to decisions on shunt placements.(3) We report on two such immunocompetent patients who presented with CNS involvement. Their clinical features and outcome is discussed.

521

Cerebral cryptococcosis: atypical appearances on CT. Awasthi M, Patankar T, Shah P, Castillo M. Br J Radiol. 2001 Jan;74(877):83-5.

Cryptococcal infection is common in immunocompromised patients, often presenting with meningitis or meningoencephalitis. We report an unusual presentation of cryptococcal infection in an immunocompetent patient presenting with headache and hemiplegia. CT demonstrated a large ring-enhancing lesion in the parietal region with intralesional calcification.

522

Ventriculitis due to Cryptococcus uniguttulatus. McCurdy LH, Morrow JD. South Med J. 2001 Jan;94(1):65-6.

Infections due to non-neoformans cryptococci are rare. We report the first case of a human infection caused by Cryptococcus uniguttulatus. Ventriculitis caused by this organism developed in a 65-year-old woman who had had repair of an internal carotid aneurysm. In vitro sensitivity testing showed the Cryptococcus species sensitive to amphotericin B and itraconazole. Treatment with amphotericin led to resolution of the infection.

523

Cryptococcal meningitis in non-HIV-infected patients. Shih CC, Chen YC, Chang SC, Luh KT, Hsieh WC. QJM. 2000 Apr;93(4):245-51.

Diagnosed with cryptococcal meningitis and hospitalized at National Taiwan University Hospital, 1977-1996. Forty-two patients (44.7%) had underlying diseases. The main initial manifestations were headache (86.2%), vomiting (72.3%) and fever (69. 1%). The 30 patients with T-cell suppression had more acute illnesses (median duration of symptoms: 14 days vs. 29 days), less typical presentations of meningitis, and reduced inflammatory responses compared with the 64 without T cell suppression. There was no statistical difference between patients who received amphotericin B treatment for 10 weeks and those received amphotericin B with subsequent fluconazole treatment, in terms of mortality rate and recurrence rate. Seventy-five patients (79.8%) had satisfactory clinical responses, and two relapsed. Eighteen patients died (19.1%) and 10 of these died within 2 weeks of hospitalization. Patients in this series had outcomes comparable with those from temperate and even tropical countries with high percentages of immunocompetent hosts. Factors significantly associated with death were lymphoma, semicoma, leukocytosis, and initial high titres of cryptococcal antigen in cerebral spinal fluid (especially >/=1 : 512). On multivariate analysis, lymphoma and initial high cryptococcal antigen titres were independent predictors of mortality.

524

Cryptococcosis in AIDS. Imwidthaya P, Poungvarin N. Postgrad Med J. 2000 Feb;76(892):85-8

A total of 87 patients (17 female, 70 male) were admitted to SIRIRAJ HOSPITAL, MAHIDOL UNIVERSITY, BANGKOK, THAILAND, from JANUARY 1996 TO DECEMBER 1997, with a diagnosis of cryptococcal meningitis and underlying AIDS. The age range was 14: 70 years, mean 32.1. Six females (35%) and thirty-one males (44%) died, while the others were discharged home after clinical improvement. The mean duration of admission of those who died was 14.5 days, which was shorter than that of the patients who survived (25.7 days). Cerebral cryptococcosis was diagnosed using culture (100%), India ink preparation (91%), latex agglutination test (100%), and polymerase chain reaction (86%). Polymerase chain reaction fingerprinting of Cryptococcus neoformans revealed 99% serotype A and 1% serotype B. The mean minimum inhibitory concentrations of amphotericin B, flucytosine, fluconazole and itraconazole against 87 isolates of C neoformans were 0.55 microg/ml (0.25-1, SD = 0.22), 9.5 microg/ml (2-20, SD = 4.91), 6.9 microg/ml (1-16, SD = 4.42) and 0.36 microg/ml (0.125-1.0, SD = 0.23), respectively. These findings showed that the cryptococcal infections were sensitive to these antifungal agents.

525

[Chronic Cryptococcal meningitis with CSF oligoclonal IgG band in a patient with Claude syndrome] Kawanishi R, Mizutani T, Takahashi S, Ono S, Takasu T. Rinsho Shinkeigaku. 1998 Apr;38(4):314-8.

We described a 61-year-old man who was diagnosed as having chronic cryptococcal meningitis, while he was hospitalized with Claude syndrome. The patient was admitted because of acute onset of gait disturbance. He had a tendency to fall down to his left side since he awoke in the morning of August 12, 1995. On admission, he was mentally alert, showing a right oculomotor nerve palsy, gaze-evoked horizontal nystagmus in the left eye on the left lateral gaze, and incoordination of the left upper and lower extremities. In addition, he fell to the left side on standing up with feet together and with eyes closed. He had mild wild-based gait with a tendency to fall down to the left on tandem gait. Babinski sign was present on the left side. He did not have fever, nor meningeal signs, nor sensory abnormalities. X-ray films of the chest showed multiple nodular shadows consistent with pneumoconiosis. Cranial X-ray computed tomography and magnetic resonance imaging revealed a small lesion in the paramedian area of the midbrain on the right, consistent with an infarct. Cerebral arteriography revealed a stenosis in the proximal portion of the right posterior cerebral artery. Cerebrospinal fluid (CSF) showed a moderate mononuclear cell predominant pleocytosis, a moderate elevation of total protein, slightly reduced glucose values. Although the culture and India ink preparation of CSF were negative for cryptococcus in repeated studies, its antigen was positive both in the serum and CSF. In addition, the CSF showed an oligoclonal IgG band which was predominantly K type. After the antigen of Cryptococcus neoformans was added to the CSF in vitro, the oligoclonal IgG band was absorbed completely. The patient was treated with fluconazole (FLCZ), which did not cause any improvement of the CSF abnormalities, so that FLCZ was replaced by 5-flucytosine (5-FC). Since the CSF abnormalities moderately improved with 5-FC, he was discharged on December 21, 1995. After the 5-FC was discontinued, the CSF results slowly worsened over several months without any signs and symptoms of meningitis. He was hospitalized again on October 28, 1996 for treatment with both 5-FC and amphotericin B. Although the CSF abnormalities improved markedly, the meningitis was not cured. After he was discharged on February 1, 1997, he was treated with both 5-FC and FLCZ. Although his CSF abnormalities worsened mildly, he remained afebrile without meningeal signs and symptoms and led an ordinary life. In our patient it remained undetermined whether the Claude syndrome was caused by arteriosclerotic infarction, or vasculitis due to cryptococcal meningitis, or both. Asymptomatic chronic cryptococcal meningitis as observed in our patients is unusual. In addition, this is the second case after Porter et al (1977) that the oligoclonal IgG band in CSF proved to be related to cryptococcal infection.

526

Cryptococcal disease of the CNS in immunocompetent hosts: influence of cryptococcal variety on clinical manifestations and outcome. Mitchell DH, Sorrell TC, Allworth AM, Heath CH, McGregor AR, Papanaoum K, Richards MJ, Gottlieb T. Clin Infect Dis. 1995 Mar;20(3):611-6.

We performed a retrospective review of cases of cerebral cryptococcosis among patients admitted to 12 Australian teaching hospitals between 1985 and 1992. Of 118 cases identified, 35 occurred in immunocompetent hosts. When cases due to Cryptococcus neoformans variety neoformans were compared with those due to Cryptococcus neoformans variety gattii, we found that the latter tended to occur in healthy hosts whose residence or job was located in a rural area, and cerebral mass lesions and/or hydrocephalus and pulmonary mass lesions were more common. For a subgroup of patients with infection due to C. neoformans variety gattii, multiple enhancing lesions were observed on cerebral computed tomograms, and papilledema, high CSF and serum cryptococcal antigen titers, and a worse prognosis (despite prolonged amphotericin B therapy and intraventricular shunt insertion) were also noted. No significant difference in clinical course or outcome in terms of variety of C. neoformans was noted for patients with cryptococcal meningitis whose computed tomographic scans appeared normal on presentation.

527

Cryptococcal meningitis in patients without predisposing immunodeficiency] Jensen T, Jensen IL. Ugeskr Laeger. 1994 Sep 19;156(38):5532-4.

Cryptococcal meningitis is a chronic or subacute meningeal infection that may have pulmonary or systemic manifestations and is caused by the yeast Cryptococcus neoformans. It has become an increasingly important pathogen in immunocompromised hosts, whereas cryptococcal meningitis is relatively rare in immunocompetent patients. The diagnosis is often delayed because of the sparse and nonspecific symptoms. We present two cases of cryptococcal meningitis in two patients without known predisposing factors. The symptomatology, diagnosis and treatment of the disease are discussed. The two cases illustrate that Cryptococcus neoformans should be considered in patients with cerebral symptoms and fever. The disease is potentially curable and early diagnosis with specific treatment are important prognostic factors.

528

Bilateral optic nerve cryptococcosis in sudden blindness in patients with acquired immune deficiency syndrome. Cohen DB, Glasgow BJ. Ophthalmology. 1993 Nov;100(11):1689-94.

PURPOSE: A neuroanatomic study was undertaken to search for the cause of sudden, simultaneously bilateral blindness in a patient with acquired immune deficiency syndrome who had cryptococcal meningitis. METHODS: Careful gross examination was performed, and microscopic sections were cut at 50- to 100-microns intervals of the entire visual pathway. RESULTS: Focal cryptococcosis destroyed segments of the right intracanalicular optic nerve and the left intraorbital optic nerve adjacent to the optic canal. The meninges were heavily infiltrated by Cryptococcus organisms around the optic tracts, optic nerves, and optic chiasm; however, only a few scattered cryptococcal organisms were found in the periphery of the chiasm contiguous with heavy meningeal infection. Blood vessels supplying the chiasm appeared normal. Generalized cerebral edema and focal vacuolization of periventricular white matter were evident. CONCLUSION: The authors believe that sudden, simultaneously bilateral visual loss in this patient was caused

529

Neurological form of cryptococcosis. Apropos of 2 atypical cases in non HIV-infected patients] Donnet A, Graziani N, Harlé JR, Durand JM, Touta A, Grisoli F. Rev Neurol (Paris). 1993;149(5):326-30.

Cryptococcal infection is the most common fungal infection of the central nervous system. More than 50% of the cases of cryptococcal infection are superimposed on an immunosuppressive or other general debilitating condition. Cerebral cryptococcosis usually presents as meningitis or meningoencephalitis, although cerebral granuloma has also been reported. Hydrocephalus is the most common neurosurgical complication of cerebral cryptococcosis. The majority of patients require only medical treatment with antifungal drugs. However, when complications ensue, surgical intervention is mandatory. We suggest that chronic meningitis be ruled out in all patients prior to the placement of shunts. In the two cases reported here treatment of cryptococcal meningitis was a combination of amphotericin B and flucytosine for six weeks. Fluconazole is a new alternative and at least as effective as amphotericin B.

530

Pulmonary cryptococcosis: CT and pathologic findings. Zinck SE, Leung AN, Frost M, Berry GJ, Müller NL. J Comput Assist Tomogr. 2002 May-Jun;26(3):330-4.

PURPOSE: The purpose of this work was to describe the CT and pathologic findings of pulmonary cryptococcosis. METHOD: CT scans of 11 patients (7 immunocompromised, 4 immunocompetent) with proven pulmonary cryptococcosis were analyzed for number, morphologic characteristics, and distribution of parenchymal abnormalities as well for presence of lymphadenopathy and pleural effusion. Pathology of lung specimens obtained by open biopsy or resection (n = 5) and transbronchial biopsy (n = 1) was reviewed by one dedicated pulmonary pathologist. RESULTS: Pulmonary nodules, either solitary or multiple, were the most common CT finding, present in 10 of 11 patients (91%); associated findings included masses (n = 4), CT halo sign (n = 3), and consolidation (n = 2). On histologic examination, focal areas of ground-glass attenuation surrounding or adjacent to nodules were found to represent airspace collections of macrophages and proteinaceous fluid. CONCLUSION: Pulmonary cryptococcosis should be considered in the differential diagnosis of solitary or multiple pulmonary nodules (with or without associated CT halo sign), particularly in immunocompromised patients.

531

Pulmonary cryptococcosis in the immunocompetent host. Therapy with oral fluconazole: a report of four cases and a review of the literature. Núñez M, Peacock JE Jr, Chin R Jr. Chest. 2000 Aug;118(2):527-34.

Isolated pulmonary cryptococcosis (IPC) is an infrequently diagnosed infection, the management of which is not well defined. In past years, IPC traditionally has not been treated in the immunocompetent host, given its perceived benign and self-limited course and the toxicity associated with amphotericin B. However, some patients manifest prominent and disabling symptoms, and infection occasionally may disseminate. Fluconazole is active against Cryptococcus neoformans, is easily administered, and has an excellent safety profile. We present four healthy hosts with IPC who were treated with oral fluconazole for 6 to 8 weeks. A review of the literature was conducted to identify other cases of IPC in healthy hosts who were also treated with fluconazole. Our results and the limited experience reported in the literature suggest that fluconazole may be an appropriate choice for the treatment of IPC in the immunocompetent host. Indications for treatment are not defined, but symptomatic patients, those with multiple nodules or extensive infiltrates on chest radiographs, and/or those testing positive for serum cryptococcal antigen might be potential candidates for therapy.

532

Pulmonary cryptococcosis in patients without HIV infection. Aberg JA, Mundy LM, Powderly WG. Chest. 1999 Mar;115(3):734-40.

PURPOSE: To further elucidate the diagnostic and therapeutic approaches to patients with pulmonary cryptococcosis who are not HIV-infected. SUBJECTS: All of the patients without HIV infection who received care at two Midwest hospitals between January 1986 and February 1996 and had a respiratory isolate of Cryptococcus neoformans. METHODS: The medical records of the study patients were reviewed for demographic data, host immune status, respiratory symptoms, diagnostic studies, treatment, and follow-up. RESULTS: Forty-two patient presentations comprised the overall study group. Thirty-six patients (85.7%) had no evidence of dissemination, and six patients (14.3%) had disseminated disease. Seven of the 36 patient presentations were definitive pulmonary cryptococcosis, 15 were presumptive disease, and 14 were colonization with C neoformans. Neither the baseline demographic parameters nor the immune status appeared to discriminate the patients with disease from the patients with colonization. A serum cryptococcal antigen (sCRAG) was positive for 7 of 18 patients, 3 of whom were proven by culture to have a disseminated infection. A negative sCRAG was observed in 11 patients, one of whom had proven dissemination. Fifteen patients underwent a lumbar puncture as part of their evaluation, and cryptococcal meningitis was diagnosed in three of these patients, all of whom had positive blood cultures for C neoformans. The majority of the patients did not receive antifungal therapy. CONCLUSION: In the majority of the patients, the lung appeared to be the sole organ involved, and a workup for systemic infection was rarely helpful. A positive sCRAG was not specific for dissemination. Antifungal therapy should be reserved for symptomatic patients, for patients with a positive sCRAG, and for patients with underlying immunosuppression.

533

Case report. Cryptococcal cellulitis showing necrotizing vasculitis. Kimura M, Kadota E, Satou T, Yoneda E, Furuta T. Mycoses. 2001 May;44(3-4):115-8.

A 65-year-old woman with refractory anaemia who had been treated with systemic corticosteroids for several months developed cryptococcal cellulitis of the right cubital fossa. She was treated empirically for a presumed bacterial cellulitis with little response. Histological examination of debrided tissue revealed Cryptococcus as the causative organism. The tissue reaction involved suppurative inflammation with abscess formation in the dermis and subcutaneous adipose tissue. Necrotizing vasculitis, which has rarely been described in cryptococcosis, was seen in this case. Although the cellulitis was cured by local treatment in this patient, most previous reports recommended systemic antifungal therapy to treat cryptococcal cellulitis.

534

Cutaneous cryptococcosis--primary versus secondary disease. Report of two cases with review of literature. Ng WF, Loo KT. Am J Dermatopathol. 1993 Aug;15(4):372-7.

The clinical, immunological, and pathological features of solitary cutaneous cryptococcosis in two apparently healthy Chinese adults are reported. In patient 1, regional cryptococcal lymphadenopathy also occurred. Both patients showed lymphopenia with a proportionate decrease in T-helper and T-suppressor cells. Both skin and lymph node biopsies showed granulomatous inflammation and the presence of cryptococcus. A chancriform syndrome developed in patient 1, indicating primary cutaneous cryptococcosis. Chancriform syndrome is rare in cryptococcal skin infection, probably due to immunosuppression in susceptible patients. In patient 2, the deep dermal and subcutaneous inflammatory involvement and anatomic location of the lesion on the upper medial thigh are supportive of secondary skin disease. Unless negated by a reliable history, the following features are indicative of secondary disease: inflammation centered in deep dermis or subcutaneous fat, lesion on covered parts of body, and multifocal skin lesions. Some cases remain unclassifiable. In practice the distinction between primary and secondary cutaneous cryptococcal disease is not essential because less toxic, effective antifungal drugs are now available.

535

Cutaneous cryptococcosis: treatment with oral fluconazole. Shuttleworth D, Philpot CM, Knight AG. Br J Dermatol. 1989 May;120(5):683-7.

A case of cutaneous cryptococcosis is described in an immunocompromised patient. The initial lesion developed on the dorsum of the hand following trauma and was initially thought to be neoplastic. Satellite subcutaneous lesions developed in a 'sporotrichoid' pattern along the forearm. Treatment with oral fluconazole resulted in the complete resolution of the lesions. This is the first published report of the use of fluconazole in the treatment of cutaneous cryptococcosis.

536

Cutaneous cryptococcosis. Chu AC, Hay RJ, MacDonald DM. Br J Dermatol. 1980 Jul;103(1):95-100.

A 31-year-old woman with long-standing renal disease, treated with systemic steroids and azathioprine, developed progressive skin ulceration and subcutaneous nodules. A diagnosis of cryptococcosis was established after histological examination of a cutaneous lesion and confirmed by culture of the organism from the biopsy specimen. A detailed description of the histology and ultrastructure of the cutaneous lesion is presented. Treatment with parenteral amphotericin B and 5-fluorocytosine resulted in dramatic resolution of the skin lesions.

537

.[Cutaneous, subcutaneous, and lymph node cryptoccosis in a patient with sarcoidosis (author's transl)] Blanchon F, Vannier R, Brunel D, Carette MF, Lancastre F, Roland J, Vergez P, Drouhet E, Brocard H. Ann Med Interne (Paris). 1979;130(10):455-8.

An Algerien patient aged 31 years with a histologically confirmed mediastinopulmonary sarcoidosis had a persistent stable miliary pulmonary x-ray image after cortisone therapy. Eighteen months after stopping the corticotherapy, he developed cryptococcosis which was mainly cutaneous, but associated with subcutaneous abscesses and peripheral adenopathy, and without lesions in the viscera or deep nodes. Cryptococcus antigens were present in the serum and there was a humoral and cellular immunity reaction towards the cryptococcus. Recovery occurred after amphotericin B and 5-fluorocytosine.

538

Cryptococcosis in organ transplant recipients: an overview. Vilchez RA, Fung J, Kusne S. Am J Transplant. 2002 Aug;2(7):575-80.

The clinical, immunological, and pathological features of solitary cutaneous cryptococcosis in two apparently healthy Chinese adults are reported. In patient 1, regional cryptococcal lymphadenopathy also occurred. Both patients showed lymphopenia with a proportionate decrease in T-helper and T-suppressor cells. Both skin and lymph node biopsies showed granulomatous inflammation and the presence of cryptococcus. A chancriform syndrome developed in patient 1, indicating primary cutaneous cryptococcosis. Chancriform syndrome is rare in cryptococcal skin infection, probably due to immunosuppression in susceptible patients. In patient 2, the deep dermal and subcutaneous inflammatory involvement and anatomic location of the lesion on the upper medial thigh are supportive of secondary skin disease. Unless negated by a reliable history, the following features are indicative of secondary disease: inflammation centered in deep dermis or subcutaneous fat, lesion on covered parts of body, and multifocal skin lesions. Some cases remain unclassifiable. In practice the distinction between primary and secondary cutaneous cryptococcal disease is not essential because less toxic, effective antifungal drugs are now available.

539

Clinical spectrum of invasive cryptococcosis in liver transplant recipients receiving tacrolimus. Singh N, Gayowski T, Wagener MM, Marino IR. Clin Transplant. 1997 Feb;11(1):66-70.

Invasive cryptococcal infections have been reported in 0.3-1% of the patients undergoing liver transplantation in the previous reports. In contrast, invasive cryptococcosis developed in 6% of 102 consecutive liver transplants at our institution receiving tacrolimus as primary immunosuppression. Cutaneous and/or osteoarticular infections due to cryptococcus were detected in 67% of the patients with cryptococcosis, whereas meningitis was present only in 17%. One of the six patients with cryptococcosis presented with refractory shock and multiorgan system failure attributable solely to cryptococcosis. Patients with cryptococcal infections were significantly older than all other liver transplant recipients (p = 0.017), suggesting reactivation as opposed to primary infection as pathogenesis of cryptococcosis. 100% of the patients with cryptococcosis resided on the Eastern coast of the United States as compared to 59% of the patients without cryptococcosis (p = 0.08). There was no difference in the severity of underlying liver disease, degree of immunosuppression or CMV infection or disease between patients who did and did not develop cryptococcosis. Atypical manifestations, e.g. cutaneous diseases or sepsis syndrome, as opposed to subclinical meningitis, may be a clinical feature of cryptococcal infection in liver transplant recipients.

540

Bioprosthetic endocarditis due to Cryptococcus neoformans. Boden WE, Fisher A, Medeiros A, Benham I, McEnany MT. J Cardiovasc Surg (Torino). 1983 Mar-Apr;24(2):164-6.

Fungal prosthetic endocarditis continues to be a lethal complication of cardiac valve replacement. We describe a patient with culture-proved Cryptococcal endocarditis and myocarditis whose non-regurgitant xenograft aortic prosthesis was successfully replaced urgently upon the occurrence of new 1st degree A-V block in the third postoperative week. Operative intervention, including vigorous debridement of the aortic root, is effective in postoperative prosthetic fungal infections involving the myocardium. The patient described herein is now infection-free, with a non-regurgitant valve, one and one-half years following operation.

