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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 intensive care unit. 5 babies had fungaemia, 2 had fungaemia and ventriculitis, and 1 had ventriculitis only. In each case H anomala was the sole pathogen isolated. Anti-Hansenula antibodies developed in 5 babies within 3 months of infection. Infected babies were successfully treated with a combination of 5-flucytosine and amphotericin B. Despite extensive searches the babies appeared to be the only reservoir of the yeast.

848

Infective endocarditis of a bicuspid aortic valve caused by Hansenula anomala. Nohinek B, Zee-Cheng CS, Barnes WG, Dall L, Gibbs HR. Am J Med. 1987 Jan;82(1):165-8.

Infective endocarditis due to Hansenula anomala developed on a bicuspid aortic valve in a 40-year-old man. H. anomala, an ascomycetous yeast, may be a member of the normal flora of the throat and alimentary tract in humans but has not been previously known to be pathogenic in humans. A past history of intravenous drug use may have contributed to the development of disease in this patient.

849

Catheter-related infections by Hansenula anomala in children. Yamada S, Maruoka T, Nagai K, Tsumura N, Yamada T, Sakata Y, Tominaga K, Motohiro T, Kato H, Makimura K. Scand J Infect Dis. 1995;27(1):85-7.

During August and September, 1992, we experienced 4 cases of Hansenula anomala (H. anomala, synonym Pichia anomala) fungemia in immunocompromised patients. Two patients had been suffering from a malignant disease, 3 of them had received broad-spectrum antibiotics and a central venous catheter (CVC) had been inserted in all of them. H. anomala was isolated as the sole pathogen from all 4 patients. Three of them responded favorably to fluconazole after withdrawal of the catheter, but one failed. H. anomala should be considered as a possible cause of catheter-related infections.

850

Hansenula polymorpha infection in a child with chronic granulomatous disease. McGinnis MR, Walker DH, Folds JD. Arch Pathol Lab Med. 1980 Jun;104(6):290-2.

In a patient with chronic granulomatous disease of childhood documented by the nitroblue tetrazolium test, an infection of the mediastinal lymph nodes developed that was caused by Hansenula polymorpha, an ascomycetous yeast. To our knowledge, this yeast has not been previously shown to be an etiologic agent of disease in man. The diagnosis was made by growing the yeast from cultures of several biopsy specimens collected at the time of thoracotomy. Susceptibility testing showed that the yeast was sensitive to amphotericin B. Treatment with amphotericin B reversed this life-threatening episode.

865

Helminthosporium corneal ulcers. Harris R, Smith RE, Wood TR, Biddle M. Ann Ophthalmol. 1978 Jun;10(6):729-33.

Two cases of fungal corneal ulcer caused by Helminthosporium are discussed. Dematiacious fungi are pigmented filamentary molds of which Helminthosporium is representative. Ulcers due to such dematiacious fungi seem to have a better prognosis than other types of fungal corneal ulcers. The importance of classifying fungal ulcers is emphasized. Therapy is considered for these keratomycoses.

866

Helminthosporium corneal ulcers. McGinnes MR. Am J Ophthalmol. 1978 Dec;86(6):853.

867

Helminthosporium corneal ulcers. Krachmer JH, Anderson RL, Binder PS, Waring GO, Rowsey JJ, Meek ES. Am J Ophthalmol. 1978 May;85(5 Pt 1):666-70.

We studied four cases of Helminthosporium corneal ulcers from four different institutions. One case occurred in an immune-deficient infant, another in a patient three months after removal of a foreign body; the third case occurred in a patient with a corneal dystrophy who was wearing soft contact lenses and using topical corticosteroids; and the fourth occurred in a patient with a history of multiple foreign bodies. Antifungal sensitivities were performed in three cases and showed relatively good sensitivity to available antifungal medications; even though all four patients improved, there was poor correlation between in vitro sensitivities and clinical response.

868

Corneal perforation due to Helminthosporium and Mima polymorpha. Chin GN. Ann Ophthalmol. 1978 Apr;10(5):607-9.