541

Cardiac lesions in acquired immunodeficiency syndrome (AIDS). Apropos of an autopsy series of 25 cases] Hofman P, Michiels JF, Saint Paul MC, Bernard, Dellamonica P, Loubiere R. Ann Pathol. 1990;10(4):247-57.

The pathologic study of the cardiac lesions in 25 persons who died of AIDS were studied from autopsies. Most of these patients were intravenous drug abusers (14 cases). Heart failure was symptomatic and lead to death in 4 cases. This study showed histological abnormalities in 76% of the cases. We observed 12 myocarditis. In 6 cases, pathogenes were found: Toxoplasma gondii (2), Cryptococcus neoformans (2), Candida (1), Aspergillus (1). A lymphocytic myocarditis was observed in 6 hearts. By immunohistochemical technique, we could distinguish 2 toxoplasmic myocarditis, and in 4 cases, solitary cysts in the myocardium without inflammation. The remaining lesions comprised respectively: 3 lymphocytic pericarditis, 2 marastic endocarditis and 1 dilated myocardiopathy.

542

Successful treatment of cryptococcal osteomyelitis and paraspinous abscess with fluconazole and flucytosine. Cook PP. South Med J. 2001 Sep;94(9):936-8.

A patient with thoracic cryptococcal osteomyelitis was treated successfully with the combination of fluconazole and flucytosine. This is the first reported case of cryptococcal osteomyelitis successfully treated with fluconazole and flucytosine.

543

Cryptococcus myelitis: atypical presentation of a common infection. Gumbo T, Hakim JG, Mielke J, Siwji S, Just-Nübling G, Ismail A. Clin Infect Dis. 2001 Apr 15;32(8):1235-6.

Cryptococcus neoformans is associated with as much as 45% of meningitis in patients admitted for hospital care in Zimbabwe, and it is an important opportunistic infection in patients infected with the human immunodeficiency virus. Cases of cryptococcosis presenting as a spinal cord syndrome have been reported from Zimbabwe and South Africa, but these were all cases of Cryptococcus vertebral osteomyelitis. We describe 3 unusual patients who presented with a myelitis-like syndrome without vertebral osteomyelitis.

544

Cryptococcal osteomyelitis with septic arthritis. taliano A, Yen BC, Rosenthal SA, Rafii M. Orthopedics. 2001 Jan;24(1):59-60.

545

Cryptococcal osteomyelitis of the spine. Govender S, Mutasa E, Parbhoo AH.

J Bone Joint Surg Br. 1999 May;81(3):459-61.

We have treated seven patients with cryptococcal spondylitis. Five presented with a neurological deficit and one was HIV-positive. Amphotericin-B and 5-flucytosine were used in five patients and ketoconazole was given orally in the remaining two. Three patients made a complete neurological recovery. Since these lesions mimic spinal tuberculosis, which is commonly seen in our environment, we draw attention to the importance of obtaining a tissue diagnosis.

546

Cryptococcal osteomyelitis: case report and review. Liu PY. Diagn Microbiol Infect Dis. 1998 Jan;30(1):33-5.

Cryptococcosis is a disseminated infection of man and animals caused by Cryptococcus neoformans. The most commonly involved sites are the lungs and the central nervous system. Isolated osteomyelitis due to C. neoformans is a rare complication of disseminated cryptococcosis. Herein we report a case of isolated osteomyelitis due to C. neoformans. A review of the English-language literature has been made and shows 40 cases (including this present report) with detailed data available since 1956. Most of the cases occurred between the ages of 21 and 59. Seventy-five percent of cases involved only one single site of bone infection, with vertebrae being the most common site. Sarcoidosis is the most common underlying disease, followed by tuberculosis and previous steroid therapy. Most of the cases (> 60%) reported were treated successfully with medical treatment alone or the combination of medical treatment and surgical curettage.

547

Osteomyelitis from Cryptococcus neoformans] Hummel H, Stosiek P, Lindner R, Bär W. Mycoses. 1996;39 Suppl 1:94-6.

A forty-three-year old patient suspected of having a bone tumor in his left femur, was submitted to the hospital. However, osteomyelitis caused by Cryptococcus neoformans has been demonstrated by culture. The history of the patient revealed a long-term therapy with corticosteroids due to sarcoidosis. The osteomyelitis was treated with fluconazole (200 mg daily p.o.) for three months. Under this therapy the infection resolved.

548

Cryptococcus neoformans vertebral osteomyelitis. Gurevitz O, Goldschmied-Reuven A, Block C, Kopolovic J, Farfel Z, Hassin D. J Med Vet Mycol. 1994;32(4):315-8.

A 67-year-old previously healthy woman presented with low back pain of 2 months duration and daily fever of 39 degrees C for 3 weeks. CT scan showed a lytic lesion in the third lumbar vertebra and a small right lower lobe lung infiltrate with mediastinal lymphadenopathy. Culture of material obtained from open biopsy of the vertebra grew Cryptococcus neoformans var. neoformans, which was also demonstrated on histology. Cryptococcal antigen was detected in the patient's serum. Treatment with amphotericin B (1000 mg total dose) and oral 5-fluorocytosine, resulted in complete recovery and resolution of the chest X-ray findings with a follow-up of 2 years. Since this case, as well as most of the previously described cases of cryptococcal osteomyelitis, were in normal hosts, cryptococcal osteomyelitis should be considered in the differential diagnosis even in a normal host, and therefore, prior to possible invasive diagnostic procedures, cryptococcal antigen in the serum should be determined.

549

Cryptococcal skeletal infections: case report and review. Behrman RE, Masci JR, Nicholas P. Rev Infect Dis. 1990 Mar-Apr;12(2):181-90.

Cryptococcus neoformans is an uncommon but treatable cause of osteomyelitis that affects both normal and immunocompromised hosts. When not considered as a diagnostic possibility, C. neoformans infection may result in increased morbidity. The spectrum of disease at presentation extends from an asymptomatic patient with an osteolytic lesion on radiograph to a patient with signs and symptoms of systemic disease. Once diagnosis has been established (often by closed aspiration), optimal therapy appears to involve a combination of amphotericin B, flucytosine, and surgical debridement.

550

The usefulness of blood culture in diagnosing HIV-related systemic mycoses: evaluation of a manual lysis centrifugation method. Bianchi M, Robles AM, Vitale R, Helou S, Arechavala A, Negroni R.Med Mycol. 2000 Feb;38(1):77-80.

The results of 5034 blood cultures, implementing a lysis-centrifugation method with saponin, are summarized in this paper. Three hundred and twenty-two blood samples (6.3%) obtained from a pool of human immunodeficiency virus (HIV)-positive patients yielded fungi. Cryptococcus neoformans was isolated in 199 samples (3.95%), Histoplasma capsulatum in 95 (1.89%). Candida parapsilosis in 12 (0.23%), C. albicans in 7 (0.13%), C. tropicalis in 2, C. krusei in 1, C. guillermondii in 1, and Prototheca wickerhamii in 4 (0.07%). Blood cultures were positive for C. neoformans in 76.23% of patients having a diagnosis of cryptococcosis and in 89.65% of those who had histoplasmosis. The blood culture was the first means of confirming the diagnosis in 23.8% of the patients with cryptococcosis and in 54% with histoplasmosis. In the four patients in whom P. wickerhamii was isolated, a diagnosis of disseminated protothecosis was not achieved by other findings. Catheter infections were responsible for the majority of recovered Candida.

551

Disseminated cryptococcosis with cutaneous lesions. Mostafa WZ, Ishak EA, Ekladious EM, Arnaout HH. J Dermatol. 1996 Mar;23(3):209-13.

A case of disseminated cryptococcosis in an HIV-negative patient presenting with cutaneous lesions is described for the first time in Egypt. The patient, a 16-year-old male, presented with cough, expectoration, loss of weight, and cutaneous lesions, mainly on the face and trunk. The lesions consisted of vegetating crusted plaques discharging purulent to sanguinous fluid and flattened, shiny, erythematous to brownish plaques. Anorexia, headache and personality changes soon followed. Histopathological examination of lesions was highly suggestive of a deep mycosis, particularly cryptococcosis. The fulminant disease advanced with central nervous system involvement. The progression was not arrested when systemic antifungal therapy was administered late in the disease course. Pathological examination of lungs, liver, pancreas and spleen revealed disseminated infection with no evidence of other underlying pathology. Disseminated cryptococcosis is a morbid infection, rare in an area where heightened awareness and raised index of suspicion will surely allow earlier diagnosis, management and better prognosis.

552

Cryptococcal peritonitis: report of a case and review of the literature. Stiefel P, Pamies E, Miranda ML, Martin-Sanz MV, Fernandez-Moyano A, Villar J. Hepatogastroenterology. 1999 May-Jun;46(27):1618-22.

We describe a patient diagnosed with AIDS and cirrhosis who had recently suffered a self-limited and non-specific esophageal ulceration. After this, he was hospitalized because of an oral bleeding with fatal evolution, and Cryptococcus neoformans was isolated from ascitic fluid during a routine paracenteses. We have reviewed the literature and, since 1963, only another 10 cases of cryptococcal peritonitis have been reported. A liver disease and not the AIDS (surprisingly, our case is the only report of cryptococcal peritonitis in a subject having both diseases) was the most common underlying disease (72.7%) and was associated with the worst prognosis (only one patient survived). An oral or upper gastrointestinal bleeding was the most common associated circumstance although recent steroid or antibiotic therapy has been also reported. Finally, diagnosis was delayed in many patients. The reasons for these delays are discussed.

553

Fungaemia due to Cryptococcus laurentii and a review of non-neoformans cryptococcaemia. Johnson LB, Bradley SF, Kauffman CA. Mycoses. 1998 Sep-Oct;41(7-8):277-80.

Cryptococcus laurentii is one of several non-neoformans cryptococci that have rarely been associated with human infection. The spectrum of clinical infection due to non-neoformans species ranges from skin lesions to fungaemia. Most cases of non-neoformans fungaemia have been nosocomially acquired and have been associated with indwelling intravascular catheters and neutropenia. Limited data on in vitro susceptibilities of non-neoformans cryptococci show these species to be more resistant to fluconazole and flucytosine than most Cr. neoformans. Two such cases are presented here.

554

First report of Cryptococcus albidus septicaemia in an HIV patient. Loison J, Bouchara JP, Gueho E, de Gentile L, Cimon B, Chennebault JM, Chabasse D. J Infect. 1996 Sep;33(2):139-40.

555

Cryptococcus laurentii fungemia in a premature neonate. Cheng MF, Chiou CC, Liu YC, Wang HZ, Hsieh KS. J Clin Microbiol. 2001 Apr;39(4):1608-11.

Cryptococcus spp. other than Cryptococcus neoformans are generally considered nonpathogenic to humans. There are only 15 case reports of disease in humans caused by Cryptococcus laurentii infection. Underlying diseases and predisposing risk factors seem to play an important role in these cases. Our patient is the first case of an extremely low birth weight infant with C. laurentii fungemia reported in the English literature. In our case, the MIC of amphotericin B for C. laurentii was 0.25 to 1 microg/ml and the patient had a good outcome following the administration of amphotericin B at 10 mg/kg combined with central venous catheter removal. There will undoubtedly be an increasing occurrence of unusual fungal infections accompanying further advances in medicine. A high degree of suspicion and improvements in the techniques for culture and identification will contribute to the earlier diagnosis and treatment of unusual fungal infections.

557

Cluster of pulmonary infections caused by Cunninghamella bertholletiae in immunocompromised patients. Rickerts V, Böhme A, Viertel A, Behrendt G, Jacobi V, Tintelnot K, Just-Nübling G. Clin Infect Dis. 2000 Oct;31(4):910-3.

Cunninghamella bertholletiae is a rare cause of pulmonary mucormycosis. We describe a cluster of invasive pulmonary infections caused by C. bertholletiae in 4 immunocompromised patients that occurred during a 2-year period at 1 center. Three of the patients were receiving antifungal prophylaxis with itraconazole. Presenting symptoms were fever unresponsive to antibacterial chemotherapy, hemoptysis, and infiltrates on chest radiograms. Three patients were treated with liposomal amphotericin B. Only 1 patient survived.

558

Infections due to Cunninghamella bertholletiae in patients with cancer: report of three cases and review. Kontoyianis DP, Vartivarian S, Anaissie EJ, Samonis G, Bodey GP, Rinaldi M. Clin Infect Dis. 1994 Jun;18(6):925-8.

Limited information is available regarding the pathogenesis and clinical manifestations of infection with Cunninghamella bertholletiae. In this report, we describe the clinical courses of three patients with leukemia and fatal C. bertholletiae infection and review the literature. In all patients, the infection developed in the setting of severe neutropenia following high doses of cytotoxic chemotherapy. Clinical presentation always consisted of fever and pneumonia and could be associated with dissemination to numerous organs. The course of infection was very rapid, and the diagnosis was made around or after the time of death. The most important risk factors for C. bertholletiae infection described in the literature include corticosteroid administration and prolonged severe granulocytopenia. Four infectious syndromes due to Zygomycetes have been described: rhinocerebral, pulmonary, cutaneous and soft tissue, and disseminated. The outcome of disseminated infection with C. bertholletiae has been almost uniformly fatal. Most previously described patients, however, did not receive aggressive treatment consisting of amphotericin B administration, resection of infected tissues, and, most importantly, control of the underlying disease.

559

Pulmonary mucormycosis caused by Cunninghamella bertholletiae in a non-immunocompromised woman] Sato M, Gemma H, Sano T, Ono T, Atsumi E, Ito I, Chida K, Nakamura H. Nihon Kokyuki Gakkai Zasshi. 2001 Oct;39(10):758-62. Japanese.

A 74-year-old woman was admitted for further examination because of an abnormal nodular shadow and thickening of the bronchovascular bundle in the left upper lobe on chest radiography and CT. The findings from a transbronchial biopsy specimen were not conclusive. A thoracoscopic lung biopsy specimen revealed a fungal infection, and partial resection of S1 + 2 of the left upper lobe was carried out. In the dilated bronchus, mucus of high viscosity was seen. Lymphocytes and plasma cells had infiltrated into the bronchioles and alveoli. Fungus was cultured from the mucus, and the morphological characteristics showed Cunninghamella bertholletiae. Pulmonary mucormycosis caused by C. bertholletiae in a non-immunocompromised person is very rare. Furthermore, this patient also had a wheeze, eosinophilia, elevation of the serum IgE level, and was positive for specific IgE to Mucor. We therefore consider that this case was an incomplete type of allergic bronchopulmonary fungusis (ABPF).

560

Cunninghamella bertholletiae infection in a bone marrow transplant patient: amphotericin lung penetration, MIC determinations, and review of the literature. Garey KW, Pendland SL, Huynh VT, Bunch TH, Jensen GM, Pursell KJ. Pharmacotherapy. 2001 Jul;21(7):855-60.

Infections caused by Cunninghamella bertholletiae, an opportunistic fungal organism, have an extremely high mortality rate. A fatal case of C. bertholletiae fungal pneumonia occurred in a man who had received an allogeneic bone marrow transplant. Aggressive debridement and high-dose liposomal amphotericin B failed to eradicate the infection. Right lung tissue samples obtained during lobectomy were assayed for amphotericin B concentrations by high-performance liquid chromatography, and minimum inhibitory concentration (MIC) determinations of amphotericin B against C. bertholletiae were determined by the macrobroth dilution method. The MIC for the isolate of C. bertholletiae was 4 microg/ml. Amphotericin B lung concentrations averaged 9.5 microg/ml (range 3.7-13.8 microg/ml), with a corresponding serum trough concentration of 0.9 microg/ml. To our knowledge, this is the first reported case of amphotericin B concentrations measured at the site of infection in a patient with a pulmonary Cunninghamella infection, together with a corresponding MIC of the organism. The patient's death, which occurred despite aggressive debridement and high amphotericin B lung concentrations, highlights the need for novel strategies to treat infections caused by invasive molds such as C. bertholletiae.

561

Cunninghamella infection post bone marrow transplant: case report and review of the literature. Darrisaw L, Hanson G, Vesole DH, Kehl SC. Bone Marrow Transplant. 2000 Jun;25(11):1213-6.

Cunninghamella spp., in the class Zygomycete and order Mucorales, are unusual opportunistic pathogens that have been identified with increased frequency in immunocompromised patients. Infections with this group of organisms have been seen most frequently in patients with hematologic malignancy. We describe an allogeneic bone marrow recipient who developed fungal pneumonitis and disseminated fungal dermatitis caused by Cunninghamella spp. To our knowledge, this is the first reported case of Cunninghamella infection in a BMT recipient. The case highlights the mortality associated with opportunistic infections in immunocompromised patients and confirms the risk factors associated with non-candida fungal infections after bone marrow transplantation.

562

[A case of pulmonary zygomycosis caused by Cunninghamella bertholletiae]. Hashiguchi K, Niki Y, Miyashita N, Kuroki M, Nakajima M, Kawane H, Matsushima T, Nishimura K. Kansenshogaku Zasshi. 1997 Mar;71(3):264-8.

Cunninghamella bertholletiae, a rare causative agent of human deep seated mycosis, has been reported with increased frequency in the Western countries, in recent years. We experienced a case of Cunninghamella bertholletiae pulmonary infection in a 63-year-old male with pulmonary fibrosis and mild diabetes mellitus. In spite of intensive anti-fungal chemotherapy following clinical diagnosis, he died of exacerbation of the underlying diseases. Postmortem examination showed Cunninghamella infection in the cavity of the lung and massive pulmonary fibrosis. There was no fungal invasion outside the cavity. This is the third report of Cunninghamella human infection in Japan.

563

Cunninghamella infections: review and report of two cases of Cunninghamella pneumonia in immunocompromised children. Cohen-Abbo A, Bozeman PM, Patrick CC. Clin Infect Dis. 1993 Aug;17(2):173-7.

Infections caused by Cunninghamella bertholletiae are being identified with increasing frequency in immunocompromised patients. We have treated two children with cancer for pulmonary infections caused by this rare fungus. Cunninghamella infection is found in a variety of populations of patients, including both children and adults undergoing chemotherapy. Clinical signs and symptoms are indistinguishable from those of other forms of zygomycosis. Outcome is poor: only three of 17 patients with such infection (including one of the two children described herein) have survived. Treatment involves aggressive surgical excision and administration of amphotericin B.

564

Cunninghamella bertholletiae: an uncommon agent of opportunistic fungal infection. Case report and review. Maloisel F, Dufour P, Waller J, Herbrecht R, Marcellin L, Koenig H, Liu KL, Weber JC, Bergerat JP, Oberling F. Nouv Rev Fr Hematol. 1991;33(4):311-5.

Cunninghamella bertholletiae is a fungus of the Zygomycetes class, Mucorales order. Only very few cases of disseminated infection have been reported. We observed a new case in a 19 years old man with severe aplastic anemia, due to pulmonary primoinfection and hematologic dissemination. This aplastic anemia failed to respond first to an antithymocyte globulin and steroid treatment and then to cyclosporine A. Deferoxamine was infused weekly to prevent iron overload. During a second antithymocyte globulin and steroid treatment, the patient developed bilateral pneumonia. Culture of the broncho-alveolar washing fluid established the diagnosis by isolation of C. bertholletiae. Despite amphotericin B and 5-fluorocytosine intravenous therapy, the patient died of disseminated infection six days after diagnosis, which was confirmed by necropsy. Underlying conditions, diagnosis and treatment are discussed, together with a review of the literature.

565

Endocarditis and hemorrhagic stroke caused by Cunninghamella bertholletiae infection after kidney transplantation. Zhang R, Zhang JW, Szerlip HM. Am J Kidney Dis. 2002 Oct;40(4):842-6.

Cunninghamella bertholletiae is a saprophytic fungus found in soil. Infection with this organism is extremely rare, occurring almost exclusively in immunosuppressed hosts. There have been only three previous cases of infection with this fungus reported in solid-organ recipients. We report an unusual case of disseminated Cunninghamella infection in a woman who had received a renal transplant. A 48-year-old woman received a living-related kidney transplant for focal segmental glomerulonephritis. She was treated with plasmapheresis and muromonab-CD3 (OKT3) for two episodes of rejection. Because of recurrent focal segmental glomerulonephritis with diuretic-resistant edema, she underwent transplant nephrectomy, was restarted on hemodialysis, and had her immunosuppression stopped. Shortly thereafter, the patient presented with pulmonary infiltrates and hemorrhagic stroke with a rapidly fatal course. Autopsy revealed widely disseminated C bertholletiae involving the central nervous system, lungs, and heart. This is the first reported case of endocarditis caused by this organism. Diagnosis of this fungal infection is often difficult. Because the few patients who have survived this infection seemed to have been diagnosed early, it is important for clinicians caring for transplant patients to be aware of this invasive infection. Successful treatment requires prompt diagnosis and high-dose amphotericin B.

566

Zygomycosis caused by Cunninghamella bertholletiae] Chiba N, Miki R. Rinsho Byori. 1990 Nov;38(11):1219-25.

Cunninghamella bertholletiae, an uncommon cause of human fungal infection, has been reported with increasing frequency in recent years in Western countries. We report a case of acute myelogenous leukemia terminated by an uncommon complication of zygomycosis caused by C. bertholletiae, which seems to be the first human case reported in Japan. In this case, the fungus disseminated many organs, including the thyroid gland.

567

Cutaneoarticular mucormycosis due to Cunninghamella bertholletiae in a patient with AIDS. Mostaza JM, Barbado FJ, Fernandez-Martin J, Peña-Yañez J, Vazquez-Rodriguez JJ. Rev Infect Dis. 1989 Mar-Apr;11(2):316-8.

A case of mucormycosis in an AIDS patient is reported. The infection was located in the skin and knee joint after open trauma of the left thigh. Cunninghamella bertholletiae was isolated. The prognosis of this infection is ominous in patients with AIDS because of their precarious immunologic status.

568

Rhinocerebral mucormycosis: a report of eleven cases. Chetchotisakd P, Boonma P, Sookpranee M, Pairojkul C. Southeast Asian J Trop Med Public Health. 1991 Jun;22(2):268-73.

Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand.
Rhinocerebral mucormycosis (RCM) is a rare, fulminant fungal infection that usually occurs in diabetic or immunocompromised patients. The mortality rate has been reduced recently with the advent of amphotericin B combined with aggressive surgery. Eleven RCM patients have been treated over the past five years at Srinagarind Hospital. Eight had underlying diabetes, five had renal failure and three of them had both. In eight patients, the diagnosis was established by KOH preparation before histological confirmation. Only two cases revealed positive cultures for Rhizopus spp and Cunninghamella spp. All patients underwent surgical treatments (extensive debridement, 8 cases; sphenoidectomy, 7 cases; ethmoidectomy 8 cases; maxillectomy 5 cases and orbital exenteration, 6 cases). Amphotericin B was administered to all patients as soon as the diagnosis of RCM was made. Only three patients survived. Early diagnosis and cooperation among ophthalmologist, otolaryngologist and physician are the most important factors for the survival of patients with mucormycosis.

569

Successful treatment of sinusitis caused by Cunninghamella bertholletiae. Ng TT, Campbell CK, Rothera M, Houghton JB, Hughes D, Denning DW. Clin Infect Dis. 1994 Aug;19(2):313-6.

Seventeen cases of infections due to Cunninghamella species have been reported worldwide in humans, and there have been only three survivors. We report a case of paranasal sinusitis due to Cunninghamella bertholletiae in an elderly patient who had diabetes mellitus and myelodysplasia. After receiving 7 weeks of therapy with deoxycholate amphotericin B (44 mg/kg or a total of 3 g) and rifampin, the patient was cured and did not have to undergo radical surgery.

570

A rare zygomycosis due to Cunninghamella bertholletiae. Dermoumi H. Mycoses. 1993 Sep-Oct;36(9-10):293-4.

An unusual endobronchial zygomycosis due to Cunninghamella bertholletiae in a leukaemic patient is reported. Following bypass operation, fungal infection developed. The patient died on day 7 after surgery as a result of long-term immunosuppressive treatment and haemodynamic complications.

571

Cunninghamella bertholletiae: an unusual agent of zygomycosis. Robinson BE, Stark MT, Pope TL, Stewart FM, Donowitz GR. South Med J. 1990 Sep;83(9):1088-91.

Cunninghamella bertholletiae shares many of the features typical of the other agents causing zygomycoses. Those who are immunocompromised constitute the major patient population at risk; the agents as a group are aggressive, the disease is often disseminated, and the pathologic picture of vascular invasion and tissue infarction is common. Unlike other agents of zygomycoses, Cunninghamella bertholletiae infection remains difficult to treat successfully even after early diagnosis and appropriate therapy.

572

Fatal Cunninghamella bertholletiae infection in an immunocompetent patient. Zeilender S, Drenning D, Glauser FL, Bechard D. Chest. 1990 Jun;97(6):1482-3.

The first fatal Cunninghamella bertholletiae infection in a clinically immunocompetent host is reported. This case differs from previously reported cases by the lack of extensive vascular invasion and thrombosis.

573

Disseminated mucormycosis due to Cunninghamella bertholletiae in a liver transplant recipient. Nimmo GR, Whiting RF, Strong RW. Postgrad Med J. 1988 Jan;64(747):82-4.

Disseminated mucormycosis occurred in a 19 year old female following orthotopic liver transplantation for fulminant Wilson's disease. The causative organism Cunninghamella bertholletiae has previously been described in ten clinical cases, but never before in this setting.

578

Molds in onychomycosis. Ramani R, Srinivas CR, Ramani A, Kumari TG, Shivananda PG. Int J Dermatol. 1993 Dec;32(12):877-8.

BACKGROUND: Onychomycosis is a major cause of nail dystrophy. The causative organisms in onychomycosis are dermatophytes, Candida and molds. A variety of molds have been isolated from nails. METHODS: Nail scrapings and clippings were collected from 100 cases and inoculated on slants containing SDA with cycloheximide 0.5 mg/mL, chloramphenicol 0.05 mg/mL, and SDA with chloramphenicol 0.05 mg/mL. RESULTS: The culture positivity rate for molds was 22%. The predominant mold isolates were Aspergillus species (86.4%, Fusarium oxysporum (4.5%), Curvularia species (4.5%) and Penicillium species (4.5%). CONCLUSION: Primary invasion of nails by molds can cause onychomycosis.

579

Human Curvularia infections. Report of five cases and review of the literature. Rinaldi MG, Phillips P, Schwartz JG, Winn RE, Holt GR, Shagets FW, Elrod J, Nishioka G, Aufdemorte TB. Diagn Microbiol Infect Dis. 1987 Jan;6(1):27-39.

Curvularia lunata is a saprobic dematiaceous mould that resides primarily in soil (Ellis, 1966). Reports of human disease caused by this organism are rare but include: endocarditis, brain abscess, skin infections, onychomycosis, keratitis, pneumonia, disseminated disease, mycetoma, allergic bronchopulmonary disease, and one case of sinusitis. Since 1983, we have encountered five cases of paranasal sinusitis due to C. lunata. None of the patients suffered from known immunologic disorders or underlying debilitating diseases. These five cases are presented and the literature of human phaeohyphomycosis caused by Curvularia spp. is reviewed.

580

A case of onychomycosis caused by Curvularia lunata (Wakker) Boedijn. Barde AK, Singh SM. Mykosen. 1983 Jun;26(6):311-6.

581

Curvularia keratitis. Wilhelmus KR, Jones DB. Trans Am Ophthalmol Soc. 2001;99:111-30; discussion 130-2.

PURPOSE: To determine the risk factors and clinical signs of Curvularia keratitis and to evaluate the management and outcome of this corneal phaeohyphomycosis. METHODS: We reviewed clinical and laboratory records from 1970 to 1999 to identify patients treated at our institution for culture-proven Curvularia keratitis. Descriptive statistics and regression models were used to identify variables associated with the length of antifungal therapy and with visual outcome. In vitro susceptibilities were compared to the clinical results obtained with topical natamycin. RESULTS: During the 30-year period, our laboratory isolated and identified Curvularia from 43 patients with keratitis, of whom 32 individuals were treated and followed up at our institute and whose data were analyzed. Trauma, usually with plants or dirt, was the risk factor in one half; and 69% occurred during the hot, humid summer months along the US Gulf Coast. Presenting signs varied from superficial, feathery infiltrates of the central cornea to suppurative ulceration of the peripheral cornea. A hypopyon was unusual, occurring in only 4 (12%) of the eyes but indicated a significantly (P = .01) increased risk of subsequent complications. The sensitivity of stained smears of corneal scrapings was 78%. Curvularia could be detected by a panfungal polymerase chain reaction. Fungi were detected on blood or chocolate agar at or before the time that growth occurred on Sabouraud agar or in brain-heart infusion in 83% of cases, although colonies appeared only on the fungal media from the remaining 4 sets of specimens. Curvularia was the third most prevalent filamentous fungus among our corneal isolates and the most common dematiaceous mold. Corneal isolates included C senegalensis, C lunata, C pallescens, and C prasadii. All tested isolates were inhibited by 4 micrograms/mL or less of natamycin. Topical natamycin was used for a median duration of 1 month, but a delay in diagnosis beyond 1 week doubled the average length of topical antifungal treatment (P = .005). Visual acuity improved to 20/40 or better in 25 (78%) of the eyes. CONCLUSIONS: Curvularia keratitis typically presented as superficial feathery infiltration, rarely with visible pigmentation, that gradually became focally suppurative. Smears of corneal scrapings often disclosed hyphae, and culture media showed dematiaceous fungal growth within 1 week. Natamycin had excellent in vitro activity and led to clinical resolution with good vision in most patients with corneal curvulariosis. Complications requiring surgery were not common but included exophytic inflammatory fungal sequestration, treated by superficial lamellar keratectomy, and corneal perforation, managed by penetrating keratoplasty.

582

Curvularia lunata endophthalmitis with secondary keratitis. Kaushik S, Ram J, Chakrabarty A, Dogra MR, Brar GS, Gupta A. Am J Ophthalmol. 2001 Jan;131(1):140-2.

PURPOSE: To report a case of pseudophakic endophthalmitis with secondary keratitis caused by Curvularia lunata. METHODS: A 40-year-old man presented with a fluffy mass in the anterior chamber with low-grade delayed postoperative inflammation in the right eye. RESULTS: The anterior chamber and vitreous aspirate demonstrated C. lunata. A large corneal infiltrate developed after aspiration of the mass. Treatment with systemic, topical, and intraocular antifungal agents cleared the vitreous, but the cornea perforated. CONCLUSION: Delayed low-grade infection with a fluffy mass in the anterior chamber after cataract surgery can rarely be a clinical presentation of dematiaceous fungal infection. Secondary keratitis may result after a diagnostic aspiration.

583

Mycotic keratitis due to Curvularia senegalensis and in vitro antifungal susceptibilities of Curvularia spp. Guarro J, Akiti T, Horta RA, Morizot Leite-Filho LA, Gené J, Ferreira-Gomes S, Aguilar C, Ortoneda M. J Clin Microbiol. 1999 Dec;37(12):4170-3.

Case of mycotic keratitis due to Curvularia senegalensis is reported. This case represents the third known reported infection caused by this rare species. Fungal hyphae were detected in corneal scrapings, and repeated cultures were positive for this fungi. The patient was presumed cured after a corneal transplant and treatment with itraconazole, but the infection recurred and the patient is waiting for a keratoplasty. The in vitro antifungal susceptibilities of the case strain and another 24 strains belonging to seven species of Curvularia were tested for six antifungal agents. With the exception of flucytosine, and occasionally fluconazole, the other drugs assayed (amphotericin B, miconazole, itraconazole, and ketoconazole) were highly effective in vitro.

584

Fungal keratitis caused by Curvularia lunata, with successful medical treatment. Dorey SE, Ayliffe WH, Edrich C, Barrie D, Fison P. Eye. 1997;11 ( Pt 5):754-5.

585

Mycotic keratitis caused by Curvularia brachyspora (Boedjin). A report of the first case. Marcus L, Vismer HF, van der Hoven HJ, Gove E, Meewes P. Mycopathologia. 1992 Jul;119(1):29-33.

Curvularia brachyspora has been identified for the first time as a cause of mycotic keratitis. Mycotic infections of the eye have assumed increasing importance in ophthalmology, resulting in a need for fungal identification and early specific treatment for the successful management of cases. A case of mycotic keratitis caused by C. brachyspora is described against the background of other Curvularia species causing mycoses.

586

Atypical skin lesions caused by Curvularia sp. and Pseudallescheria boydii in two patients after allogeneic bone marrow transplantation. Bonduel M, Santos P, Turienzo CF, Chantada G, Paganini H. Bone Marrow Transplant. 2001 Jun;27(12):1311-3.

We report two patients who developed atypical skin lesions caused by Curvularia sp. and Pseudallescheria boydii after allogeneic bone marrow transplantation for severe aplastic anemia. The first patient (female, 18-year-old) had multiple hemorrhagic vesicles on day +30 after her second BMT for graft failure. Pseudallescheria boydii was isolated from a skin biopsy. The patient died of respiratory failure probably as a consequence of systemic fungal infection. The second patient (male, 9-year-old) developed an ecthyma gangrenosum-like lesion on his right palm on day +8. Curvularia sp. was isolated from a skin biopsy. Liposomal amphotericin was given to achieve a total dose of 30 mg/kg and followed by oral itraconazole until steroids were discontinued. The infection resolved completely and the patient has remained disease-free. We conclude that emerging fungal organisms such as those described in this report are increasingly recognized in this setting. Early recognition and biopsy of these cutaneous lesions will allow prompt initiation of therapy to prevent systemic infection.

587

Two cases of cutaneous phaeohyphomycosis caused by Curvularia pallescens. Agrawal A, Singh SM. Mycoses. 1995 Jul-Aug;38(7-8):301-3.

Two cases of cutaneous phaeohyphomycosis caused by Curvularia pallescens are described. Lesions were found on the feet, thigh and thumb and were irregularly marginated, pruritic black and occasionally purulent. Histopathology revealed heavy infection of the stratum corneum and other cutaneous layers as well as host tissue response. The fungus appeared as dark, aggregated to simple branched hyphae. Oxiconazole was most effective 'in vitro' against the pathogen. This is the first report of C. pallescens as an opportunistic pathogen of human skin.

588

Case report: phaeohyphomycosis due to Curvularia lunata involving skin and subcutaneous tissue after an explosion at a chemical plant. Grieshop TJ, Yarbrough D 3rd, Farrar WE. Am J Med Sci. 1993 Jun;305(6):387-9.

Cases of phaeohyphomycosis due to dematiaceous fungi have been reported in increasing numbers and diversity. The optimal roles of antifungal chemotherapy and surgical debridement in the management of these infections have not been determined. A case of acute cutaneous and subcutaneous phaeohyphomycosis due to Curvularia lunata after an explosion at a chemical plant is reported, in which the organisms may have been inoculated into the tissues by the force of the blast. No organisms were found by histopathologic examination or culture of excisional biopsy specimens taken 10 days after initiation of therapy with intravenous amphotericin B; the antifungal therapy may have eradicated the infection.

589

Invasive sinusitis with intracranial extension caused by Curvularia lunata. Ismail Y, Johnson RH, Wells MV, Pusavat J, Douglas K, Arsura EL. Arch Intern Med. 1993 Jul 12;153(13):1604-6.

Curvularia lunata has previously been linked to localized sinus infection in immunocompetent hosts. We treated a case of pansinusitis with extensive bone destruction and intracranial extension caused by C lunata. Curvularia lunata was identified when typical fungal macroconidia appeared on culture. Numerous surgical procedures, in addition to a 12-month course of antifungal therapy consisting of 4 g of intravenous amphotericin B and an 8-month course of 400 mg of oral ketoconazole daily, were required to control the infection. This unusual case of invasive sinusitis caused by C lunata alerts the treating physician to the presence of this mold and gives an overview of diagnostic method as well as the management.

590

Invasive sinusitis and cerebritis due to Curvularia clavata in an immunocompetent adult. Ebright JR, Chandrasekar PH, Marks S, Fairfax MR, Aneziokoro A, McGinnis MR. Clin Infect Dis. 1999 Mar;28(3):687-9.

591

Fungal sternal wound infection due to Curvularia lunata in a neonate with congenital heart disease: case report and review. Yau YC, de Nanassy J, Summerbell RC, Matlow AG, Richardson SE. Clin Infect Dis. 1994 Oct;19(4):735-40.

We describe a neonate with congenital heart disease in whom a sternal wound infection caused by the filamentous fungus Curvularia lunata developed following cardiac surgery. Despite their widespread distribution in the environment, Curvularia species rarely cause human infection. We also review the 43 cases of curvularia infection previously reported in the English-language literature; only four of these cases occurred in children. A wide spectrum of infections--including keratitis, cutaneous infections, sinusitis, allergic bronchopulmonary disease, pneumonia, chronic ambulatory peritoneal dialysis-related infections, endocarditis and disseminated infections--have been described. Curvularia is a pathogen that can cause disease in both immunocompetent and immunocompromised hosts, although more severe and disseminated disease occurs in patients with defective immune function. Surgery alone usually is successful for treating locally invasive disease, although a combination of medical and surgical therapy is necessary for treating disseminated infections.

592

Curvularia/Drechslera sinusitis. Killingsworth SM, Wetmore SJ. Laryngoscope. 1990 Sep;100(9):932-7.

Sinusitis due to unusual fungal pathogens is thought to occur primarily in immunocompromised individuals. However, the fungi Curvularia, Drechslera, and others produce sinusitis in healthy young adults. The signs and symptoms produced by these organisms are usually considered to be complications of sinusitis. Of the three cases that we report, two manifested decreased visual acuity, and the third presented with acute onset of seizures. Computed tomography scans were helpful in delineating the extent of disease and in following the results of therapy. Aggressive surgical treatment is necessary; indeed, two of our cases required a second operation to eradicate all disease. If histopathology shows tissue invasion by the fungus, intravenous amphotericin B is recommended. Fungal cultures and smears should be obtained when healthy patients present with complications of sinusitis.

593

Fungal maxillary sinusitis caused by Curvularia lunata. Nishioka G, Schwartz JG, Rinaldi MG, Aufdemorte TB, Mackie E. Arch Otolaryngol Head Neck Surg. 1987 Jun;113(6):665-6.

Recently, reports have surfaced in which saprobic fungi, as well as fungi pathogenic for plants, seem to be evolving as human pathogens. While the bulk of infected patients are immunocompromised, many individuals appear to be immunocompetent. To our knowledge, this is the second known published case of maxillary sinusitis caused by Curvularia lunata in an immunocompetent patient. An interesting feature of this case is that the patient was treated with only surgery (débridement and irrigation) with complete resolution and no recurrence.

594

Curvularia lunata endocarditis treated with terbinafine: case report. Bryan CS, Smith CW, Berg DE, Karp RB. Clin Infect Dis. 1993 Jan;16(1):30-2.

A 44-year-old man developed endocarditis due to Curvularia lunata on a Carpentier-Edwards porcine heterograft with clinical involvement of the ring of the aortic valve and the aortic root. Because curative surgery was considered to be extremely high risk, he was treated with antifungal drugs for nearly 7 years. Initial treatment with amphotericin B and ketoconazole was followed by long-term treatment with terbinafine, an experimental allyamine derivative. No adverse effects were attributed to terbinafine. At surgery nearly 7 years later, the aortic valve ring and aortic root appeared to be uninvolved, and the valve was replaced uneventfully. To our knowledge, this is the first report of successful treatment of curvularia endocarditis.

595

Pulmonary and cerebral mycetoma caused by Curvularia pallescens. Lampert RP, Hutto JH, Donnelly WH, Shulman ST. J Pediatr. 1977 Oct;91(4):603-5.

596

Case report. Eumycetoma due to Curvularia lunata. Janaki C, Sentamilselvi G, Janaki VR, Devesh S, Ajithados K. Mycoses. 1999;42(4):345-6.

Eumycetoma caused by Curvularia lunata affecting the right foot is described in a 27-year-old farmer with the mycological and mycopathological features. The patient was being treated with oral ketoconazole 200 mg daily for 2 months and followed.

597

Mycetomas caused by Curvularia lunata, Madurella grisea, Aspergillus nidulans, and Nocardia brasiliensis in Sudan. Mahgoub ES. Sabouraudia. 1973 Jul;11(2):179-82.

598

Disseminated Curvularia lunata infection in a football player. Rohwedder JJ, Simmons JL, Colfer H, Gatmaitan B. Arch Intern Med. 1979 Aug;139(8):940-1.

For ten years, a 25-year-old immune-competent man experienced a progressive disseminated infection with the saprophytic soil fungus, Curvularia lunata, following presumptive cutaneous inoculation while playing football. Deep, soft tissue abscesses, pulmonary suppuration, paravertebral abscess, and cerebral abscess all followed leg ulcers from neglected abrasions. The patient's delay in obtaining treatment was partially responsible for the paravertebral-mediastinal-pleural-cutaneous fistula that resulted. The importance of prompt and aggressive surgical drainage procedures is clear. Infection was arrested only by surgery. The fungus was inhibited by miconazole nitrate and amphotericin B but it developed resistance to flucytosine. Miconazole appeared to cause resolution of the cerebral abscess. Amphotericin B (1 mg/kg/day) clearly was beneficial but only after effective drainage procedures were done. The patient refused to continue amphotericin B after 5.4 g had been given in two treatments. He became bedridden one year later from back pain that was caused by recurrent disease.

599

Disseminated Curvularia infection. de la Monte SM, Hutchins GM. Arch Pathol Lab Med. 1985 Sep;109(9):872-4.

Curvularia is a saprophyte that rarely causes infection, and then usually occurs in immunocompromised patients. A 41-year-old man, previously in good health, developed pulmonary and cerebral infection with Curvularia lunata. With surgery and amphotericin B therapy, he recovered and was free of infection one year later.

600

Disseminated Curvularia infection. Additional therapeutic and clinical considerations with evidence of medical cure. Pierce NF, Millan JC, Bender BS, Curtis JL. Arch Pathol Lab Med. 1986 Oct;110(10):959-61.

A previously reported case of cerebral infection due to Curvularia lunata is more fully described. Medical cure was apparently achieved after 30 months' treatment with amphotericin B. Success was achieved only when the drug was given in a dose of 40 mg, three times per week, and was continued for six months after enhanced computed tomographic scans no longer showed cerebral lesions. Immunologic studies suggested the infection was accompanied by an unexplained defect in cell-mediated immunity.

601

Disseminated Curvularia infection. Pierce NF, Millan JC, Bender BS, Curtis JL. Arch Pathol Lab Med. 1986 Oct;110(10):871.

604

White grain mycetoma caused by a Cylindrocarpon sp. in India. Hemashettar BM, Siddaramappa B, Padhye AA, Sigler L, Chandler FW. J Clin Microbiol. 2000 Nov;38(11):4288-91.

We describe a case of white grain eumycetoma of the foot of an Indian male caused by a slow-growing, poorly sporulating fungus that does not match any known agent of this infection. Histologic examination of a biopsy tissue specimen showed oval, lobular, white granules composed of hyaline, septate hyphae, and thick-walled chlamydospores. Culture of granules from a draining sinus yielded compact, very-slow-growing, poorly sporulating colonies producing a strong reddish brown pigment that diffused into the medium. The fungus was identified as a Cylindrocarpon sp. based on the development of rare cylindrical conidia borne from solitary phialides lacking collarettes, in addition to chlamydospores formed singly or in short chains.