This apparently is the first reported case of corneal perforation due to a mixed infection of Helminthosporium species and Mima polymorpha. These 2 organisms separately rarely cause ocular infection and when present together could produce serious damage to the eye. In long-standing diseases of the cornea, mixed infection should be suspected when the infection fails to respond to conventional medical therapy. Thorough laboratory evaluation should be done. Selection of appropriate antibiotics should be based on clinical impression, initial Gram stain findings and final cultural results.

869

Exogenous Helminthosporium endophthalmitis. Das T, Gopinathan U, Sharma S. Br J Ophthalmol. 1994 Jun;78(6):492-3.

873

Spinal cord histoplasmoma. A case report] Rivierez M, Heyman D, Brebion A, Landau-Ossondo M, Desbois N, Vally P. Neurochirurgie. 2002 Feb;48(1):44-8.

Over a period of 2 months, a 60-year-old man, a chicken breeder, experienced low back pain, lower limb weakness predominant on the right side, and urinary difficulties, leading progressively to a flaccid paraplegia with sphincter impairment. Concomitant poor cognitive performances were noted. MRI showed enlargement of the conus terminalis, with a low-intensity signal on T1-weighted images, high-intensity signal on T2-weighted images, and areas of intramedullar contrast enhancement. A biopsy of the lesion showed macrophages containing yeast cells, with PAS and Grocott staining aspects compatible with the presence of Histoplasma capsulatum (Hc). A brain MRI showed multiple localizations in the brain stem and in both hemispheres with associated edema. Disseminated histoplasmosis was confirmed by a biopsy of a sub-maxillary ganglion demonstrating a necrotic tuberculoid lymphadenitis containing yeast cells resembling Hc. Immune tests disclosed the presence of HTLV1 anti-bodies without immunodeficiency nor HIV co-infection. An anti-micotic treatment was started 2 weeks after surgery, with intra-venous amphotericin B, for 21 days, followed by itraconazole, orally for 90 days. Cognitive functions improved significantly in 5 weeks while paraplegia and sphincter impairment remained unchanged. Seven months later, cerebral MR aspects dramatically improved while the conus medullaris lesion diminished, and the edematous component disappeared in all areas. Even though histoplasmosis is endemic in our region, CNS localization is rare, generally in disseminated forms associated with immunodeficiency. Brain granulomas are well-known, but spinal cord histoplasmomas are exceptional: only four cases have been evaluated by MRI. Unlike our case, spinal cord forms generally improve, due to surgery associated with antifungus medication, or sometimes due to specific medical treatment alone but with sufficient dosage.

874

Epidemiological investigation of Histoplasma capsulatum infection in China. Zhao B, Xia X, Yin J, Zhang X, Wu E, Shi Y, Tong M, Sun S, Gui X, Zhao Z, Ayinuer, Feng X. Chin Med J (Engl). 2001 Jul;114(7):743-6.

OBJECTIVE: To provide reliable information concerning the presence or the absence of Histoplasma capsulatum (H. capsulatum) infection in China, and data concerning this respect. METHODS: Three hundred normal people and 435 hospitalized patients, who lived in Hunan and Jiangsu provinces, and the Xinjiang Autonomous Region, were tested with yeast-phase histoplasmin (ALK/Berkerley Biologicals Laboratories, USA) and human pure protein derivative of tuberculin (PPD) on the volar surface of the forearm. Any reaction to the antigens over 5.0 mm in diameter of induration at 48-72 hours was considered positive. RESULTS: A total of 138 subjects (18.8%) in 735 patients reacted to histoplasmin with 5.0-45.0 (9.1 +/- 4.3) mm indurations. Significant differences of positive skin reaction rates in normal subjects were found in Hunan, Jiangsu and Xinjiang (8.9% vs 15.1% vs 2.1%). The overall positive rate of patients was 25.5%. Patients with tuberculosis [31.7% (78/246)] had a significantly higher positive skin reaction rate in comparison with those suffering from pneumonia [17.7% (11/62)], lung cancer [20.9% (9/43)], chronic obstructive pulmonary disease [17.3% (9/52)] and other diseases [12.5% (4/32)] (P < 0.01). Of 562 cases, 292 cases (52.0%) reacted to PPD with indurations of 5-50 (13.7 +/- 4.9) mm in diameter, 63 cases (11.2%) reacted to both histoplasmin and PPD, while 38 cases (6.9%) reacted to histoplasmin but not to PPD. CONCLUSIONS: The data suggest that there is H. capsulatum herd infection in China. The infection rate in Southeast China is higher than that in the Northwest, and the infection rate of patients with pulmonary tuberculosis is higher than that of normal persons and other pneumonopathy patients.