605

Mycetoma of the foot caused by Cylindrocarpon destructans. Zoutman DE, Sigler L. J Clin Microbiol. 1991 Sep;29(9):1855-9.

A 39-year-old male, originally from Antigua, West Indies, presented with a 12-year history of swelling of the left foot. A pathogen could not be recovered in cultures of three surgical biopsy specimens. During follow-up, pus and grains were expressed from a draining sinus tract and Cylindrocarpon destructans grew in pure culture. Retrospective examination of histologic sections of tissue removed during the third biopsy demonstrated a grain characteristic of eumycotic mycetoma. Although the fungus was susceptible to amphotericin B and ketoconazole in vitro, the patient refused treatment, and the clinical course over almost 19 years has been one of slow but progressive bone destruction. The fungus was identified by its microconidial morphology, the presence of chlamydospores, and an intense brown diffusible pigment. It was compared with another poorly known agent of white grain mycetoma, Phialophora cyanescens, characterized by phialidic conidia, chlamydospores in aggregations, and an intense diffusing pigment.

606

Keratomycosis caused by Cylindrocarpon lichenicola. Mangiaterra M, Giusiano G, Smilasky G, Zamar L, Amado G, Vincentín C. Med Mycol. 2001 Feb;39(1):143-5.

We present a case of keratomycosis caused by Cylindrocarpon lichenicola in a 30-year-old immunocompetent male patient living in a rural area of Formosa Province (north-eastern Argentina). No ocular trauma is reported in his case history. There are no previous reports of infections caused by this fungus in Argentina.

607

Cutaneous infection caused by Cylindrocarpon lichenicola in a patient with acute myelogenous leukemia. Iwen PC, Tarantolo SR, Sutton DA, Rinaldi MG, Hinrichs SH. J Clin Microbiol. 2000 Sep;38(9):3375-8.

Cylindrocarpon lichenicola is a saprophytic soil fungus which has rarely been associated with human disease. We report the first case of localized invasive cutaneous infection caused by this fungus in a 53-year-old male from the rural midwestern United States with relapsed acute myelogenous leukemia. On admission for induction chemotherapy, the patient was noted to have an abrasive laceration between the fourth and fifth metacarpophalangeal joints and on the dorsum of the right hand, which progressed to frank ulceration following chemotherapy. A biopsy provided an initial diagnosis of an invasive fungal infection consistent with aspergillosis based on the histopathological appearance of the mold in tissue. Multiple positive fungal cultures which were obtained from the biopsied tissue were subsequently identified by microscopic and macroscopic characteristics to be C. lichenicola. The infection resolved following marrow regeneration, aggressive debridement of the affected tissue, and treatment with amphotericin B. This case extends the conditions associated with invasive disease caused by C. lichenicola.

608

Peritonitis in continuous ambulatory peritoneal dialysis due to Cylindrocarpon lichenicola infection. Sharma R, Farmer CK, Gransden WR, Ogg CS. Nephrol Dial Transplant. 1998 Oct;13(10):2662-4.

609

Disseminated infection due to Cylindrocarpon lichenicola in a patient with acute myeloid leukaemia. James EA, Orchard K, McWhinney PH, Warnock DW, Johnson EM, Mehta AB, Kibbler CC. J Infect. 1997 Jan;34(1):65-7.

We describe what is to our knowledge the first reported case of disseminated infection due to Cylindrocarpon. The presumed source was athlete's foot, a condition with which this fungus has previously been associated. Diagnosis was made by needle aspiration of a cutaneous lesion. Radiographic evidence of pulmonary involvement was present. The infection resolved following marrow regeneration and treatment with amphotericin B. Correct identification of Cylindrocarpon may be useful in guiding antifungal therapy.

612

Subcutaneous phaeohyphomycosis caused by Cyphellophora pluriseptata. Bittencourt AL, Machado PR, Araujo MG. Eur J Dermatol. 2002 Jan-Feb;12(1):103-6.

We present the first case of subcutaneous phaeohyphomycosis caused by Cyphellophora pluriseptata, a fungus described in 1986 by DeVries. The patient was apparently healthy and presented an extensive infiltration of the left ear simulating borderline leprosy. Microscopically a heavy infiltration of lymphocytes admixed with multinucleated giant cells in the dermis was observed in the absence of abscesses. The histopathological diagnosis was achieved through the finding of dematiaceous hyphae. Based on a review of the specific literature the authors discuss the unusual aspects of this case and emphasize the importance of isolating the etiologic agent in cases of phaeohyphomycosis.

613

Keratomycosis caused by Dichotomophthoropsis nymphaearum. Wright ED, Clayton YM, Howlader A, Nazrul I, Husain R. Mycoses. 1990 Sep-Oct;33(9-10):477-81.

A case of Dichotomophthoropsis nymphaearum, a dematiaceous hyphomycete, is described from Bangladesh. This species has not previously been reported as a human pathogen. Hyphae were observed in Gram stained corneal scrapings and the species was grown from cultured corneal material. Treatment with topical econazole and subconjunctival injections of miconazole was successful in the short term but long-term outcome could not be determined. The results of sensitivity tests for six antifungal drugs are reported for the isolate.

620

Intracranial and paranasal sinus infection due to Drechslera. Ruben SJ, Scott TE Jr, Seltzer HM. South Med J. 1987 Aug;80(8):1057-8.

Drechslera, a common soil fungus, has rarely been reported as a human pathogen. We have reported a case of Drechslera paranasal sinus and intracranial infection successfully treated with surgical resection, amphotericin B, and ketoconazole.

621

Prevalence of fungal corneal ulcers in northern India. Chander J, Sharma A. Infection. 1994 May-Jun;22(3):207-9.

Fungal corneal ulcer is common in India due to the tropical climate and a large agrarian population that is at risk. Various factors such as trauma, the injudicious use of topical antibiotics and corticosteroids are involved. Many of the age and sex-related risk factors also play a minor role. This 6-year study from Northern India revealed that fungi were detected in 61 (8.4%) out of 730 patients investigated. Direct microscopy was positive in 51 (7%) and culture in 53 (7.3%) patients. Aspergillus spp. were the most common causative agents accounting for 25 (40.1%) of the isolates, followed by Fusarium sp. with ten (16.4%), Curvularia sp. with five (8.2%), Candida albicans with five (8.2%), Acremonium sp. with four (6.6%), Paecilomyces sp. with three (4.9%), Penicillium sp. with two (3.3%), Alternaria sp. with two (3.3%), Fonsecaea pedrosoi var. cladosporium with two isolates (3.3%) and Pseudallescheria boydii, Drechslera sp. and Aureobasidium pullulans with one isolate (1.6%) each. The prevalence of fungal ulcers in males was three times higher than in females. The affected individuals had a rural background and were in the 51-60 year age group.

622

Studies on mycotic keratitis. Sundaram BM, Badrinath S, Subramanian S.

Mycoses. 1989 Nov;32(11):568-72.

One hundred and fifty cases of corneal ulcers from the Government Ophthalmic Hospital, Madras, were investigated during 1980-1982 for the mycoflora. 68 cases (45%) were positive for fungi, comprising species of Aspergillus (36 cases), Penicillium, Fusarium (8 cases each), Curvularia (4 cases), Candida albicans and Mucor (3 cases each), Drechslera (2 cases) and Cladosporium, Cephalosporium, Pullularia, and Allescheria boydii (1 case each). Incidence of these fungi in mycotic keratitis is correlated with factors such as age, sex and occupation of the patients and is discussed in detail.

623

Inhibition of mitochondrial respiration by asteltoxin, a respiratory toxin from Emericella variecolor. Kawai K, Fukushima H, Nozawa Y. Toxicol Lett. 1985 Nov;28(2-3):73-7.

Asteltoxin, a respiratory toxin from Emericella variecolor, was examined for an inhibitory effect on mitochondrial function. Asteltoxin strongly inhibited state 3 respiration, which was released by an uncoupling agent, 2,4-dinitrophenol (DNP), indicating that the action site of asteltoxin is localized in the energy transfer system of mitochondria. Asteltoxin strongly depressed Mg2+-ATPase activity in mitochondria and only slightly affected Na+, K+-activated ATPase in microsomes at the concentration range for inhibition of mitochondrial respiration.

636

Pneumonia due to Fonsecaea pedrosoi and cerebral abscesses due to Emericella nidulans in a bone marrow transplant recipient. Morris A, Schell WA, McDonagh D, Chaffee S, Perfect JR. Clin Infect Dis. 1995 Nov;21(5):1346-8.

637

Mycologic identification of Emericella nidulans and Aspergillus flavus causing pulmonary infection. Shao JZ, Liao WQ, Li SQ, Wu SX, Zhang JZ, Huang JJ. Chin Med J (Engl). 1983 Apr;96(4):306-8.

638

Case Report. Maxillary sinus infection due to Emericella nidulans. Horré R, Schumacher G, Marklein G, Krömer B, Wardelmann E, Gilges S, De Hoog GS, Wahl G, Schaal KP. Mycoses. 2002 Nov;45(9-10):402-5.

Fungal infections of the maxillary sinus are frequently caused by Aspergillus species, particularly A. fumigatus. In otherwise healthy persons there is an association with overfilling of dental root canals, when zinc-containing filling materials were used. Below, a maxillary sinus aspergilloma is reported in a young immunocompetent female patient caused by Aspergillus (Emericella) nidulans.

639

Emericella nidulans in a maxillary sinus fungal mass. Mitchell RG, Chaplin AJ, Mackenzie DW. J Med Vet Mycol. 1987 Oct;25(5):339-41.

Sexual reproductive stages of fungi are very rarely found within mammalian tissues. We report here coexistence of cleistothecia associated with Emericella nidulans and its conidial state, Aspergillus nidulans, in a fungal mass which developed in a maxillary sinus.

640

Pulmonary adiaspiromycosis: casual finding in a patient who died of yellow fever] Moraes MA, Gomes MI, Vianna LM. Rev Soc Bras Med Trop. 2001 Jan-Feb;34(1):83-5.

During an outbreak of yellow fever (rural form of the infection) occurred recently in the State of Goiás, Brazil, a patient, with clinical manifestations suggestive of the infection, died in the University Hospital of Brasilia, DF, on the fifth day from admission. Postmortem examination revealed, microscopically, the characteristic alterations of the infection, and discovered in the lungs and hilar lymph nodes round microrganisms identified as adiaconidia of Emmonsia parva var. crescens.

641

Pulmonary adiaspiromycosis: report of two cases. dos Santos VM, Fatureto MC, Saldanha JC, Adad SJ. Rev Soc Bras Med Trop. 2000 Sep-Oct;33(5):483-8.

Two cases of human pulmonary adiaspiromycosis are reported. Patients were 29 and 54-year-old males, farm workers, with "grippe-like" symptoms and radiographic findings suggestive of granulomatous interstitial disease. Transthoracoscopic and transbronchial biopsies were performed. Pulmonary function was measured by spirometry. One patient used ketoconazole. Possibility of misdiagnosed pulmonary adiaspiromycosis is emphasized.

642

Pulmonary adiaspiromycosis in a patient with acquired immunodeficiency syndrome. Turner D, Burke M, Bashe E, Blinder S, Yust I. Eur J Clin Microbiol Infect Dis. 1999 Dec;18(12):893-5.

Adiaspiromycosis is a noninfectious, nonarthropod-transmitted fungal infection that occurs worldwide in lower vertebrates, especially rodents. However, humans may become accidental hosts. Reported here is a case of adiaspiromycosis of the lung in an HIV-positive, 40-year-old, bisexual man who first presented with cough and dyspnea. Cultures of a bronchoalveolar lavage and protected brush specimen revealed the presence of fungal elements that were identified as Emmonsia parva var. parva. The patient was successfully treated with amphotericin B and thereafter with fluconazole. This organism should be added to the list of pathogens that cause pulmonary infection in AIDS patients.

643

[Adiaspiromycosis, 2 cases of incidental finding] Thomas De Montpréville V, Huerre M, Dulmet E. Ann Pathol. 1999 Dec;19(6):513-5.

Two apparently solitary granulomas, each containing an adiaconidia, 200 and 300 microm in diameter, were incidentally found in the lung parenchyma on a pleuro-pneumonectomy specimen for malignant mesothelioma, and in the stroma of a pulmonary adenocarcinoma, respectively. These two cases of adiaspiromycosis illustrate well the characteristic morphology of this strictly pulmonary, rare, ubiquitous, and histologically diagnosed mycosis.

644

[Human adiaspiromycosis. A report of a case treated with ketoconazole] Martins RL, Santos CG, França FR, Moraes MA. Rev Soc Bras Med Trop. 1997 Nov-Dec;30(6):507-9.

A case of human disseminated pulmonary adiaspiromycosis is reported. The patient, from Goianésia, GO, was admitted to the Brasilia University Hospital, in November 1992, with wet cough, dyspnea and weight loss--manifestations that had appeared two months before. Prior to admission, he had been treated for a suspected miliary tuberculosis, because a chest roentgenogram had shown a diffuse reticulonodular infiltrate in both lungs. This therapy brought no improvement to the patient status. An open chest biopsy was then performed, and the microscopic examination of the lung tissue revealed the fungal nature of the disease. Ketoconazole, 400mg/day, was started and the patient discharged from the hospital. He was seen again two months later: the respiratory manifestations had disappeared and a new chest roentgenogram showed complete resolution of the pulmonary lesions. The usefulness of ketoconazole is, however, questioned, since, as there is no multiplication of the fungus in the host organism--adiaspiromycosis is believed to be, usually, a self-healing disease--the efficacy of this imidazole derivative against the agent in animal tissues remains to be confirmed.

645

[Disseminated pulmonary adiaspiromycosis. A case report] dos Santos VM, Santana JH, Adad SJ, Lopes GP, Fatureto Mda C. Rev Soc Bras Med Trop. 1997 Sep-Oct;30(5):397-400.

A case of thoracoscopic lung biopsy proven diffuse human adiaspiromycosis is reported. The patient, a 26-year-old male farm worker presented with a three-week history of fever, sweating, dyspnea and unproductive cough. Radiographic findings were those of granulomatous pulmonary interstitial disease. Treated with ketoconazole he improved very well, resuming work normal activities a month later.

646

Pulmonary adiaspiromycosis in a two year old girl. Nuorva K, Pitkänen R, Issakainen J, Huttunen NP, Juhola M. J Clin Pathol. 1997 Jan;50(1):82-5.

A case of disseminated bilateral pulmonary adiaspiromycosis is reported in a two year old Finnish girl. She recovered from this rare infection after treatment with amphotericin B. She is the first human case of adiaspiromycosis in Scandinavia and she is the youngest child with this disease reported so far. Electron microscopy showed that the three layers of the spore wall were not typical; rather, there seemed to be a gradual transition between the main wall zones, which may be split into an indefinite number of thin layers. Varying numbers and thicknesses were seen with different staining methods, and in different spores. Diagnosis relies on recognition of the fungus in a pulmonary biopsy specimen, because there are no reliable serological tests and culture of the fungus is time consuming and not always successful. It was thought that this patient had become infected as a result of contact with soil dust containing the spores in the yard surrounding her home, and as a result of her mother's work in a large garden shop.

647

Adiaspiromycosis: an unusual fungal infection of the lung. Report of 11 cases. England DM, Hochholzer L. Am J Surg Pathol. 1993 Sep;17(9):876-86.

Adiaspiromycosis (ad"i-ah-spi"ro-mi-kósis) is a worldwide, noninfectious, nonarthropod transmitted fungal infection of lower vertebrates, most commonly rodents. Humans become an accidental host by inhaling dust-borne spores (conidia) of the saprophytic soil fungus, Emmonsia crescens (recently renamed Chrysosporium parvum variety crescens). We report 11 cases of this unusual deep mycosis from South America, Europe, and the United States. The severity of the disease depends on the number of spores inhaled. In limited inoculum, the disease remains localized (two cases), whereas in heavy inocula the fungus involves both lungs (nine cases) and presents as a diffuse reticulonodular infiltrate. In this disseminated form, patients usually complain of cough, dyspnea on exertion, and low-grade fever mimicking other systemic fungal infections and tuberculosis. It is difficult to unmask the fungus because it is not easily cultured nor is there a reliable serologic test. Therefore, a biopsy is required and the pathologist must recognize the large (ranging in size from 50 to 500 microns), round, Gomori methenamine-silver nitrate and periodic acid-Schiff reagent-positive spherules with a trilaminar wall. The spherules can be surrounded by either suppuration, epithelioid granulomas with or without necrosis, or concentric, hyalinized fibrosis. In the latter chronic stage, the organism may collapse, forming a variety of sizes and shapes thereby resembling other fungi, helminths, mineral particles, or inhaled pollen grains. Clinically, the infection most commonly regresses spontaneously, but may persist, or rarely progress, requiring surgical intervention with limited resection to attain cure.

648

Disseminated adiaspiromycosis in a patient with AIDS. Echavarria E, Cano EL, Restrepo A. J Med Vet Mycol. 1993;31(1):91-7.

A case of disseminated adiaspiromycosis in an AIDS patient is described. The most notable characteristic of the infection was the extensive osteomyelitis exhibited by the patient. Positive cultures for Chrysosporium parvum var. parvum were obtained from pus taken from a lesion of the wrist during surgery as well as from sputum samples and a bone marrow aspirate. Treatment with amphotericin B controlled the fungal infection.

649

Fulminant disseminated pulmonary adiaspiromycosis in humans. Peres LC, Figueiredo F, Peinado M, Soares FA. Am J Trop Med Hyg. 1992 Feb;46(2):146-50.

A case of fulminant disseminated pulmonary adiaspiromycosis is reported. The patient, a 35-year-old black male farm worker, presented with a four-week history of generalized weakness, unproductive cough, evening fever, and a weight loss of 8 kg. He died 12 days after hospitalization of respiratory failure due to granulomatous lung disease. The clinical and radiographic findings were indistinguishable from those of miliary tuberculosis. Microscopic examination of material obtained at autopsy revealed the large fungus characteristic of adiaspiromycosis in the center of suppurative granulomas throughout the lungs. This is believed to be the first fatal case of pulmonary adiaspiromycosis reported in humans, and it may have been occupationally acquired.

650

Pulmonary adiaspiromycosis] Eri Z, Klem I, Durić B, Durić M, Pavlović S. Plucne Bolesti. 1991 Jan-Jun;43(1-2):69-71.

A 54-yr old male patient with a history of dyspnea and cough is presented. Due to the clinical course of disease and the radiological changes in the chest a diagnosis of sarcoidosis was established. However, the open lung biopsy revealed the true nature of the pulmonary disease: pulmonary adiaspiromycosis, only secondary to asbestosis, siderosis and silicosis as due to the well known occupational exposure to asbestos and other dusts.

651

Human pulmonary adiaspiromycosis. A new case of disseminated form] Moraes MA, Silva AE, Raick AN. Rev Soc Bras Med Trop. 1990 Jul-Sep;23(3):171-4.

A case of disseminated pulmonary form of adiaspiromycosis is reported. This is the second case of the disease found in Brasilia, DF. The patient, a 42-year-old peasant, lived in Corrente - State of Piaui, where he certainly acquired the infection. He was admitted to the Social Security Hospital, in Brasilia, with fever, chills, dry cough and dyspnea. At that time, he had been sick for about ten months and the decision of seeking medical care in Brasilia resulted from an exacerbation of the symptoms that had occurred two months before. At a right thoracotomy for a lung biopsy, disseminated white nodular lesions, a few millimeters in diameter, could be observed on the lung surface. Microscopically, round structures, 300 microns or more in diameter, identified as adiaconidia of Chrysosporium parvum var. crescens were seen in the center of some of these lesions. The tisssue response to the causative agent consisted of microabscesses, surrounded by cells in palisading arrangement, and granulomas of the mixed and foreign body types. The two kinds of lesions were thought to represent evolutive stages of the inflammatory process, and to be related to different exposures to the conidia, on separated occasions. The suppurative lesions would be recent lesions, started some weeks or a few months before, while the others, in which the granulomatous reaction predominated, were possibly older lesions, with an evolutions of at least several months.

652

. Chrysosporium parvum keratomycosis. Wagoner MD, Badr IA, Hidayat AA. Cornea. 1999 Sep;18(5):616-20.

PURPOSE: To report a case of corneal infection with Chrysosporium parvum, a filamentous fungus usually associated with pulmonary infections. METHODS: A 43-year-old Saudi man had a corneal stromal infiltrate and perforation of his left eye. He was treated with a therapeutic penetrating keratoplasty and topical and systemic antifungal therapy. Corneal scrapings, microbiologic evaluation, and histopathologic examination of the surgical specimen were performed to establish the diagnosis. After the development of recurrent stromal keratitis at the graft-host junction, similar diagnostic and therapeutic maneuvers were performed. RESULTS: Corneal scrapings and histopathologic examination were positive for numerous septate hyphae with endospores, consistent with a diagnosis of filamentous keratomycosis. Microbiologic isolation confirmed the diagnosis of Chrysosporium parvum. Similar diagnostic maneuvers for recurrent keratitis produced identical results. CONCLUSION: To our knowledge, this is the first case of Chrysosporium parvum keratomycosis.

653

[Peritoneal form of adiaspiromycosis (author's transl)] Drápela J, Viklický J, Novák J, Tousek J, Vána M. Z Erkr Atmungsorgane. 1980;155(3):393-8.

A female patient, aged 30 years was subjected in 1977 to an appendectomy because of a perforated gangrenous appendix associated with purulent peritonitis. Postoperatively she developed an intractable constipation persisting for more than one year. Because of suspected intestinal stenosis an exploratory laparotomy was performed which failed to disclose the presence of stenosis. Histological studies of excised peritoneal specimens were suggestive of tuberculous peritonitis. Since cultivation failed to provide evidence of mycobacteria and the clinical symptoms were not characteristic of a tuberculous involvement of the peritoneum it was decided to carry out a re-evaluation of the original histological slides. This revealed that the patient was infected with adiaspores of the fungus Emmonsia crescens which were disseminated over the entire peritoneum from the perforated appendix. The difficulties associated with the diagnosis which are due to the striking morphologic similarity between the minute nodules in adiasporosis and those in productive miliary tuberculosis, as well as because of the acid-fast adiaspore capsules, are stressed. Since Emmonsia crescens is spread in some regions of Czechoslovakia it may be expected that humans will come into contact with its spores either by inhalation or by alimentary ingestion.