875

Disseminated histoplasmosis presenting as pyoderma gangrenosum-like lesions in a patient with acquired immunodeficiency syndrome. Laochumroonvorapong P, DiCostanzo DP, Wu H, Srinivasan K, Abusamieh M, Levy H. Int J Dermatol. 2001 Aug;40(8):518-21.

A 33-year-old Hispanic woman with newly diagnosed human immunodeficiency virus (HIV) infection, a CD4 T-lymphocyte count of 2, viral load of 730,000 copies/mL, candidal esophagitis, seizure disorder, a history of bacterial pneumonia, and recent weight loss was admitted with tonic clonic seizure. On admission, her vital signs were: pulse of 88, respiration rate of 18, temperature of 37.7 degrees C, and blood pressure of 126/76. Her only medication was phenytoin. On examination, the patient was found to have multiple umbilicated papules on her face, as well as painful, erythematous, large, punched-out ulcers on the nose, face, trunk, and extremities of 3 months' duration (Fig. 1). The borders of the ulcers were irregular, raised, boggy, and undermined, while the base contained hemorrhagic exudate partially covered with necrotic eschar. The largest ulcer on the left mandible was 4 cm in diameter. The oral cavity was clear. Because of her subtherapeutic phenytoin level, the medication dose was adjusted, and she was empirically treated with Unasyn for presumptive bacterial infection. Chest radiograph and head computed tomography (CT) scan were within normal limits. Sputum for acid-fast bacilli (AFB) smear was negative. Serologic studies, including Histoplasma antibodies, toxoplasmosis immunoglobulin M (IgM), rapid plasma reagin (RPR), hepatitis C virus (HCV), and hepatitis B virus (HBV) antibodies were all negative. Examination of the cerebrospinal fluid was within normal limits without the presence of cryptococcal antigen. Blood and cerebrospinal cultures for bacteria, mycobacteria, and fungi were all negative. Viral culture from one of the lesions was also negative. The analysis of her complete blood count showed: white blood count, 2300/microl; hemoglobin, 8.5 g/dL; hematocrit, 25.7%; and platelets, 114,000/microl. Two days after admission, the dermatology service was asked to evaluate the patient. Although the umbilicated papules on the patient's face resembled lesions of molluscum contagiosum, other infectious processes considered in the differential diagnosis included histoplasmosis, cryptococcosis, and Penicillium marnefei. In addition, the morphology of the ulcers, particularly that on the left mandible, resembled lesions of pyoderma gangrenosum. A skin biopsy was performed on an ulcer on the chest. Histopathologic examination revealed granulomatous dermatitis with multiple budding yeast forms, predominantly within histiocytes, with few organisms residing extracellularly. Methenamine silver stain confirmed the presence of 2-4 microm fungal spores suggestive of Histoplasma capsulatum (Fig. 2). Because of the patient's deteriorating condition, intravenous amphotericin B was initiated after tissue culture was obtained. Within the first week of treatment, the skin lesions started to resolve. Histoplasma capsulatum was later isolated by culture, confirming the diagnosis. The patient was continued on amphotericin B for a total of 10 weeks, and was started on lamivudine, stavudine, and nelfinavir for her HIV infection during hospitalization. After amphotericin B therapy, the patient was placed on life-long suppressive therapy with itraconazole. Follow-up at 9 months after the initial presentation revealed no evidence of relapse of histoplasmosis.

876

A case of Histoplasma capsulatum causing granulomatous liver disease and Addisonian crisis. Wong P, Houston S, Power B, Lalor E, Bain VG. Can J Gastroenterol. 2001 Oct;15(10):687-91.