654

Adiaspiromycosis of human skin caused by Emmonsia crescens. Kamalam A, Thambiah AS. Sabouraudia. 1979 Dec;17(4):377-81.

Two cases of cutaneous adiaspiromycosis by Emmonsia crescens are reported. This is the first human skin infection by this species and is the first report of its kind in man from India. In the first patient, the agent was demonstrated in KOH mounts, histology and culture from irregular, pigmented skin plaques on the right gluteal area. The lesion also contained calcium. In the second patient the fungus was demonstrated histologically in a knee lesion. The agent had elicited a histiocytic and giant cell reaction in the dermis in both cases. The first patient suffered from anaemia and epilepsy and the second suffered from nephropathy with chyluria. The skin lesions were surgically excised with skin grafting in the first patient.

655

Engyodontium album endocarditis. Augustinsky J, Kammeyer P, Husain A, deHoog GS, Libertin CR. J Clin Microbiol. 1990 Jun;28(6):1479-81.

This is the first reported case of native valve endocarditis caused by Engyodontium album. This fungus, rarely seen as a human pathogen, is separated from Tritirachium species by its lack of pigmentation and from Beauveria species by the presence of conidiogenous cells in whorls.

668

Prevalence and awareness of tinea pedis in Italian sailors. Ingordo V, Fracchiolla S, Figliola F, D'Andria G, Colecchia B, Naldi L. Dermatology. 2000;201(4):349-50.

BACKGROUND: It is difficult to carry out studies on the prevalence of tinea pedis in the community. Some studies are performed on selected groups of subjects, exposed to the same risk factors, i.e. schoolchildren, public bathers, athletes and military men. OBJECTIVE: The aim of this work was to detect in a sample of military men the prevalence of tinea pedis and the awareness of their condition, and to relate the infection to risk factors of the group as well. METHODS: 410 male Italian navy cadets in an Italian navy petty officers school were clinically examined and mycological cultures were performed, employing the skin scrapings obtained from suspected lesions. RESULTS: Dermatophytes were isolated from toe clefts in 10 subjects, giving a point prevalence of 2.4% (95% confidence interval 1.3-4.4%). The isolated dermatophytes were Trichophyton mentagrophytes (70%), Trichophyton rubrum (20%) and Epidermophyton floccosum (10%). None of the subjects was aware of his disease. No significant association was observed between tinea pedis and risk factors (i.e. hyperhidrosis and habits). CONCLUSION: The prevalence in our sample was lower than that observed in previous studies on military men. That can be attributed to the general amelioration of hygienic conditions and strengthening of preventive habits. Therefore the prevalence of tinea pedis in Italian sailors seems to be reduced but still rather relevant. That is important because these subjects are a reservoir of ringworm infection.

669

The frequency of tinea pedis in patients with tinea cruris in Tehran, Iran. Sadri MF, Farnaghi F, Danesh-Pazhooh M, Shokoohi A. Mycoses. 2000;43(1-2):41-4.

The objective of this study is to define the frequency of tinea pedis in patients with tinea cruris. Sixty patients (46 males and 14 females) entered our study. Epidermophyton floccosum was the most frequently isolated fungus in tinea cruris. Four patients (6.4%) had concurrent tinea pedis and the only isolate from the foot was Trichophyton mentagrophytes. In three of them, the corresponding dermatophyte in the groin was E. floccosum.

670

Epidemiology of dermatomycoses of humans in central Poland. Part III. Tinea pedis. Lupa S, Seneczko F, Jeske J, Głowacka A, Ochecka-Szymańska A. Mycoses. 1999;42(9-10):563-5.

The total number of dermatophytoses (7393) included 2025 (27.4%) tinea pedis cases. Etiological factors in descending order by contribution were: Trichophyton rubrum (41.7%), Trichophyton mentagrophytes var. granulosum (30.9%), T. mentagrophytes var. interdigitale (10.0%), Epidermophyton floccosum (7.4%), T. mentagrophytes var. quinckeanum (6.9%), Trichophyton tonsurans (2.3%), Trichophyton spec. (0.4%), Trichophyton terrestre (0.2%), Trichophyton violaceum (0.1%). In the years 1987-93 the incidence of tinea pedis substantially increased over 1994-96. Today tinea pedis is second by incidence among all clinical forms of dermatophyte infections of skin and skin appendages in the Lódź region.

671

Dermatophytosis in schoolchildren in Ekpoma, Nigeria. Enweani IB, Ozan CC, Agbonlahor DE, Ndip RN. Mycoses. 1996 Jul-Aug;39(7-8):303-5.

Of 1400 pupils from two public primary schools in Ekpoma, Edo State, Nigeria, who were screened for dermatophyte infection, 188 (13.4%) were infected. The causative agents isolated included Microsporum audouinii in 88 (46.8%), Trichophyton mentagrophytes in 48 (25.5%), T. rubrum in 40 (21.3%), T. tonsurans in four (2.1%) and Epidermophyton floccosum in eight (4.3%). There were significant differences in the rate of infection between male and female schoolchildren as well as between children from different socioeconomic backgrounds.

672

Dermatophytoses in Iran. Khosravi AR, Aghamirian MR, Mahmoudi M. Mycoses. 1994 Jan-Feb;37(1-2):43-8.

A total of 12,150 cases of suspected dermatophytoses in different areas of Iran were studied between 1986 and 1991. The age groups most commonly infected were 1-9 and 20-29 years. Clinical diagnosis was confirmed in only 9345 cases by laboratory examination. Of these positive samples, 1633 cases were found to be positive by direct microscopic observation only, 429 by culture only and 7283 by both techniques. Scalp ringworm of children was the most common type of tinea. But according to the rate of infection, tinea corporis, tinea pedis, tinea cruris, tinea manuum, tinea unguium and tinea barbae were the next most prevalent in that order. The frequencies of dermatophytes isolated from patients were as follows: Microsporum canis 19.4%, Trichophyton rubrum 16.5%, Epidermophyton floccosum 14.9%, Trichophyton mentagrophytes var. interdigitale 14.6%, Trichophyton verrucosum 11.5%, Trichophyton mentagrophytes 6%, Trichophyton violaceum 8.7%, Trichophyton schoenleinii 5.5%, Trichophyton tonsurans 1.3%, Trichophyton erinacei 0.8% and Microsporum gallinae 0.2%.

673

Dermatophytosis of children in Kuwait. al-Fouzan AS, Nanda A. Pediatr Dermatol. 1992 Mar;9(1):27-30.

Five hundred fifty-six children constituted 39.5% of total smear- and culture-positive cases of dermatophytosis and 0.6% of the total new dermatology outpatients seen over a period of five years. Males outnumbered females. The youngest child was a 20-day-old neonate (age range 20 days-12 yrs) with a peak of fungal infections seen in patients between 4 and 6 years of age. Microsporum canis was the most prevalent (70.5%) species, followed by Trichophyton violaceum, Microsporum audouinii, Trichophyton rubrum, and Epidermophyton floccosum. Rarely, other species were also isolated. Tinea capitis was the most common (73.7%) clinical type, followed by tinea corporis (19.1%), tinea faciei (3.4%), tinea cruris (3.4%), tinea pedis (0.9%), tinea unguium (0.9%), and tinea manus (0.2%). No racial variations were observed; however, the predominant species differed with the clinical types.

674

A study of dermatophytoses in Bangkok (Thailand). Imwidthaya S, Thianprasit M. Mycopathologia. 1988 Apr;102(1):13-6.

A total of 719 cases of dermatophytoses was studied in the Division of Dermatology, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, during January to December 1986. Infection caused by fungus comprises 12%, while the incidence of dermatophytoses was 5.5% of skin disorders. The age group commonly infected was 12-21 years old (mean age of 18 years); 40% was female and 47.5% was male. In the female patients the common prevalent infections were tinea corporis 29%, tinea cruris 23%, tinea pedis 16%, while in male patients it was 28%, 39% and 14% respectively. Only 4 species of dermatophytes were isolated. The prevailing ones were: Trichophyton rubrum 66%, T. mentagrophytes 15%, Epidermophyton floccorum 13% and Microsporum gypseum 6%.

675

Epidemiology and clinical features of dermatomycoses and dermatophytoses. Svejgaard E. Acta Derm Venereol Suppl (Stockh). 1986;121:19-26.

Dermatophytosis, candidosis and pityriasis versicolor account for the majority of fungal skin diseases in Denmark and are seen in 8% of patients with dermato-venerological problems. In children, zoophilic species like Microsporum canis (from cats), Trichophyton (T) verrucosum (from cattle) and T. mentagrophytes granulare (from rodents) are the common causes of dermatophytosis and are seen in approximately 15% of all cases. Anthropophilic species are the main cause of dermatophytosis in adults and are isolated more often in males than in females. T. rubrum (48%), T. mentagrophytes interdigitale (14%) and Epidermophyton floccosum (10%) are the species usually involved. The feet are the site of infection in about 50% of the cases, toenails, glabrous skin and inguinal folds equally often in 42%, palms in 6% and the scalp in 2%. The prevalence of tinea pedis in 15-year-old school children and 20-year-old males was found to be 4% and 6%, respectively. A relative risk of 3.1 for contracting tinea pedis when being an atopic or having an atopic family was demonstrated in the former group. Pityriasis versicolor and candidosis of skin and mucosal membranes are both secondary dermatomycoses caused by endosaphrophytic yeasts. Local or systemic predisposing disorders are usually required for the development of symptoms.

676

[Tinea manuum. Report of 13 cases] Wanke NC, Wanke B. Med Cutan Ibero Lat Am. 1985;13(6):497-501.

The authors report 13 cases of tinea manuum and emphasize that this condition is not commonly described in the Brazilian medical literature. Eight males and five females, aged 18 to 72 years, presented an infection ranging from 1 month to 20 years. The main clinical picture was of desquamating type on the palms without fingernails lesions. All patients had associated dermatophytosis of the feet. Trichophyton mentagrophytes, T. rubrum and Epidermophyton floccosum were the species isolated from the hands. The trichophytin test was positive in all cases and treatment with oral griseofulvin and topical clotrimazole and miconazole was rather effective. Clinical evaluation at the end of the treatment and afterwards did not show relapses.

677

Fungal diseases in Shiraz. Nikpoor N, Buxton MW, Leppard BJ. Pahlavi Med J. 1978 Jan;9(1):27-49.

In 122 patients with fungal diseases studied over a six month period, sixty were seen with dermatophyte infections. Tinea pedis, cruris and ungruium occurred mainly in adult males attending the private hospital and tinea corporis and capitis children attending the University Hospital. The organisms found were Trichophyton rubrum, T. mentagrophytes, T. schonleinii, T. tonsurans, Epidermophyton floccosum and Microsporum canis. Infections with Candida albicans occurred both in the urban and rural population and included case of familial chronic muco-cutaneous candidiasis. Pityriasis versicolor was the commonest fungal disease seen.

678

Epidemiology of dermatomycoses of humans in central Poland. Part V. Tinea corporis. Jeske J, Lupa S, Seneczko F, Głowacka A, Ochecka-Szymańska A. Mycoses. 1999;42(11-12):661-3.

The total number of dermatophytoses (7393) included 2204 (29.8%) cases of tinea glabrosa. Etiological factors in descending order were: Microsporum canis (23.5%), Trichophyton mentagrophytes var. granulosum (21.6%), Trichophyton rubrum (17.8%), Trichophyton tonsurans (10.4%), Epidermophyton floccosum (7.7%), T. mentagrophytes var. quinckeanum (6.0%), Microsporum gypseum (5.3%), Trichophyton violaceum (3.7%), T. mentagrophytes var. interdigitale (2.3%), Microsporum equinum (0.7%), Trichophyton verrucosum (0.4%), Trichophyton spec. (0.4%), Microsporum cookei (0.14%). At present tinea glabrosa is dominant among all clinical forms of dermatophyte infections of skin and skin appendages in the Lódź region.

679

Case report. Disseminated tinea of the verrucous type due to epidermophyton floccosum. Qiangqiang Z, Limo Q, Qixian Q. Mycoses. 2001;44(7-8):326-9.

A case is presented of an 8-year-old boy suffering from disseminated verrucous lesions with some purulent drainage on his right foot, shank, thigh, scrotum, penis, perianal area and abdomen. Epidermophyton floccosum was isolated from these lesions. The patient was treated with oral ketoconazole for 4 months and the lesions resolved completely. There was no evidence of relapse during a 12-month follow-up.

680

Invasive disease due to Epidermophyton floccosum in an immunocompromised patient with Behcet's syndrome. Seddon ME, Thomas MG. Clin Infect Dis. 1997 Jul;25(1):153-4.

690

Onychomycosis due to Exophiala jeanselmei. Boisseau-Garsaud AM, Desbois N, Guillermin ML, Ossondo M, Gueho E, Cales-Quist D. Dermatology. 2002;204(2):150-2.

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.

691

Phaeohyphomycosis caused by Exophiala species in immunocompromised hosts. Liou JM, Wang JT, Wang MH, Wang SS, Hsueh PR. J Formos Med Assoc. 2002 Jul;101(7):523-6.

Exophiala species are rarely implicated in clinical diseases. In the past 2 years, we have treated phaeohyphomycosis caused by Exophiala species in three immunocompromised patients. Two of these patients presented with subcutaneous abscess or cutaneous verrucous lesions due to Exophiala jeanselmei. The former, an 81-year-old woman, had pulmonary tuberculosis and the latter, a 62-year-old man, had undergone heart transplantation and was receiving immunosuppressive treatment. The third patient, a 62-year-old woman, had acute lymphoblastic leukemia and developed lymphadenitis due to Wangiella (Exophiala) dermatitidis. In each case, the fungus was discovered on a Gram stain of the aspirated material and was identified by conventional tests. One patient died of bacterial pneumonia with acute respiratory distress syndrome and the other two were treated successfully with surgical excision and antifungal agents. With the more frequent and widespread use of immunosuppressive agents, the incidence of Exophiala infection will certainly increase. Surgical excision or debridement with or without antifungal agents may offer the possibility of cure for phaeohyphomycosis due to Exophiala species.

692

. Subcutaneous phaeohyphomycotic cysts caused by Exophiala jeanselmei in a lung transplant patient. Xu X, Low DW, Palevsky HI, Elenitsas R. Dermatol Surg. 2001 Apr;27(4):343-6.

BACKGROUND: Phaeohyphomycosis is a skin fungal infection caused by dematiaceous fungi that often affects immunocompromised patients. Local recurrence after medication or surgical treatment is common in these patients. We present a case in which a 42-year-old woman status post-bilateral lung transplant developed phaeohyphomycotic cysts with local recurrence and then was successfully treated by local excision with pre- and postsurgery oral itraconazole treatment. OBJECTIVE: To demonstrate the utility of pre- and postsurgery oral itraconazole in immunocompromised patients with recurrent phaeohyphomycosis. METHODS: Local excision with pre- and postsurgery oral itraconazole treatment. RESULTS: Simple excision or excision with postsurgery oral itraconazole resulted in local recurrence in this patient. Local excision with pre- and postsurgery oral itraconazole was effective in preventing the local recurrence. CONCLUSION: Phaeohyphomycosis can run a prolonged course in immunocompromised patients with multiple recurrences. Local excision with pre- and postsurgery oral itraconazole can be used to treat these patients with recurrent phaeohyphomycosis.

693

A case of cutaneous Exophiala spinifera infection. Oba M, Suzuki Y, Kawasaki M. Nippon Ishinkin Gakkai Zasshi. 2000;41(1):17-21.

A 66-year-old female had a solitary dark-red nodule measuring 1 cm in diameter on her left forearm. She often had trauma to her hands and arms. A histopathologic examination demonstrated granulomatous changes in the dermis. Under the high-power magnification yeast-like cells and short toruloid hyphal elements were observed in the granuloma. A few giant cells contained fungal elements. No sclerotic cells were found. On the basis of the histopathologic and mycologic findings, the lesion was diagnosed as a dematiaceous fungal infection caused by Exophiala spinifera. She was treated with oral itraconazole (200 mg/day) and topical heat therapy. The lesion was clinically improved within 58-days. However, E. spinifera was still isolated from the excisional specimen 92-days later. We believe that surgical excision is the choice of therapy if the lesion is small.

694

Phaeohyphomycosis caused by Exophiala dermatitidis following intra-articular steroid injection. Woollons A, Darley CR, Pandian S, Arnstein P, Blackee J, Paul J. Br J Dermatol. 1996 Sep;135(3):475-7.

A patient with long-standing rheumatoid arthritis presented with a painful pigmented chronic nodule on the dorsum of the right hand, at the site of intra-articular steroid injections undertaken 5 years previously. Histology showed pigmented fungal elements consistent with phaeohyphomycosis. Cultures yielded black yeast-like colonies, identified as Exophiala dermatitidis and sensitive to itraconazole and amphotericin. A 1-month course of itraconazole resulted in marked clinical improvement but surgical excision and skin grafting were required for complete resolution. Phaeohyphomycosis has been related to inoculation injury but association with intra-articular steroid injection appears hitherto to be unreported.

695

Exophiala werneckii endophthalmitis following cartaract surgery in an immunocompetent individual. Huber CE, LaBerge T, Schwiesow T, Carroll K, Bernstein PS, Mamalis N. Ophthalmic Surg Lasers. 2000 Sep-Oct;31(5):417-22.

A case of infectious endophthalmitis caused by the saprophyte Exophiala werneckii is reported. This has not been recognized as a pathogen for ocular infections previously. The infection followed uncomplicated cataract surgery involving phacoemulsification and IOL implant. Clinical presentation was that of an indolent endophthalmitis with relatively acute onset. Pars plana vitrectomy, fungal stains, and culture established the diagnosis. Initial management consisted of empirical intravitreal injection of vancomycin, ceftazidime, and amphotericin B. Treatment was supplemented with a 3-week course of systemic fluconazole and topical therapy with natamycin, atropine, ciprofloxacin, and diclofenac. The visual acuity returned to 20/20-2 with no recurrence of infection. The source of the infection could not be determined. Fungal endophthalmitis has to be considered as a rare, though important, complication following ophthalmic surgery. Specific fungal stains and cultures are helpful for establishing the diagnosis early in the course of disease. E werneckii should be considered in the differential diagnosis of fungal endophthalmitis.

696

Exophiala jeanselmei causing late endophthalmitis after cataract surgery. Hofling-Lima AL, Freitas D, Fischman O, Yu CZ, Roizenblatt R, Belfort R Jr. Am J Ophthalmol. 1999 Oct;128(4):512-4.

PURPOSE: To report two cases of late endophthalmitis caused by Exophiala jeanselmei after cataract surgery. METHODS: Case reports, including clinical evaluation, direct examination, and culture of the aqueous humor. RESULTS: In each case, samples from the anterior chamber had positive growth of yeasts with toruloid hyphae and pseudohyphae. Intravitreal and anterior chamber amphotericin B were used in both cases. Apparent clinical resolution was achieved, but after 3 months in one case and 6 months in the other the infection recurred more aggressively, with severe endophthalmitis leading to ocular atrophy. CONCLUSION: E. jeanselmei causes a severe intraocular infection and isolation, and identification of the agent ensures proper diagnosis and treatment. After clinical resolution of the infection, careful and long-term follow-up is recommended to promptly detect relapse and immediately reintroduce treatment.

697

A case of Exophiala dermatitidis ulceration]. Gerard C, Duchesne B, Hayette MP, Lavalleye B, Marechal-Courtois C. Bull Soc Belge Ophtalmol. 1998;268:103-8.

The authors present one case of corneal Exophiala dermatitidis ulceration. This case is analyzed in the field of corneal mycosis infection. Classification, rate, clinical history, biomicroscopy aspects will be discussed. Technical samples will be described. Anatomopathologic slides will be discussed. Finally the medical or surgical treatment will be considered.

698

A case of Exophiala dermatitidis ulceration]. Gerard C, Duchesne B, Hayette MP, Lavalleye B, Marechal-Courtois C. Bull Soc Belge Ophtalmol. 1998;268:103-8.

The authors present one case of corneal Exophiala dermatitidis ulceration. This case is analyzed in the field of corneal mycosis infection. Classification, rate, clinical history, biomicroscopy aspects will be discussed. Technical samples will be described. Anatomopathologic slides will be discussed. Finally the medical or surgical treatment will be considered.

699

Pulmonary infection due to Exophiala jeanselmei: successful treatment with ketoconazole. Manian FA, Brischetto MJ. Clin Infect Dis. 1993 Mar;16(3):445-6.

700

Exophiala dermatitidis pneumonia in cystic fibrosis. Kusenbach G, Skopnik H, Haase G, Friedrichs F, Dohmen H. Eur J Pediatr. 1992 May;151(5):344-6.

The chest X-ray film of a girl with cystic fibrosis (CF) showed slowly increasing mottled densities during the 6th and 7th year of her life. Pulmonary symptoms and distress proceeded fast in spite of intensive treatment with antibiotics, corticosteroids, and physiotherapy. Three different fungal organisms were repeatedly cultured from the sputum: Candida albicans, Aspergillus fumigatus, and Exophiala dermatitidis. Antibodies against C. albicans were in the normal range. Candida antigen in blood and antibodies against A. fumigatus were absent. Antibodies against E. dermatitidis were detected by a recently developed indirect immunofluorescence assay. It seems most probable that E. dermatitidis was the causal agent for fungal pneumonia in this case. Under therapy with amphotericin B and flucytosine the clinical course and radiological appearance improved but definitive eradication of E. dermatitidis was only achieved after treatment with itraconazole. The isolation of this fungus from the sputum of a CF patient is reported for the first time. The significance of fungal infections in CF is discussed.