A 56-year-old man with persistently elevated liver enzyme levels, fatigue, lethargy and a 9.0 kg weight loss over six months underwent a percutaneous liver biopsy that demonstrated multiple granulomas. Screening serologies were positive for histoplasmosis, and he was started on itraconazole treatment. He returned to hospital the same night with coffee-ground emesis and in Addisonian crisis requiring parenteral steroids and intensive care unit support. An abdominal computed tomography scan revealed bilaterally enlarged, nonenhancing adrenal glands suggestive of infarcts, presumed secondary to histoplasmosis. Treatment was initiated with amphotericin B, and Histoplasma capsulatum was cultured from his urine and cerebrospinal fluid. A serum immunodiffusion test was also positive for both H and M bands, indicating active infection with Histoplasmosis species. His serum and urine samples were also weakly positive for the antigen. Despite complications of renal failure, pneumonia and congestive heart failure, he recovered with medical therapy and was discharged home to complete a prolonged course of itraconazole therapy. While hepatic granulomas often reflect an occult disease process, the cause may remain undiscovered in 30% to 50% of patients despite exhaustive investigations. H capsulatum is an uncommon cause of granulomatous liver disease, and with its protean clinical presentation, a high index of suspicion is needed to make the diagnosis and avoid the potentially high fatality rate associated with disseminated infection.

877

Pathogenesis of Histoplasma capsulatum. Woods JP, Heinecke EL, Luecke JW, Maldonado E, Ng JZ, Retallack DM, Timmerman MM. Semin Respir Infect. 2001 Jun;16(2):91-101.

Histoplasma capsulatum is well adapted to be infectious and pathogenic for humans. As a soil fungus with no known requirement for interacting with a mammalian host as part of an obligate lifecycle, its plethora of strategies for successful pathogenesis is particularly remarkable. These features include the dimorphic mold-yeast transition, entry into host macrophages, subcellular localization, intracellular survival and proliferation during active infection, and persistence during clinically inapparent infection with the capacity for reactivation. To thrive within the harsh environment of a professionally phagocytic and antimicrobial host cell, H. capsulatum displays mechanisms for modulating its microenvironmental pH level, resisting host reactive oxygen and nitrogen intermediates and degradative enzymes, and withstanding nutrient starvation conditions, including acquisition of iron and calcium and biosynthesis of nucleic acid precursors. Attention has been focused on identifying virulence-associated phenotypic traits and genes that are differentially expressed under relevant conditions, such as yeast morphotype-specific genes and genes that are up-regulated during infection. These studies, together with the increasing ability to perform molecular genetic manipulations in this fungus, may yield novel antifungal drug or vaccine targets as well as elucidating pathogenic mechanisms.

878

Histoplasmosis capsulatum as a cause of lower gastrointestinal bleeding in common variable immunodeficiency. Kane S, Brasitus T. Dig Dis Sci. 2000 Nov;45(11):2133-5.

Infection with Histoplasma capsulatum is the most common systemic fungal infection in the United States, but symptomatic gastrointestinal disease is rare. Gastrointestinal involvement is seen in patients with an established immunosuppressed state that predates any infection. We report a patient presenting with gastrointestinal bleeding ultimately diagnosed with disseminated histoplasmosis. Work-up led to the diagnosis of common variable immunodeficiency, a diagnosis not previously described as associated with gastrointestinal histoplasmosis. Resolution of the colonic ulcer was documented after appropriate antifungal therapy, underscoring the importance of including this infectious process in the differential of a patient without other risk factors for colonic ulceration.

879

Histoplasmosis: an unusual presentation. Singh SK, Bhadada SK, Singh SK, Sharma OP, Arya NC, Shukla VK, Agrawal JK. J Assoc Physicians India. 2000 Sep;48(9):923-5.

Histoplasma capsulatum (HC) infection is rare in India. We document a case of unilateral adrenal histoplasmosis in a 56 year male. The patient presented with hepatosplenomegaly, unilateral adrenal mass and significant weight loss. Since FNAC of adrenal mass was inconclusive, he underwent splenectomy, adrenalectomy and liver biopsy, histology of these specimens revealed HC only in adrenal mass. Subsequently, histoplasmin test was also performed which was also found to be positive. He responded well to parenteral amphotericin B and is under regular follow-up with no complaints now.