701

Pulmonary phaeohyphomycosis in a patient with hemoptysis. Barenfanger J, Ramirez F, Tewari RP, Eagleton L. Chest. 1989 May;95(5):1158-60.

A 79-year-old retired schoolteacher had a history of bronchiectasis. She developed recurrent hemoptysis requiring multiple blood transfusions. Exophiala dermatitidis was cultured repeatedly from bronchial lavages. To our knowledge, this is the first documented case of isolated pulmonary phaeohyphomycosis due to E dermatitidis, and it was successfully treated with amphotericin B and 5-fluocytosine.

702

Acute cerebral phaeohyphomycosis due to Wangiella dermatitidis accompanied by cerebrospinal fluid eosinophilia. Chang CL, Kim DS, Park DJ, Kim HJ, Lee CH, Shin JH. J Clin Microbiol. 2000 May;38(5):1965-6.

We report a case of cerebral phaeohyphomycosis due to Wangiella dermaitidis in an immunocompetent adult man. His cerebrospinal fluid (CSF) showed pleocytosis with a high eosinophil count but without peripheral blood eosinophilia. The present case suggested that this black yeast-like fungus should be included when the causes of CSF eosinophilia are considered, even though it is an extremely rare pathogen.

703

Brain abscess caused by Wangiella dermatitidis: case report. Ajanee N, Alam M, Holmberg K, Khan J. Clin Infect Dis. 1996 Jul;23(1):197-8.

704

Isolation of Exophiala (Wangiella) dermatitidis in a case of otitis externa. Kerkmann ML, Piontek K, Mitze H, Haase G. Clin Infect Dis. 1999 Oct;29(4):939-40.

705

Wangiella dermatitidis peritonitis in a CAPD patient.Vlassopoulos D, Kouppari G, Arvanitis D, Papaefstathiou K, Dounavis A, Velegraki A, Hadjiconstantinou V. Perit Dial Int. 2001 Jan-Feb;21(1):96-7.

706

Chromoblastomycosis in a patient with a cardiac transplant. Kinkead S, Jancic V, Stasko T, Boyd AS. Cutis. 1996 Nov;58(5):367-70.

Cases of chromoblastomycosis have been reported in immunocompromised patients. However, chromoblastomycosis is rarely caused by Exophiala jeanselmei. While this organism has been reported to induce pheohyphomycosis in a recipient of a cardiac transplant, chromoblastomycosis has not been described. We present a case of chromoblastomycosis caused by Exophiala jeanselmei in a patient who had received a cardiac transplant.

707

Chromoblastomycosis caused by Exophiala spinifera. Padhye AA, Hampton AA, Hampton MT, Hutton NW, Prevost-Smith E, Davis MS. Clin Infect Dis. 1996 Feb;22(2):331-5.

We report the second case of chromoblastomycosis caused by Exophiala spinifera; this is the first known case in the United States. Examination of biopsied tissue showed thick-walled, internally septated, chestnut brown muriform cells (sclerotic bodies) within multinucleated giant cells present in the dermis that were characteristic of chromoblastomycosis. The individual cells within the muriform cells disarticulated from the outer wall of the parent cell and from each other to form endoconidia within the outer walls of the parent cells. After fracture of the outer walls, the endoconidia were released. This unique process of endoconidial formation in vivo for the propagation of muriform cells was observed for the first time. Initial treatment with itraconazole and 5-fluorocytosine followed by treatment with itraconazole and heat resulted in marked improvement in the patient's lesions. This infection reiterates the fact that the dematiaceous fungus E. spinifera, a well-known etiologic agent of phaeohyphomycosis, can cause more than one type of infection and supports earlier observations that chromoblastomycosis and phaeohyphomycosis represent extremes of a continuum of infections.

708

Human infection caused by Exophiala pisciphila: case report and review. Sughayer M, DeGirolami PC, Khettry U, Korzeniowski D, Grumney A, Pasarell L, McGinnis MR. Rev Infect Dis. 1991 May-Jun;13(3):379-82.

Fungi have become increasingly important causes of nosocomial bloodstream infections. The major cause of nosocomial fungemia has been Candida spp, but increasingly molds and other yeasts have caused disease. Exophiala jeanselmei and members of the genus Rhinocladiella are dematiaceous moulds, which have been infrequently associated with systemic infection and have not been described as causes of fungemia. In this paper, the occurrence of 23 cases of fungemia due to these organisms over a 10-month period is reported and the clinical characteristics of patients and outcomes are described. The majority of patients were immunosuppressed; 21 of 23 (91%) had received blood products and 78% had a central venous catheter. All patients had at least one manifestation of fever, but only one patient had signs or symptoms suggesting deep-seated infection. Antifungal therapy was given to 19 of the 23 patients; of those who did not receive therapy, 3 died prior to the culture result and 1 had been discharged without therapy. Antifungal susceptibility of the organisms showed activity of amphotericin B, itraconazole, and the new triazole antifungals voriconazole and posaconazole. E. jeanselmei and Rhinocladiella species are potential causes of nosocomial fungemia and may be associated with systemic infection.

709

Antimycotic susceptibility testing of agents of black grain eumycetoma. Venugopal PV, Venugopal TV, Ramakrishna ES, Ilavarasi S. J Med Vet Mycol. 1993;31(2):161-4.

Antimycotic susceptibility testing of 17 strains of eumycetes including Madurella mycetomatis, Madurella grisea, Pyrenochaeta romeroi, Exophiala jeanselmei and Leptosphaeria tompkinsii, isolated from cases of black grain mycetoma, was carried out against ketoconazole, itraconazole, miconazole and econazole by broth microdilution and agar dilution methods. Itraconazole and ketoconazole were more active inhibiting 50% of the strains (MIC 50) at 0.5 and 1 microgram ml-1 and 90% (MIC 90) at 2.5 and 5 micrograms ml-1, respectively. The MIC 50s of econazole and miconazole were 2.5 and 5 micrograms ml-1 and MIC 90s 10 micrograms ml-1 for both drugs.

710

Nosocomial outbreak of Exophiala jeanselmei fungemia associated with contamination of hospital water. Nucci M, Akiti T, Barreiros G, Silveira F, Revankar SG, Wickes BL, Sutton DA, Patterson TF. Clin Infect Dis. 2002 Jun 1;34(11):1475-80.

From December 1996 through September 1997, we diagnosed 19 cases of fungemia due to Exophiala jeanselmei. We conducted a matched case-control study in which we cultured specimens of blood products, intravenous solutions, and water from a hospital water system. Isolates from environmental cultures were compared to those recovered from patients by random amplification of polymorphic DNA (RAPD). Multivariate analysis showed that neutropenia, longer duration of hospitalization, and use of corticosteroids were risk factors for infection. Environmental cultures yielded E. jeanselmei from 3 of 85 sources: deionized water from the hospital pharmacy, 1 water tank, and water from a sink in a non-patient care area. Use of deionized pharmacy water to prepare antiseptic solutions was discontinued, and no additional cases of infection occurred. RAPD typing showed that isolates from case patients and isolates from the pharmacy water were highly related, whereas the patterns of isolates recovered from the 2 other sources of water were distinct.

711

Nosocomial fungemia due to Exophiala jeanselmei var. jeanselmei and a Rhinocladiella species: newly described causes of bloodstream infection. Nucci M, Akiti T, Barreiros G, Silveira F, Revankar SG, Sutton DA, Patterson TF. J Clin Microbiol. 2001 Feb;39(2):514-8.

Fungi have become increasingly important causes of nosocomial bloodstream infections. The major cause of nosocomial fungemia has been Candida spp, but increasingly molds and other yeasts have caused disease. Exophiala jeanselmei and members of the genus Rhinocladiella are dematiaceous moulds, which have been infrequently associated with systemic infection and have not been described as causes of fungemia. In this paper, the occurrence of 23 cases of fungemia due to these organisms over a 10-month period is reported and the clinical characteristics of patients and outcomes are described. The majority of patients were immunosuppressed; 21 of 23 (91%) had received blood products and 78% had a central venous catheter. All patients had at least one manifestation of fever, but only one patient had signs or symptoms suggesting deep-seated infection. Antifungal therapy was given to 19 of the 23 patients; of those who did not receive therapy, 3 died prior to the culture result and 1 had been discharged without therapy. Antifungal susceptibility of the organisms showed activity of amphotericin B, itraconazole, and the new triazole antifungals voriconazole and posaconazole. E. jeanselmei and Rhinocladiella species are potential causes of nosocomial fungemia and may be associated with systemic infection.

712

Catheter-associated fungemia due to Wangiella (Exophiala) dermatitidis. Nachman S, Alpan O, Malowitz R, Spitzer ED. J Clin Microbiol. 1996 Apr;34(4):1011-3.

We describe a case of catheter-associated Wangiella (Exophiala) dermatitidis fungemia in a human immunodeficiency virus-infected child who was successfully treated with antifungal therapy and catheter removal. Catheter-associated W. dermatitidis fungemia appears to be distinct from previously described cases of disseminated infection with organ involvement.

713

Exserohilum rostratum causing keratitis in India. Mathews MS, Maharajan SV. Med Mycol. 1999 Apr;37(2):131-2.

A case of mycotic keratitis due to atypical Exserohilum rostratum is reported in a 42-year-old male with Hansens disease.

714

Corneal phaeohyphomycosis due to Exserohilum rostratum. A case report and brief review. Kanungo R, Srinivasan R. Acta Ophthalmol Scand. 1996 Apr;74(2):197-9

We report a rare case of corneal phaeohyphomycosis due to Exserohilum rostratum following organic trauma. A known cause of cutaneous and subcutaneous phaeohyphomycosis, this fungus has been very rarely associated with infections of the eye. Being a plant pathogen, along with other saprophytic dematiaceous fungi the possible role in keratomycosis is discussed.

715

A case of cutaneous phaeohyphomycosis caused by Exserohilum rostratum, its in vitro sensitivity and review of literature. Agarwal A, Singh SM. Mycopathologia. 1995 Jul;131(1):9-12.

A 40 year old woman presented with the infection of skin of 3 years duration on the upper anterior aspect of fore-arm. Histologic examination of the skin tissue revealed dematiaceous hyphae, aggregated structures or single celled elements. On detailed mycological examination the isolate was identified as Exserohilum rostratum. Among the antimycotic tested in vitro amorolfine was found to be most effective with MIC value of 3 mcg/ml. This is the first report of E. rostratum infection of man from India.

716

Corneal ulcer due to Exserohilum longirostratum. Bouchon CL, Greer DL, Genre CF. Am J Clin Pathol. 1994 Apr;101(4):452-5.

A 47-year-old man sustained a traumatic injury to the left eye, and a corneal ulcer subsequently developed. Histologic examination of the corneal tissue revealed septate hyphae with acute angle branching. The mycologic and bacterial cultures yielded a dematiaceous fungus with ellipsoidal pigmented macroconidia borne sympodially on geniculate conidiophores. The multicellular macroconidia had prominent, protruding, truncated hila. The shorter macroconidia averaged 5-7 septa, and the longer conidia 13-21 septa. Growth on V-8 agar, alternating between fluorescent light and the dark, produced macroconidia more than 200 microns in length. The isolate was identified as Exserohilum longirostratum. This is believed to be the first documented case of mycotic keratitis caused by the phaeohyphomycete E longirostratum.

717

Cutaneous and subcutaneous phaeohyphomycosis caused by Exserohilum rostratum. Hsu MM, Lee JY. J Am Acad Dermatol. 1993 Feb;28(2 Pt 2):340-4.

Phaeohyphomycosis of the skin caused by Exserohilum is rare. Four cases have been reported; all were subcutaneous in type and all were caused by Exserohilum rostratum. We report two types of skin infection, cutaneous and subcutaneous, that were caused by E. rostratum in two immunocompromised men. Pleomorphic fungal elements were noted within the dermal suppurative and granulomatous infiltrate in case 1 and only within the central hyperkeratotic horny layer of a porokeratosis-like lesion in case 2. E. rostratum was isolated in both cases. Case 2 represents the first documented case of cutaneous Exserohilum phaeohyphomycosis. The clinical and histologic features in this case resembled superficial porokeratosis. To the best of our knowledge these findings have not been reported previously in fungal infections of the skin. The ambiguous terminology that is used in the classification of phaeohyphomycosis is also discussed.

718

Phaeohyphomycosis of the eye caused by Exserohilum rostratum in India. Anandi V, George JA, Thomas R, Brahmadathan KN, John TJ. Mycoses. 1991 Nov-Dec;34(11-12):489-91.

A 40-year-old woman developed a corneal ulcer with hypopyon following a traumatic episode. In a KOH mount dematiaceous, septate, branched hyphae were demonstrated, and heavy growth of Exserohilum rostratum was obtained in culture. No bacterial pathogens were isolated. The patient was treated with natamycin and subsequently with ketoconazole. In spite of antimycotic therapy a descemetocele of the eye remained. This observation represents the first documented case of an Exserohilum infection in India.

719

Subcutaneous phaeohyphomycosis caused by Exserohilum rostratum in an immunocompetent host. Burges GE, Walls CT, Maize JC. Arch Dermatol. 1987 Oct;123(10):1346-50.

A healthy, 55-year-old woman developed a subcutaneous abscess and systemic symptoms of nausea, dizziness, and chills following minor trauma to her leg. Histopathologic examination of a skin biopsy specimen revealed golden-brown colored mycelial elements, and culture resulted in growth of a dematiaceous fungus identified as Exserohilum rostratum. Surgical excision of the abscess and concomitant oral therapy with ketoconazole resulted in resolution of symptoms. In previously reported cases of human phaeohyphomycosis caused by Exserohilum and related Bipolaris species in both immunocompromised and immunocompetent hosts, treatment has varied from topical antimicrobial therapy to combined surgery and intravenous antifungal chemotherapy. Our experience leads us to believe that surgical débridement of an accessible focus of infection along with orally administered ketoconazole may provide adequate therapy in an immunocompetent host.

720

Emerging agents of phaeohyphomycosis: pathogenic species of Bipolaris and Exserohilum. McGinnis MR, Rinaldi MG, Winn RE. J Clin Microbiol. 1986 Aug;24(2):250-9.

Study of numerous living isolates of Bipolaris, Drechslera, Exserohilum, and Helminthosporium spp., as well as a mycological assessment of published case reports of phaeohyphomycosis attributed to these fungi, showed that Bipolaris australiensis, B. hawaiiensis, B. spicifera, Exserohilum longirostratum, E. mcginnisii, and E. rostratum are well-documented pathogens. Conidial shape, septation, and size, hilar characteristics, the origin of the germ tube from the basal cell and, to a lesser extent, from other conidial cells, and the sequence and location of the conidial septa are useful criteria for distinguishing these taxa.

721

Human Exserohilum and Bipolaris infections: report of Exserohilum nasal infection in a neutropenic patient with acute leukemia and review of the literature. Douer D, Goldschmied-Reouven A, Segev S, Ben-Bassat I. J Med Vet Mycol. 1987 Aug;25(4):235-41.

A neutropenic patient with acute myeloid leukemia developed nasal and perinasal infection caused by the fungus Exserohilum rostratum. Early amphotericin B treatment along with marrow recovery resulted in resolution of the infection. A review of other previously reported cases of Exserohilum and Bipolaris infections show a favourable outcome in most patients who receive systemic antifungal treatment with amphotericin B.

722

Phaeohyphomycosis of the nasal sinuses caused by a new species of Exserohilum. Padhye AA, Ajello L, Wieden MA, Steinbronn KK. J Clin Microbiol. 1986 Aug;24(2):245-9.

A 27-year-old man with a 6-year history of allergies developed nasal polyps that occluded his nose and prevented visual examination beyond the nasal vestibules. Histological examination of the polyps and bony tissue revealed septate, dematiaceous hyphae invading the bone trabeculae. A dematiaceous fungus was isolated in pure culture from the diseased tissue. Detailed mycological examination of the isolate showed that it produced numerous, distinctive poroconidia from erect, geniculate, sympodial conidiophores. The conidia were straight and cylindroellipsoidal, had 8 to 13 distosepta, and had protruding hila. The outer cell walls of the conidia, which were initially smooth, became unevenly roughened on aging. Comparison with other Exserohilum species revealed that the isolate represented an undescribed species; it is named Exserohilum mcginnisii sp. nov.

723

Fatal disseminated infection due to Exserohilum rostratum in a patient with aplastic anemia: case report and review. Aquino VM, Norvell JM, Krisher K, Mustafa MM. Clin Infect Dis. 1995 Jan;20(1):176-8.

Exserohilum rostratum is a dematiaceous fungus that rarely causes infection in humans. We describe a patient with severe aplastic anemia who developed fatal disseminated disease caused by E. rostratum, and we review the English-language literature on this unusual agent. Our patient initially presented with signs and symptoms of sinusitis, which progressed to invasive pulmonary disease. The clinical course and histopathologic findings at autopsy were similar to those seen in cases of invasive aspergillosis or mucormycosis in that a propensity for vascular invasion and dissemination was seen.

726

Chromoblastomycosis: a review of 100 cases in the state of Rio Grande do Sul, Brazil. Minotto R, Bernardi CD, Mallmann LF, Edelweiss MI, Scroferneker ML. J Am Acad Dermatol. 2001 Apr;44(4):585-92.

BACKGROUND: If not diagnosed earlier, chromoblastomycosis has a chronic evolutional course that may cause several problems, such as difficulty in managing therapy because of the recrudescent character of the disease, potential association with the growth of epidermoid carcinoma in affected regions, and poor quality of life and work incapacity to the patient. Although infrequent, new cases are reported in the state of Rio Grande do Sul every year, ratifying the necessity for further studies on this disease. OBJECTIVE: The purpose of this study was to review clinical features and response to therapy in patients with chromoblastomycosis and present data on the demography and history of this disease in the state of Rio Grande do Sul, Brazil. METHODS: We reviewed case records of 100 patients with skin lesions caused by chromoblastomycosis, who were treated between 1963 and 1998. The cases were confirmed by the histopathologic and mycologic analyses made by the Dermatology Service of the Universidade Federal do Rio Grande do Sul at the Santa Casa de Misericórdia Hospital. RESULTS: There was a predominance of male patients (4:1) and of white farmers whose ages ranged from 50 to 59 years, with lesions on their lower limbs. Most of them were from the northern regions of the state. The average time between the appearance of the disease and medical diagnosis was 14 years. The verrucous type proved to be the most frequently reported lesion (53%). Thorn wounds were associated with the disease in 16% of the cases. Lesions uncommon to some parts of the body were also reported. In two of the cases, cutaneous lesions caused by paracoccidioidomycosis and chromoblastomycosis were found in the same patient. Epidermoid carcinoma was found in the same parts of the body affected by chromoblastomycosis. Eumycotic mycetoma and chromoblastomycosis were associated. Fonsecaea pedrosoi was found in 96% of the cases, and Phialophora verrucosa in 4% of the cases. CONCLUSION: In our study, we observed a predominance of cases in the regions of Missões and Alto Uruguay, followed by the upper and lower northeastern slopes and the lowlands. Severe cases of chromoblastomycosis with intense skin involvement (eg, lesions with carcinoma) were observed. Statistical analysis showed recrudescence of the disease in 43% of cases despite the treatment used.

727

Chromoblastomycosis in India. Sharma NL, Sharma RC, Grover PS, Gupta ML, Sharma AK, Mahajan VK. Int J Dermatol. 1999 Nov;38(11):846-51.

BACKGROUND: Four patients with chromoblastomycosis are presented. An additional 30 infected Indian patients are reviewed. RESULTS: These 34 patients ranged in age from 12 to 80 years with a male to female ratio of 5.8 : 1. Onset before the age of 20 years was seen in 24% of cases which was comparatively high. Culture was positive in 72% of cases and sclerotic bodies were observed in 84% of cases. A relatively higher prevalence (15%) of Fonsecaea compacta was observed. Unusual cutaneous sites afflicted were the penile shaft, vulva, and ala of the nose, and unusual extracutaneous spread was seen in the pleural cavity, ileocecal region, laryngotracheal area, and tonsils. Extracutaneous involvement was seen in 24% of cases. Overlapping infection with another fungus, Geotrichum candidum, was seen in one case. CONCLUSIONS: Combination therapy with two azoles was attempted with some success for clinical cure.

728

Chromoblastomycosis--a clinical and mycological study of 71 cases from Sri Lanka. Attapattu MC. Mycopathologia. 1997;137(3):145-51.

Chromoblastomycosis, a well-documented chronic fungal infection, represents a specific clinical entity with typical warty cutaneous nodules and a worldwide distribution. Although more prevalent in tropical and subtropical regions, only a few reports are available from Sri Lanka or from Asia. Five etiologic agents of chromoblastomycosis have been recognized worldwide. Of these the majority of infections have been caused by Fonsecaea pedrosoi. During the period from 1952 to 1962, only twelve culturally proven cases of this disease had been recorded from Sri Lanka. The fungus responsible was F. pedrosoi. The present report presents a study of the clinical and mycological features of 71 Sri Lankan patients with chromoblastomycosis for the 16-year period from 1978 to 1993. It documents three etiological agents. Culture identification was made in 69 cases. The three fungal species were Fonsecaea pedrosoi (64), Phialophora verrucosa (3) and a fungus compatible morphologically with F. compacta (2). The isolation of a fungus morphologically compatible with F. compacta is of significance since only 12 cases have been documented in the world's literature so far.

729

Corneal chromoblastomycosis. Barton K, Miller D, Pflugfelder SC. Cornea. 1997 Mar;16(2):235-9.