880

Disseminated cutaneous histoplasmosis and AIDS: case report. Kucharski LD, Dal Pizzol AS, Fillus J Neto, Guerra IR, Guimarães CC, Manfrinato LC, Mulinari Brenner FA. Braz J Infect Dis. 2000 Oct;4(5):255-61.

Histoplasmosis is caused by the dimorphic fungus Histoplasma capsulatum. It manifests by the presence of fever as the only symptom in most individuals. The disease may present as self-limited pneumonia, or as an hematogenous widespread fungal infection with a potentially fatal outcome in elderly individuals and people with compromised T-cell mediated immunity. Here, we report a case of disseminated cutaneous histoplasmosis in a patient with AIDS. The patient was a 33 year old male homosexual, intravenous drug user, who had been diagnosed with HIV infection 5 years earlier. He was in good health, but had erythematous papules and pustules in the skin of the scalp, face, back, thighs, abdomen, palms, and soles. He was placed on anti-retroviral therapy, fluconazole for mucosal candidiasis, trimethoprim/sulfamethoxazole for pneumocystis prophylaxis, and antibiotics for the skin pustules. The skin lesions improved remarkably within 14 days. He was discharged and soon lost to follow-up. After his discharge, skin biopsy and fungal culture results revealed H. capsulatum. He was seen again 1 year later. The interim history revealed that he had taken fluconazole 100 mg/day for 1 month and fluconazole 150 mg/week for 7 months. He had not continued anti-retroviral therapy, nor taken other antifungal drugs. The clinical evolution of the disease was exceptional in that there was disappearance of all the skin lesions attributed to histoplasmosis with fluconazole. Although itraconazole remains the drug of choice for histoplasmosis. Cutaneous histoplasmosis should be considered in the differential diagnosis of atypical cutaneous lesions in individuals infected with HIV.

881

Histoplasmosis of the thyroid. Goldani LZ, Klock C, Diehl A, Monteiro AC, Maia AL. J Clin Microbiol. 2000 Oct;38(10):3890-1.

Fungal infection of the thyroid is rare. Most reported cases have involved Aspergillus, Coccidioides, and Candida species in the setting of disseminated disease. Infection of the thyroid with Histoplasma capsulatum is rarely reported as part of disseminated disease, even in geographic areas where histoplasmosis is endemic. We report a 52-year-old woman with a previous Hashimoto's disease and non-Hodgkin's lymphoma in which a diffuse enlarged thyroid gland with a large nodule was the only apparent locus of histoplasmosis. Fine-needle aspiration of the thyroid was an important diagnostic tool in establishing the diagnosis of histoplasmosis of the thyroid. The patient was initially treated with itraconazole (400 mg/day) for the fungal infection and six cycles of chemotherapy for the lymphoma. At a 6-month follow-up examination, the patient was doing well on suppressive therapy of itraconazole (200 mg/day), with no symptoms and with regression of the thyroid nodule and cervical adenopathy.

882

Endogenous endophthalmitis caused by Histoplasma capsulatum var. capsulatum: a case report and literature review. Gonzales CA, Scott IU, Chaudhry NA, Luu KM, Miller D, Murray TG, Davis JL. Ophthalmology. 2000 Apr;107(4):725-9.

OBJECTIVE: We report the first case of clinically diagnosed endogenous endophthalmitis caused by Histoplasma capsulatum var. capsulatum in a patient with the acquired immune deficiency syndrome. DESIGN: Interventional case report and literature review. INTERVENTION: Pars plana vitrectomy and scleral buckling procedure in the left eye with intravenous and intravitreal amphotericin in both eyes. MAIN OUTCOME MEASURES: The clinical features, culture results, visual outcome, and complications were studied. RESULTS: This case demonstrates a bilateral endophthalmitis with severe subretinal exudation, choroidal granulomas, and intraretinal hemorrhage leading to exudative bilateral retinal detachments. Vitreous cultures grew H. capsulatum var. capsulatum. Treatment consisted of intravenous amphotericin, intravitreal amphotericin (both eyes), pars plana vitrectomy (left eye), and scleral buckling procedure (left eye) with resulting counting fingers vision (right eye) and 20/300 (left eye). Four cases of Histoplasma endophthalmitis have been reported previously, all of which had a documented history of disseminated histoplasmosis and resulted in enucleation. CONCLUSIONS: H. capsulatum should be considered a possible etiologic agent of endophthalmitis, especially in patients with a history of disseminated histoplasmosis and/or immune deficiency.