PURPOSE: We sought to illustrate the difficulty in managing uncommon, pigmented mold-related corneal ulceration and to highlight the role of itraconazole in treating these patients. METHOD: We describe the management and clinical course of a patient with a recurring corneal infection caused by Fonsecaea pedrosoi and discuss this experience in the light of existing literature on management of cutaneous chromoblastomycosis. RESULTS: A corneal ulcer caused by this organism healed initially on treatment with topical and systemic antifungal medication, but infection recurred in the deep stroma 4 months after cessation of therapy. After failure to respond to a further period of medical therapy, a small therapeutic penetrating keratoplasty was performed. Culture of a fibrinous membrane from the anterior iris surface demonstrated intraocular fungal infection, and postoperatively, an episode of marked fibrinous uveitis developed, suggesting the presence of viable intraocular fungal elements. A large penetrating keratoplasty was therefore performed with excision of involved iris in combination with extracapsular cataract extraction. F. pedrosoi was again cultured from the fibrinous membrane adherent to the iris and from the anterior lens capsule. Postoperatively the patient received a 5-month course of systemic itraconazole, and no further recurrences have been encountered after a further 2 months. CONCLUSION: F. pedrosoi is the organism most commonly isolated from the chronic cutaneous mycosis, chromoblastomycosis, and is relatively resistant to medical therapy. As has been reported for cutaneous disease, surgery in combination with systemic itraconazole may provide the best chance of cure in corneal chromoblastomycosis.

730

Chromoblastomycosis in Gabon. Study of 64 cases] Kombila M, Gomez de Diaz M, Richard-Lenoble D, Renders A, Walter P, Billiault X, Joire A, Coniquet-Folquet S, Duong TH, de Bièvre C. Sante. 1995 Jul-Aug;5(4):235-44.

During the last 25 years, 64 cases of chromoblastomycosis were diagnosed in Gabon. They came from the entire territory, where living in rural zones men as well as women were affected. The evolution of the disease has lasted for more than 10 years for the majority of the cases. The preferential location is the lower limb for 78.5% of the patients, with a double localization for one case and an exceptional malignant transformation for another case. Two clinical aspects emerged, despite an apparent polymorphism: extensive patches and warty nodules, spread apart from or adjacent to the others. The histological images were classical and the fumagoid cells, sometimes budding and filamentous, were easily detected during examination of the squama and scabs. Fonsecaea pedrosoï was the only identified species. The 5-fluorocytosine treatment constantly led to an improvement of the lesions. The major problem for these destitute patients is economic, concerning the cost of the therapy.

731

Chromomycosis: a twenty-year analysis of histologically confirmed cases in Jamaica. Bansal AS, Prabhakar P. Trop Geogr Med. 1989 Jul;41(3):222-6.

Thirty-one cases of histologically confirmed chromomycosis seen at the University Hospital of the West Indies (UHWI) between 1967 and 1986 were reviewed. A mean age of 56 years and a 5 to 1 male to female ratio were recorded. The lower limb was infected most frequently and both the macroscopic and microscopic disease showed typical features. Fonsecaea species were isolated in all 16 cases in whom mycological information was available (14 cases of F. pedrosoi). Surgical excision and split skin grafting produced long term cure in 7 to 10 cases with limited disease. Chromomycosis is more common in Jamaica than previous records would suggest.

732

Cerebral phaeohyphomycosis caused by Fonsecaea pedrosoi in Saudi Arabia. al-Hedaithy SS, Jamjoom ZA, Saeed ES. APMIS Suppl. 1988;3:94-100.

A case of cerebral phaeohyphomycosis (CPM) in a 70-yr-old Saudi male was diagnosed recently at King Khalid University Hospital in Riyadh. Computerized tomography (CT) scans of the patient's brain unveiled 2 abscesses in the left frontal and a 3rd abscess in the right frontal lobes. Aspirated pus from the abscesses contained branched, septate, brown hyphae diagnostic of CPM. Culturing of pus yielded a slow-growing, dematiaceous fungus which was identified as Fonsecaea pedrosoi. Combined therapy of amphotericin B and 5-fluorocytosine had little or no effect as the patient continued to have spiking fever and his condition remained more or less unchanged. Medical care of the patient was unfortunately discontinued as he was discharged, with a rather poor prognosis, at the insistence of his family and against medical advice. Prior to this case, work had been done on identifying the agents responsible for two previously diagnosed cases of CPM in Saudi patients with fatal outcome. The dematiaceous fungi that were isolated remained sterile for quite a time before we succeeded in inducing sporulation. Both these isolates were also identified as being Fonsecaea pedrosoi.

733

Experience with brain abscess in the central province of Saudi Arabia. Jamjoom A, Jamjoom ZA, Naim-Ur-Rahman, Tahan A, Malabarey T, Kambal A. Trop Geogr Med. 1994;46(3):154-6.

The characteristics of brain abscess in the Central Province of Saudi Arabia are outlined in this report which is a review of 22 consecutive cases that were treated at King Khalid University Hospital between 1985-1991. The incidence of brain abscess in Saudi Arabia is calculated to be 3.6 cases/500,000 population/year which is twice as high as the incidence reported from the West. There were 17 males and 5 females with an age range of 8 months-80 years (mean 29.9 years). The parietal lobe was involved in 27%, while the abscess was in the posterior fossa in 14% and multiple in another 14% of cases. The primary source of sepsis was unknown in 50%, post-traumatic in 18% and from a dental and mastoid origin in 14% of cases only. Duration of symptoms ranged between 4-30 days (mean 12 days). Fever was present in 55% of cases and epilepsy in 23%. Sixteen (73%) cases had burr hole aspiration, while 3 (14%) had craniotomy and excision, and 3 (14%) cases were managed with antimicrobial treatment only. Staphylococci were the pathogens in 27%, while streptococci were cultured in 23% cases and the culture was negative in 23%. Three (14%) cases all of which died had fungal abscesses caused by Fonsecaea pedrosoi. The mortality was 18%, good recovery in 68% and fair recovery in 14%. Follow-up was from 3 months to 5.5 years (mean 1.8 years).

734

Primary mycotic abscess of the brain caused by Fonsecaea pedrosoi. Case report. Santosh V, Khanna N, Shankar SK, Pal L, Das S, Chandramukhi A, Kolluri VR. J Neurosurg. 1995 Jan;82(1):128-30.

A case of cerebral abscess caused by Fonsecaea pedrosoi is reported in a nonimmunocompromised 15-year-old boy. In the absence of a primary cutaneous lesion, this fungus was considered to be a primary neuropathogen. The fungus was cultured and characterized from the abscess material obtained at surgery. Prompt therapy using amphotericin B and 5-flucytosine helped in the successful recovery of this patient.

773

Cutaneous infection by Fusarium species in healthy and immunocompromised hosts: implications for diagnosis and management. Nucci M, Anaissie E. Clin Infect Dis. 2002 Oct 15;35(8):909-20.

IInfections by Fusarium species frequently involve the skin, either as the primary or the metastatic site. To better understand the pathophysiology of these infections, 43 new patients with fusariosis were evaluated, and the literature was reviewed. A total of 259 patients (232 immunocompromised and 27 immunocompetent) were identified. Skin involvement was present in 70% of patients, particularly in immunocompromised patients (72% vs. 52%; P=.03). In immunocompetent patients, cutaneous infections were characterized by preceding skin breakdown, localized involvement, slow pace of progression, and good response to therapy. In contrast, skin involvement in immunocompromised patients was only occasionally preceded by skin breakdown and typically was presented as rapidly progressive disseminated lesions at various stages of evolution. Metastatic skin lesions were associated with fungemia, neutropenia, and death. Skin was the single source of diagnosis for the majority of immunocompromised and immunocompetent patients. Recommendations for the prevention of fatal fusariosis originating from skin are presented.

774

Fusarium infections of the skin. Gupta AK, Baran R, Summerbell RC. Curr Opin Infect Dis. 2000 Apr;13(2):121-128.

Fusarium species are ubiquitous and may be found in the soil, air and on plants. Fusarium species can cause mycotoxicosis in humans following ingestion of food that has been colonized by the fungal organism. In humans, Fusarium species can also cause disease that is localized, focally invasive or disseminated. The pathogen generally affects immunocompromised individuals with infection of immunocompetent persons being rarely reported. Localized infection includes septic arthritis, endophthalmitis, osteomyelitis, cystitis and brain abscess. In these situations relatively good response may be expected following appropriate surgery and oral antifungal therapy. Disseminated infection occurs when two or more noncontiguous sites are involved. Over eighty cases have been reported, many of which had a hematologic malignancy including neutropenia. The species most commonly involved include Fusarium solani, Fusarium oxysporum, and Fusarium moniliforme (also termed F. verticillioides). The diagnosis of Fusarium infection may be made on histopathology, gram stain, mycology, blood culture, or serology. Portals of entry of disseminated infection include the respiratory tract, the gastrointestinal tract, and cutaneous sites.The skin can be an important and an early clue to diagnosis since cutaneous lesions may be observed at an early stage of the disease and in about seventy-five cases of disseminated Fusarium infection. Typical skin lesions may be painful red or violaceous nodules, the center of which often becomes ulcerated and covered by a black eschar. The multiple necrotizing lesions are often observed on the trunk and the extremities. Onychomycosis most commonly due to F. oxysporum or F. solani has been reported. The onychomycosis may be of several types: distal and lateral subungual (DLSO), white superficial (WSO), and proximal subungual (PSO). In proximal subungual onychomycosis there may be associated leukonychia and/or periungual inflammation. Patients with Fusarium onychomycosis have been cured following therapy with itraconazole, terbinafine, ciclopirox olamine lacquer, or topical antifungal agent. In other instances nail avulsion plus antifungal therapy has been successful. In patients with hematologic malignancy or bone marrow transplant, who may experience prolonged or severe neutropenia during the course of therapy, the skin and nails should be carefully examined and consideration given to treating potential infection sites that may serve as portals for systemic dissemination. When disseminated Fusarium infection is present therapy with antifungal agents has generally been disappointing with the chances of a successful resolution being enhanced if the neutropenia can be corrected in a timely manner.

775

Mycetoma caused by Fusarium solani with osteolytic lesions on the hand: case report. Tomimori-Yamashita J, Ogawa MM, Hirata SH, Fischman O, Michalany NS, Yamashita HK, Alchorne M. Mycopathologia. 2002;153(1):11-4.

Eumycetoma is a mycotic disease caused by saprophytic soil fungi that are usually inoculated through minor injuries. A case of mycetoma in a Brazilian farmer aged 71 years is reported. This patient presented erythema and edema on the dorsal surface of the left hand with multiple crusted and cicatricial lesions. No macroscopic grains were observed. The histopathological findings showed grains consisted of numerous hyphae which stained well with Gomori-Grocott method. This material obtained by cutaneous biopsy was submitted to culture on Sabouraud's medium and the colonies were identified as Fusarium solani. The radiological studies revealed bone osteolytic lesions and the ultrasound showed pseudocysts and fistulae at the site of this infection. The patient was treated with oral ketoconazole with a good clinical response.

776

A cutaneous ulcer induced by fungi of the genus Fusarium] Negroni R, Martino O, Robles AM, Orduna T, Arechavala A, Brusca S, Helou S. Rev Soc Bras Med Trop. 1997 Jul-Aug;30(4):323-8.

A case of cutaneous hyalohyphomycosis, due to Fusarium oxysporum, in a 40 years old man is presented. The patient came from Paraguay where he worked in a tropical rural area. His disease had begun 2 months before his admission as a skin ulcer located in the left leg. Clinical characteristics, diagnosis methods, differential diagnosis with other ulcers of the legs in tropical areas as well as therapeutic measures are discussed in this presentation.

777

Skin lesions associated with Fusarium infection. Bodey GP, Boktour M, Mays S, Duvic M, Kontoyiannis D, Hachem R, Raad I. J Am Acad Dermatol. 2002 Nov;47(5):659-66.

Infections caused by Fusarium species are increasing in frequency among immunocompromised hosts. We identified 35 patients with cancer who had Fusarium skin lesions. Twenty patients had disseminated infection, 6 had primary localized skin infections, 4 had skin lesions associated with sinus infections, and 5 had onychomycosis. All patients (except 3 with onychomycosis) had hematologic malignancies and neutropenia. Skin lesions associated with disseminated infection included red or gray macules, papules (some with central necrosis or eschar), pustules, and subcutaneous nodules. Most patients had a variety of lesions simultaneously. Multiple red or gray macules with central ulceration or black eschar are characteristic of Fusarium infection. Disseminated infection may originate from skin lesions or onychomycosis. Most infections fail to respond to antifungal therapy unless there is resolution of the patient's neutropenia.

778

Subcutaneous Fusarium foot abscess in a renal transplant patient. Girardi M, Glusac EJ, Imaeda S. Cutis. 1999 May;63(5):267-70.

Fusarium species are ubiquitous plant and grain phytopathogens that rarely cause opportunistic infections in immunocompromised patients. While disseminated Fusarium infections are almost always fatal, localized infections may be responsive to a combination of systemic antibiotic therapy and surgical debridement. We present a diabetic renal transplant patient who developed a foot abscess due to Fusarium solani. Infection persisted despite aggressive surgical debridement and a 3-month course of intravenous liposomal amphotericin B.

779

Extensive subcutaneous hyphomycosis caused by Fusarium oxysporum. Attapattu MC, Anandakrishnan C. J Med Vet Mycol. 1986 Apr;24(2):105-11.

Subcutaneous granulomatous lesions by hyaline moulds are rare. This report describes a case of hyalohyphomycosis by Fusarium oxysporum. The patient was a 16-year-old Sri Lankan girl who had had extensive lesions in both arms almost from infancy. The fungus was demonstrated in KOH mounts and in histopathological sections. It was isolated repeatedly from her lesions over a period of 10 months. Combined therapy with ketoconazole and 5-fluorocytosine resulted in marked improvement. An inherent immune defect is postulated to account for the prolonged and extensive infection by a relatively non-aggressive fungus.

780

Cutaneous infection in man caused by Fusarium moniliforme. Collins MS, Rinaldi MG. Sabouraudia. 1977 Jul;15(2):151-60.

Fusarium moniliforme was isolated from a pustular lesion on the hand of an otherwise healthy male. Branching hyphae were seen in pus stained by the periodic acid-Schiff method. Pustular lesions containing branching hyphae were produced in mice after subcutaneous injection of microconidia. The experimental infection in mice and the naturally occurring lesion in man healed without treatment in 1 to 2 weeks. Although production of catenulate microconida was abundant on several common laboratory media, the characteristic macroconidia of F. moniliforme were produced only on barley-pea-rice straw agar.

781

Primary pulmonary involvement of Fusarium solani in a lung transplant recipient. Arney KL, Tiernan R, Judson MA. Chest. 1997 Oct;112(4):1128-30.

A case of cavitary lung disease caused by Fusarium solani in a lung transplant recipient is presented. A mechanism for development of this infection is proposed. Lipid complex amphotericin B (Abelcet) was effective in eradicating this infection. To our knowledge, invasive lung disease caused by the Fusarium species has not been previously reported in a solid organ transplant recipient.

782

Operative treatment of Fusarium fungal infection of the lung. Lupinetti FM, Giller RH, Trigg ME. Ann Thorac Surg. 1990 Jun;49(6):991-2.

Systemic fungal infections with Fusarium occur predominantly in immunocompromised patients and are usually fatal. We report a patient with acute lymphocytic leukemia and fusariosis involving the skin and lungs. This patient underwent antifungal chemotherapy and bilateral pulmonary resections. She subsequently had successful bone marrow transplantation. The results of this treatment suggest that this aggressive management of pulmonary fusariosis offers the best chance of survival.

783

Endocarditis due to Fusarium dimerum four years after coronary artery bypass grafting. Camin AM, Michelet C, Langanay T, de Place C, Chevrier S, Guého E, Guiguen C. Clin Infect Dis. 1999 Jan;28(1):150.

784

Disseminated Fusarium solani infection with endocarditis in a lung transplant recipient. Guinvarc'h A, Guilbert L, Marmorat-Khuong A, Lavarde V, Chevalier P, Amrein C, Guillemain R, Berrebi A. Mycoses. 1998 Jan-Feb;41(1-2):59-61.

Eleven days after double lung transplantation for cystic fibrosis, an 18-year-old patient developed a disseminated Fusarium solani infection with tricuspid valve endocarditis. This infection occurred under fluconazole and immunosuppressive therapy with cyclosporin, prednisone and azathioprine, with a normal leucocyte count. Liposomal amphotericin B allowed blood culture negativation. The patient died from a bacterial septic shock.

785

Fatal Fusarium endocarditis complicated by hemolytic anemia and thrombocytopenia in an infant. Hsu CM, Lee PI, Chen JM, Huang LM, Wu MH, Chiu IS, Lee CY. Pediatr Infect Dis J. 1994 Dec;13(12):1146-8.

786

Fusarium endocarditis involving aortic valve following coronary artery surgery. Jorens PG, Van Den Heuvel PA, Van Cauwelaert PA, Parizel GA, Mertens AN. Eur Heart J. 1990 May;11(5):476-8.

This article describes a case of infective aortic valve endocarditis due to Fusarium oxysporum occurring 4 years after coronary artery bypass grafting. It is the first reported case of endocarditis caused by Fusarium.

787

Mycetoma of the renal pelvis caused by Fusarium species. Nakar C, Livny G, Levy I, Samra Z, Linder N, Ashkenazi S, Livne P, Sirota L. Pediatr Infect Dis J. 2001 Dec;20(12):1182-3.

A preterm infant, with posterior urethral valves had a mycetoma of the renal pelvis caused by Fusarium species. Prolonged treatment with amphotericin B alone or with flucytosine failed. Combined surgical drainage and medical therapy resulted in full resolution.

788

Mycetoma of the foot due to Fusarium sp. treated with oral ketoconazole. Baudraz-Rosselet F, Monod M, Borradori L, Ginalsky JM, Vion B, Boccard C, Frenk E. Dermatology. 1992;184(4):303-5.

We report the case of a 30-year-old Nigerian patient with mycetoma of the foot without bone involvement caused by Fusarium sp..Long-term administration of ketoconazole produced a significant improvement with good clinical and biological tolerance.

789

Fusarium moniliforme, a new mycetoma agent. Restudy of a European case. Ajello L, Padhye AA, Chandler FW, McGinnis MR, Morganti L, Alberici F. Eur J Epidemiol. 1985 Mar;1(1):5-10.

Fusarium moniliforme was demonstrated to be the etiologic agent in an Italian case of eumycotic mycetoma. The fungus produced white granules, which measured 80 X 133 by 212 X 478 microns. Their edges were entire or lobed and were surrounded by an eosinophilic homogeneous material. The hyphae comprising the granules were not embedded in cement. The etiologic agent, first considered to be an Acremonium species, was restudied and identified as F. moniliforme on the basis that it not only produced chains of microconidia but also curved, multi-septate macroconidia typical of the genus Fusarium.

790

Clinical patterns of Fusarium infections in immunocompromised patients. Martino P, Gastaldi R, Raccah R, Girmenia C. J Infect. 1994 May;28 Suppl 1:7-15.

Fusarium is an ubiquitous fungus commonly found in soil and on plants. Human infection usually occurs as a result of inoculation of the organism through the body surface, thus causing skin infection, onychomycosis, keratitis, endophthalmitis and arthritis. Dissemination may occur in subjects with underlying immunodeficiency. Among immunocompromised hosts, Fusarium sp. is an emerging pathogen in neutropenic patients. To our knowledge, since 1973, when the first disseminated fusariosis in a child with acute leukemia was reported, about 80 new cases have been reported, mainly occurring in patients with haematologic malignancies. Specific portals of entry are not well understood, nevertheless the respiratory tract, colonised gastrointestinal tract, onychomycosis, disrupted skin barrier and central venous catheter have been reported as entry sites of deep seated Fusarium infections. Fever, positive blood cultures, severe myalgias, disseminated ecthyma gangrenosum-like skin lesions, ocular symptoms and multiple-organ-system involvement are distinctive features in most cases of disseminated fusariosis. The prognosis is very poor with death generally following despite antifungal therapy, unless an increase in the white blood cell count occurs. All available antifungal drugs show a low activity against the various species of Fusarium. Nevertheless, amphotericin B seems to have the highest in vitro activity and, even if it does not appear to be effective in persistently neutropenic patients, it should be currently considered to be the treatment of choice.

791

Septic arthritis due to Fusarium moniliforme. Gradon JD, Lerman A, Lutwick LI. Rev Infect Dis. 1990 Jul-Aug;12(4):716-7.

792

Treatment of Fusarium peritonitis in a peritoneal dialysis patient. Giacchino F, Belardi P, Merlino C, Aimino M, Garneri G, Cuffini AM, Tullio V. Perit Dial Int. 1997 Jul-Aug;17(4):403-4.

793

Fusarium peritonitis in a child on peritoneal dialysis: case report and review of the literature. Flynn JT, Meislich D, Kaiser BA, Polinsky MS, Baluarte HJ. Perit Dial Int. 1996 Jan-Feb;16(1):52-7.

OBJECTIVE: To review various aspects of the management of peritonitis due to Fusarium, a soil mold which infrequently causes infections in humans. DATA SOURCES: A case of Fusarium peritonitis in a child on chronic peritoneal dialysis (PD) is presented. The child developed Fusarium peritonitis 2 weeks after an episode of bacterial peritonitis. His Tenckhoff catheter was removed, and he was maintained on hemodialysis while receiving intravenous amphotericin. Following 2 weeks of treatment with amphotericin, he was successfully returned to PD. A literature review of all previously reported cases of Fusarium peritonitis was then conducted to determine features common to infections caused by Fusarium. Emphasis was also placed on unique characteristics of the organism that may affect patient management, as well as patient characteristics that may increase the risk for infection by Fusarium. RESULTS: Fusarium may cause infection in immunosuppressed individuals, such as cancer patients or patients on chronic PD. The organism has a propensity to attach to foreign bodies such as intravascular and intraperitoneal catheters. Therefore, successful treatment of infections caused by Fusarium may require catheter removal in addition to systemic antifungal therapy. CONCLUSIONS: This report presents the first known case of Fusarium peritonitis in a child. In view of the difficulties posed by this unusual organism, optimal therapy of Fusarium peritonitis should consist of immediate catheter removal and treatment with systemic antifungal drugs.