883

Disseminated histoplasmosis caused by Histoplasma capsulatum with cerebral involvement occurring 13 years after the primary infection] Bérard H, Astoul P, Frenay C, Cuguillière A, Cho K, Boutin C. Rev Mal Respir. 1999 Nov;16(5):829-31.

A 49-year-old man with disseminated histoplasmosis (pulmonary and central nervous system involvement) successfully treated with ketoconazole and fluconazole combination is reported. Histoplasma capsulatum infection of the central nervous system is extremely rare in France partly because the organism is not endemic. Oral treatment with newer triazoles may be useful for central nervous system histoplasmosis, but additional information is needed to establish their effectiveness.

884

Chronic pulmonary histoplasmosis in the State of Rio de Janeiro, Brazil. Capone D, Wanke B, Monteiro PC, Lazéra MS, de Noronha Andrade G, do Valle AC, Moreno AM, Londero AT. Mycopathologia. 1999;145(2):75-9.

Three cases of chronic pulmonary histoplasmosis affecting aged patients with chronic obstructive pulmonary disease are reported. They had a history of recurrent episodes of respiratory infection and presented radiological lung lesions inducing a misdiagnosis of chronic pulmonary tuberculosis of the adults. The diagnosis of histoplasmosis, suggested by the immunodiffusion test and the detection of yeastlike cells in smeared and stained sputum, was confirmed by the isolation and identification of Histoplasma capsulatum var. capsulatum in selective media. The treatment was carried out with amphothericin B and ketoconazole or itraconazole. Clinical, radiologic, mycologic and serologic improvement was obtained in all the patients. However, relapses occurred within a period of 1 to 18 months after the interruption of the treatment. Mycological diagnosis and the difficulties observed in the treatment were discussed. In addition data on the epidemiology of histoplasmosis in the state of Rio de Janeiro, Brazil, were presented.

885

Disseminated histoplasmosis presenting as bilateral adrenal masses. Giacaglia LR, Lin CJ, Lucon AM, Goldman J. Rev Hosp Clin Fac Med Sao Paulo. 1998 Sep-Oct;53(5):254-56.

Histoplasma capsulatum is a universal dimorphic fungus found mainly in soil contaminated with excrement of birds and bats. Bilateral adrenal masses with massive tissue destruction are a rare primary presentation of disseminated histoplasmosis. As it behaves as an opportunistic pathogen there is a higher susceptibility for dissemination on those patients with immunodeficiency or immunosuppression. We report a case in an elderly diabetic patient with bilateral adrenal enlargement, diagnosed as histoplasmosis only after surgical exploration, with symptoms probably occurring at least 60 years after the original infection. She was successfully treated with itraconazole.

886

Disseminated histoplasmosis causing reversible gaze palsy and optic neuropathy. Perry JD, Girkin CA, Miller NR, Mann RB. J Neuroophthalmol. 1999 Jun;19(2):140-3.

Subacute disseminated histoplasmosis is an uncommon entity. Typical neuro-ophthalmologic manifestations are usually secondary to histoplasmomas or encephalitis. A 45-year-old man noted blurred vision while receiving empiric antituberculosis therapy for fever and diffuse granulomatous disease of unknown origin. Vertical-gaze palsy, right horizontal-gaze paresis, and mild right optic neuropathy were found on neuro-ophthalmologic examination. Further questioning revealed a history of frequent contact with fighting cocks from South America. Magnetic resonance images were consistent with multiple hemorrhagic infarcts, areas of inflammation, or both, and cerebral angiography showed changes consistent with vasculitis. A previously obtained biopsy specimen from the duodenum was restained and found to be positive for fungal elements. Serum antigen titers for Histoplasma capsulatum demonstrated evidence of active infection. This case is a rare example of a supranuclear ocular motility disturbance and optic neuropathy secondary to an occlusive vascular process in a patient with subacute disseminated histoplasmosis.