794

Fusarium solani peritonitis: infrequent complication of peritoneal dialysis] Nuño E, Cisneros JM, Regordan C, Montes R, Guerrero MA, Martín C. Enferm Infecc Microbiol Clin. 1995 Mar;13(3):196-7.

795

Fusarium peritonitis in peritoneal dialysis: report of two cases. Chiaradia V, Schinella D, Pascoli L, Tesio F, Santini GF. Microbiologica. 1990 Jan;13(1):77-8.

This report describes two cases of peritoneal dialysis-related peritonitis caused by Fusarium species which have been incriminated in a variety of disease conditions. Treatment with 5-Fluorocytosine was unsuccessful, but removal of the catheter resulted in a rapid resolution of the infections.

796

Disseminated cutaneous and peritoneal hyalohyphomycosis caused by Fusarium species: three cases and review of the literature. Rippon JW, Larson RA, Rosenthal DM, Clayman J. Mycopathologia. 1988 Feb;101(2):105-11.

Three recent cases of hyalohyphomycosis caused by Fusarium sp. illustrate differing aspects of infections produced by these organisms. One patient was undergoing continuous ambulatory peritoneal dialysis when peritonitis developed caused by Fusarium moniliforme. Removal of the catheter and amphotericin B were used in successful management. In a neutropenic patient on therapy for leukemia, multiple persistent infections occurred including JK diptheroids, and Candida albicans sepsis. Finally, numerous florid skin lesions caused by Fusarium oxysporum developed even while the patient was receiving amphotericin B and he died. In a second neutropenic patient on treatment for leukemia, sinus and cutaneous lesions developed due to Fusarium. These resolved on amphotericin B therapy following the return of circulating neutrophils. The literature on Fusarium infections and aspects of the biology of the organism are reviewed.

797

Granulomatous peritonitis in fish associated with Fusarium solani. Ostland VE, Ferguson HW, Armstrong RD, Asselin A, Hall R. Vet Rec. 1987 Dec 19-26;121(25-26):595-6.

798

Fungal peritonitis in patients on continuous ambulatory peritoneal dialysis. Kerr CM, Perfect JR, Craven PC, Jorgensen JH, Drutz DJ, Shelburne JD, Gallis HA, Gutman RA. Ann Intern Med. 1983 Sep;99(3):334-6.

Fungal peritonitis is a rare complication in patients on continuous ambulatory peritoneal dialysis. We report five recent cases and their management. The fungi isolated were Candida albicans, C. parapsilosis, Exophiala jeanselmei, Drechslera spicifera, and a Fusarium species. Chemotherapy was attempted with various regimens including oral ketoconazole, intravenous or intraperitoneal amphotericin B, and oral flucytosine. Pharmacokinetic studies were done in two patients receiving treatment with one of these drugs. Three patients were cured of their fungal infection. Three patients whose Tenckhoff catheters were left in situ died, whereas two patients whose catheters were removed survived. Our experience suggests that removal of the peritoneal catheter should be considered once the diagnosis of fungal peritonitis is established.

799

Brain abscesses in children with cancer. Antunes NL, Hariharan S, DeAngelis LM. Med Pediatr Oncol. 1998 Jul;31(1):19-21.

BACKGROUND: Brain abscesses in pediatric patients are rare events, and the causative organism and prognosis vary with the population under study. Children with cancer seem to be particularly susceptible to the development of brain abscesses because of the immunological changes induced by cancer and its treatment. We reviewed the records of children who developed a brain abscess during treatment of a malignancy to define the clinical characteristics, prognosis, and management of these patients. PROCEDURE: We performed a retrospective review of the clinical and laboratory characteristics of all cancer patients younger than age 20 years who were admitted to our institution between 1980 and 1996 for a brain abscess. RESULTS: Twelve children were identified. Cancer diagnoses were brain tumor in two, systemic PNET in two, and leukemia in eight. Six patients had multiple abscesses. Eleven received prior chemotherapy. Abscesses were surgically excised or aspirated in seven, and empiric antibiotics were given to the other five. At surgery, Listeria monocytogenes, Aspergillus fumigatus (3), Fusarium, and Candida lusitanea were cultured. Aspergillus was identified in other locations in four patients. Abscesses were successfully treated in seven patients, two of whom received antibiotics only; five patients (42%) died from infection. CONCLUSIONS: Mortality is high in this immunosuppressed population, in part due to the preponderance of fungal infection. The finding of very rare organisms suggests that drainage and culture should be performed whenever possible; empiric antibiotics that include an antifungal agent may, on occasion, be successful.

800

Fusarium meningoencephalitis in a child with acute leukemia. Agamanolis DP, Kalwinsky DK, Krill CE Jr, Dasu S, Halasa B, Galloway PG. Neuropediatrics. 1991 May;22(2):110-2.

A 15-year-old boy with acute lymphoblastic leukemia (ALL) developed disseminated fusarium infection with meningoencephalitis following a contaminated skin wound. With antifungal therapy, the cutaneous lesions cleared but central nervous system (CNS) infection persisted causing a fibrosing meningitis and a brain granuloma. Fusaria are soil saprophytes that are more commonly associated with superficial eye and skin lesions, but may also cause severe systemic infections with CNS involvement in immuno-compromised patients. The organism may be confused with Aspergillus in tissue sections, and can only be diagnosed by culture.

801

The spectrum of Fusarium infection in immunocompromised patients with haematological malignancies and in non-immunocompromised patients: a single institution experience over 10 years. Musa MO, Al Eisa A, Halim M, Sahovic E, Gyger M, Chaudhri N, Al Mohareb F, Seth P, Aslam M, Aljurf M. Br J Haematol. 2000 Mar;108(3):544-8.

Fusarium is a newly emerging fungal pathogen associated with significant morbidity and mortality in the immunocompromised host. We have reviewed our hospital's experience with Fusarium between 1985 and 1995. Fusarium species were isolated from 22 specimens, representing 11 patients. Cases were not clustered by time period. The median age of the patients was 36.5 years (range 17-69 years). The sources of the organism were 12 skin lesions from eight patients, seven blood cultures from two patients and one specimen each from a Hickman catheter tip, nail clippings and a bronchoalveolar lavage. Seven of the patients had chemotherapy-induced neutropenia when the Fusarium was isolated. Five of them developed invasive fusarosis during acute leukaemia induction treatment. They remained neutropenic, and none survived. The other two patients recovered from neutropenia and were treated successfully for this infection. The remaining four patients were not neutropenic or immunocompromised. Three grew Fusarium from skin or nail clippings and one from bronchial alveolar lavage (BAL). There was no evidence of invasive disease in any of the four. None of them received antifungal therapy, and they were all alive at last follow-up. We conclude that Fusarium is a newly emerging infection in neutropenic patients. A high index of suspicion, especially for skin lesions, will help in early diagnosis before systemic and visceral dissemination. Excision of the initial focus of infection and antifungal therapy, aided by speedy neutrophil recovery, are likely to protect patients threatened with these fatal infections. Fusarium isolated from non-neutropenic, non-immunosuppressed patients is not significant and does not merit systemic antifungal treatment.

802

Disseminated Fusarium infection identified by the immunohistochemical staining in a patient with a refractory leukemia. Saito T, Imaizumi M, Kudo K, Hotchi M, Chikaoka S, Yoshinari M, Suwabe N, Sato A, Suzuki H, Iinuma K. Tohoku J Exp Med. 1999 Jan;187(1):71-7.

The difficulty and uncertainty encountered in diagnosing a systemic mycosis often lead to a delay in starting antifungal therapy. We reported a disseminated infection of multiple fungal isolates including Fusarium species during donor leukocyte transfusion (DLT) after allogeneic bone marrow transplantation in a 20-year-old woman with a refractory leukemia. Skin lesions are the feature of Fusarium and occur in the early period of the infection. In this case, during immunosuppression state after DLT, she presented with the whole body ache and erythematous lesions which appeared rapidly on her trunk and extremities. While administration of amphotericin B was started, her condition was further deteriorated and she died. Autopsy materials revealed that she had multiple fungal infection with different isolates, including Aspergillus and Candida in the brain, lung and liver, but not in the skin. With the immunohistochemical staining with specific antibody, Fusarium or Aspergillus infection was identified from the biopsy skin or autopsy brain, respectively. This rapid and specific immunohistochemical method may be useful for the diagnosis and treatment of invasive fungal infection without delay.

803

Systemic Fusarium oxysporum infection in an immunocompetent patient with an adult respiratory distress syndrome (ARDS) and extracorporal membrane oxygenation (ECMO). Sander A, Beyer U, Amberg R. Mycoses. 1998 Mar-Apr;41(3-4):109-11.

We report a case of disseminated fusariosis in a 42-year-old patient with adult respiratory distress syndrome (ARDS) and extracorporal membrane oxygenation (ECMO), but without definite immunosuppression. Fusarium oxysporum was isolated from a bronchial lavage taken 6 days ante mortem. Despite antifungal treatment with amphotericin B and flucytosine the patient died in septic multiorgan failure. A post-mortem examination was performed. The patient's liver was found to contain fungus cells and F. oxysporum could be cultured from ascites.

804

Fungaemia due to Fusarium spp. in cancer patients. Krcmery V Jr, Jesenska Z, Spanik S, Gyarfas J, Nogova J, Botek R, Mardiak J, Sufliarsky J, Sisolakova J, Vanickova M, Kunova A, Studena M, Trupl J. J Hosp Infect. 1997 Jul;36(3):223-8.

Five cases of fungaemia due to Fusarium spp. in cancer patients are described. Two were breakthrough cases, despite ongoing therapy with amphotericin B. Three were caused by Fusarium solani, one by F. oxysporum and one by F. dimerum. Four patients died, three of them despite therapy with amphotericin B for between 5-37 days. We describe only the second reported case of F. dimerum fungaemia. Since 1972, 93 cases of systemic infection with Fusarium spp. have been described: 43 had positive blood cultures and the overall mortality was 72%.

805

Systemic Fusarium nygamai infection in a patient with lymphoblastic non-Hodgkin's lymphoma. Krulder JW, Brimicombe RW, Wijermans PW, Gams W. Mycoses. 1996 Mar-Apr;39(3-4):121-3.

We report the case history of a 35-year-old male patient with lymphoblastic non-Hodgkin's lymphoma who acquired a systemic infection with Fusarium nygamai during the granulocytopenic phase of cytostatic treatment. The patient survived this infection after haematological recovery and treatment with intravenous amphotericin B (total dose 543 mg). Subsequent chemotherapy courses were not complicated by fungal infections. A recent trip to Egypt and severe chemotherapy-induced mucositis were probably the major causes of this severe infection.

814

Oral Geotrichum candidum infection associated with HIV infection. A case report. Heinic GS, Greenspan D, MacPhail LA, Greenspan JS. Oral Surg Oral Med Oral Pathol. 1992 Jun;73(6):726-8.

Infections with Geotrichum species, although rare, are sometimes seen in immunocompromised hosts. We report a case of oral geotrichosis in a patient seropositive for human immunodeficiency virus who had erythematous mandibular and maxillary gingiva but was otherwise free of any active systemic disease. Geotrichum candidum was shown by both culture and histopathology to be present in the lesion and was deduced to be the causative organism. The patient responded well to several weeks of treatment involving oral topical administration of nystatin vaginal tablets.

815

[A case of high intestinal obstruction caused by mycotic bezoar of the duodenum] Goszcz A, Mach T, Bogdał J. Pol Tyg Lek. 1989 Apr 10-17;44(15-16):367-9.

A case of the mycotic bezoar in the female patient with gastric hypersecretion is reported. The symptoms of the high intestinal obstruction accompanied underlying disease. Bezoar formed of Geotrichum candidum was fragmentated with biopsical forceps of "alligator" type. Then, natamycin was administered for 5 weeks. The patients recovered completely.

816

Gastrointestinal phycomycosis in acute nonlymphatic leukemia. Mozes B, Pines A, Segev S, Horowitz A, Goldschmied-Reouven A, Douer D, Ben-Bassat I. Isr J Med Sci. 1988 Feb;24(2):93-5.

A 37-year-old patient with acute nonlymphatic leukemia developed gastrointestinal phycomycosis during failure in bone marrow production. The clinical presentation was of acute typhlitis. Laparotomy revealed a necrotic mass in the region of the iliocecal valve, and on histologic examination hyphae of phycomycetes with invasion of the blood vessels were seen. The patient died as a result of widespread infection.

MeSH Terms: Acute Disease Adult Appendicitis/*etiology/pathology Case Report *Geotrichosis/microbiology/pathology Geotrichum/isolation & purification Human Leukemia/*complications

817

Fungal diarrhoea: association of different fungi and seasonal variation in their incidence. Talwar P, Chakrabarti A, Chawla A, Mehta S, Walia BN, Kumar L, Chugh KS. Mycopathologia. 1990 May;110(2):101-5.

A total of 854 patients (640 children and 214 adults) admitted with acute or chronic diarrhoea suspected of non-invasive overgrowth of fungi in intestine were screened during a period of 3 years. Fungal proliferation was noted in 54.8% of these patients (53.6% in children, 58.4% in adults). The predominant fungal species isolated were Candida albicans (64.5%), followed by C. tropicalis (23.3%) C. krusei (6.9%). Torulopsis glabrata (1.6%). Trichosporon sp. and Geotrichum sp. were found to be responsible in 2.3% of adults. As seen in bacterial diarrhoea, higher incidence was noted in children from April to August. No such seasonal variation was noted in adults.

818

Brain abscesses due to Geotrichum candidum. Kasantikul V, Chamsuwan A. Southeast Asian J Trop Med Public Health. 1995 Dec;26(4):805-7.

819

Geotrichum septicemia. Sheehy TW, Honeycutt BK, Spencer JT. JAMA. 1976 Mar 8;235(10):1035-7.

Although disseminated geotrichosis is an unusual disease (to our knowledge, only six cases have been reported), Geotrichum candidum is not a very virulent fungus. In our case, there was neutrophillic phagocytosis of the arthrosphores of G candidum, with rapid clearance of the fungus from the plasma of a chronically ill patient whose immune defenses were still intact.

840

Hansenula anomala outbreak at a surgical intensive care unit: a search for risk factors. Kalenic S, Jandrlic M, Vegar V, Zuech N, Sekulic A, Mlinaric-Missoni E. Eur J Epidemiol. 2001;17(5):491-6.

During a 5-month period, Hansenula anomala (H. anomala), an opportunistic fungus, caused an outbreak of infections in eight adult patients treated at a surgical intensive care unit (ICU). The source of the infections and route of transmission could not be identified. A case-control study included 32 patients treated simultaneously at the surgical ICU. Univariate analysis pointed to the following significant risk factors: blood alkalosis, reduced urea, duration of hospitalization, bacteremia and colonization with Pseudomonas aeruginosa, and an APACHE II score >17 (during bacteremia or fungemia). The stepwise logistic regression multivariate analysis showed only the duration of blood alkalosis to be significant in case patients.

841

Pichia anomala outbreak in a nursery: exogenous source? Aragão PA, Oshiro IC, Manrique EI, Gomes CC, Matsuo LL, Leone C, Moretti-Branchini ML, Levin AS; IRIS Study Group Pediatr Infect Dis J. 2001 Sep;20(9):843-8.

BACKGROUND: Pichia anomala is a rare cause of fungemia. From February to April, 1998, eight cases of fungemia occurred in the intensive care and high risk units of the Nursery. There were four infants with P. anomala infection, one of whom also had Candida parapsilosis infection, two cases with C. parapsilosis infection and two with Candida albicans infection. OBJECTIVE: To determine factors associated with fungemia in the intensive care and high risk units of the Nursery, especially P. anomala. METHODS: A cohort study with 59 newborns. RESULTS: Factors associated with fungemia were: central venous catheter (CVC) (P = 0.0006); total parenteral nutrition (TPN) (P = 0.0005); lipid emulsion (P = 0.002); previous antimicrobial use (P = 0.002); and other invasive procedures (P = 0.002). Factors associated with P. anomala fungemia were: CVC (P = 0.004); TPN (P = 0.018); previous antibiotic use (P = 0.037); and other invasive procedures (P = 0.037). Evaluation of the units demonstrated that there were several technical problems involving administration of TPN that was manipulated in the Nursery without precautions. Changes in TPN formulation and education as to adequate technique were implemented. During follow-up (1998 to 1999) only two fungemias occurred that were caused by C. albicans. Cultures of hands of personnel were negative for P. anomala. Electrophoretic karyotyping of P. anomala showed three profiles. CONCLUSIONS: Factors associated with fungemia were catheter use, invasive procedures and total parenteral nutrition, suggesting that the acquisition of P. anomala was exogenous.

842

Outbreak of Pichia anomala infection in the pediatric service of a tertiary-care center in Northern India. Chakrabarti A, Singh K, Narang A, Singhi S, Batra R, Rao KL, Ray P, Gopalan S, Das S, Gupta V, Gupta AK, Bose SM, McNeil MM. J Clin Microbiol. 2001 May;39(5):1702-6.

An outbreak of nosocomial fungemia due to the unusual yeast, Pichia anomala occurred in the pediatric wards of our hospital over a period of 23 months (April 1996 to February 1998). A total of 379 neonates and children (4.2% admissions) were infected. The probable index case was admitted to the pediatric emergency ward, with subsequent transmission to the premature nursery, pediatric intensive care units, and other children wards. Carriage on the hands of health care personnel was likely to be responsible for dissemination of the fungus. The outbreak could only be controlled after a health education campaign to improve hand-washing practices was instituted and after nystatin-fluconazole prophylaxis to all premature neonates and high-risk infants was introduced. In a case-control study, we identified a lower gestational age, a very low birth weight (<1,500 g), and a longer duration of hospital stay as significant risk factors associated with P. anomala fungemia in premature neonates. We conducted a culture prevalence survey of 50 consecutive premature neonates and found that 28% were colonized with P. anomala at a skin or mucosal site on the date of delivery and that 20% of these neonates subsequently developed P. anomala fungemia. We performed multilocus enzyme electrophoresis on 40 P. anomala outbreak isolates (including patient and health care workers' hand isolates), and the results suggested that these isolates were identical. Our study highlights the importance of P. anomala as an emerging nosocomial fungal pathogen.

843

Pichia ohmeri fungemia. Bergman MM, Gagnon D, Doern GV. Diagn Microbiol Infect Dis. 1998 Mar;30(3):229-31.

A patient with a history of diabetes, coronary artery disease, stroke, previous renal transplantation, and multiple hospital admissions for recurrent pancreatitis was transferred to the hospital from a chronic care facility because of fever and severe epigastric discomfort. At the time of admission, she was receiving hyperalimentation through a central venous TPN catheter. Multiple blood cultures obtained on the first and second hospital days yielded pure cultures of the yeast, Pichia ohmeri. The patient developed acute renal failure, and despite high-dose amphotericin B therapy, ultimately expired.

844

Fungaemia caused by Hansenula anomala--an outbreak in a cancer hospital. Thuler LC, Faivichenco S, Velasco E, Martins CA, Nascimento CR, Castilho IA. Mycoses. 1997 Oct;40(5-6):193-6.

Yeasts belonging to the genus Hansenula are rarely encountered as the cause of infection in clinical practice. A wide spectrum of infections caused by these fungi can be seen, ranging from asymptomatic fungaemia to severe disease. We describe an outbreak of 24 cases of infection due to H. anomala in an oncological hospital in Rio de Janeiro, Brazil. The median age of the patients was 11 years, of whom 54.2% were female; 91.7% of the Hansenula fungaemia occurred in the haematology unit. The most frequent primary disease diagnosis was leukaemia (62.5%), and all of those infected had had a central venous catheter or peripheral venous catheter and had been treated previously with broad-spectrum antibiotics. Numerous other risk factors were observed in our cases: previous use of steroids, chemotherapy, radiation therapy and neutropenia (data not shown). No deaths could be attributed to Hansenula.

845

Hansenula anomala infection in acute leukemia] López F, Martín G, Paz ML, Sanz MA. Enferm Infecc Microbiol Clin. 1990 Jun-Jul;8(6):363-4.

Hansenula anomala infection is a clinical rarity which has only been reported in 21 cases. Although most reported cases had one or more of the risk factors of fungemia, only three developed in hematological patients. In the present study we report two cases of Hansenula anomala infection in acute leukemia, one in its teleomorphic form and another in the asexual form of this yeast, Candida pelliculosa. The sustained chemotherapy and steroid and antibiotic treatment were some of the risk factors of fungemia which were present in these patients, one of which was a carrier of a central venous catheter. As it has been suggested that Hansenula anomala has a low virulence and a high susceptibility to amphotericin B, we emphasize the potential morbidity and mortality that this organism can induce in patients with hematological disease.

846

Hansenula anomala fungemia. Haron E, Anaissie E, Dumphy F, McCredie K, Fainstein V. Rev Infect Dis. 1988 Nov-Dec;10(6):1182-6.

Fungi of the genus Hansenula have rarely been reported as pathogenic in humans. A case of catheter-related Hansenula anomala fungemia in a patient with acute leukemia in remission is presented, and the clinical features of 11 additional patients infected with Hansenula species are reviewed. The spectrum of disease with these organisms ranges from asymptomatic fungemia to life-threatening disseminated infection. Predisposing factors appear to be immunosuppression, use of intravenous devices, and previous treatment with antibacterial drugs. Clinical experience and limited in vitro susceptibility data show that amphotericin B remains the drug of choice in the treatment of hansenula infections.

847

Infection and colonisation of neonates by Hansenula anomala. Murphy N, Buchanan CR, Damjanovic V, Whitaker R, Hart CA, Cooke RW. Lancet. 1986 Feb 8;1(8476):291-3.

Over a 13-month period 52 neonates (10% of those admitted to the Mersey Regional Neonatal Intensive Care Unit) were found to be colonised with the ascosporagenous yeast Hansenula anomala. 8 babies became infected, all but 1 of whom were heavily colonised before infection. 7 of the 8 infected babies were of very low birth-weight (less than 1500 g). All 8 had multiple problems associated with low birth-weight and prematurity and were kept in the intensi