887

Oral histoplasmosis: a case report. Mead GE, Wilks D, McLaren K, Fergusson RJ. J Infect. 1998 Jul;37(1):73-5.

We report a case of biopsy-proven histoplasmosis in an 81-year-old man with mouth ulcers. The initial infection was probably contracted whilst he was a prisoner of war in Sumatra, and was reactivated during intercurrent illness with congestive cardiac failure and oral corticosteroid treatment for idiopathic thrombocytopaenic purpura. Of particular note is the latent period of 50 years, and a positive cytoplasmic antineutrophil cytoplasmic antibody (cANCA) titre.

888

Cerebral histoplasmosis in an Australian patient with systemic lupus erythematosus. Sullivan AA, Benson SM, Ewart AH, Hogan PG, Whitby RM, Boyle RS. Med J Aust. 1998 Aug 17;169(4):201-2.

A 39-year-old woman with systemic lupus erythematosus suffered a prolonged neurological illness associated with very low levels of glucose in her cerebrospinal fluid (CSF). Six months later, and after numerous CSF investigations, Histoplasma capsulatum was cultured. To our knowledge, this is the first report of cerebral histoplasmosis in Australia in a patient who is not HIV positive.

889

Acute pulmonary histoplasmosis: progressive pneumonia resulting from high inoculum exposure. Meals LT, McKinney WP. J Ky Med Assoc. 1998 Jul;96(7):258-60.

Histoplasmosis is endemic in certain areas of North, Central, and South America, especially within the Ohio and Mississippi River Valleys of the United States. We describe a case of histoplasmosis in a farm-dwelling resident of Kentucky who probably had multiple prior opportunities for exposure. However, during the gathering of topsoil containing chicken droppings for use as fertilizer, he was likely to have been exposed to such a high inoculum of the organism that he developed a severe pulmonary infection. He presented with a one-week history of malaise, myalgias, fever to 103 degrees F, and headaches. A chest X-ray showed bilateral reticulonodular infiltrates. He was initially treated for community-acquired pneumonia. When his symptoms did not resolve, a bronchoscopy was performed. Washings from the broncho-alveolar lavage grew Histoplasma capsulatum, and he responded well to itraconazole therapy. This case is presented to emphasize risks from high-inoculum exposure and the hazard imposed by harvesting certain types of organic material for use as fertilizer.

890

Acute pulmonary histoplasmosis: progressive pneumonia resulting from high inoculum exposure. Meals LT, McKinney WP. J Ky Med Assoc. 1998 Jul;96(7):258-60.

Histoplasmosis is endemic in certain areas of North, Central, and South America, especially within the Ohio and Mississippi River Valleys of the United States. We describe a case of histoplasmosis in a farm-dwelling resident of Kentucky who probably had multiple prior opportunities for exposure. However, during the gathering of topsoil containing chicken droppings for use as fertilizer, he was likely to have been exposed to such a high inoculum of the organism that he developed a severe pulmonary infection. He presented with a one-week history of malaise, myalgias, fever to 103 degrees F, and headaches. A chest X-ray showed bilateral reticulonodular infiltrates. He was initially treated for community-acquired pneumonia. When his symptoms did not resolve, a bronchoscopy was performed. Washings from the broncho-alveolar lavage grew Histoplasma capsulatum, and he responded well to itraconazole therapy. This case is presented to emphasize risks from high-inoculum exposure and the hazard imposed by harvesting certain types of organic material for use as fertilizer.

891

African histoplasmosis: osteomyelitis of the radius. Onwuasoigwe O, Gugnani HC. Mycoses. 1998 Mar-Apr;41(3-4):105-7.

Bone lesions in African histoplasmosis caused by Histoplasma capsulatum var, duboisii, without other signs of the infection, are often misdiagnosed as cancer. A case of isolated osteomyelitis due to this fungus in a 30-year-old woman is described. Diagnostic and therapeutic problems of isolated bone lesions in African histoplasmosis are discussed. A high diagnostic index of African histoplasmosis is advocated in isolated bone lesions in the endemic region of this disease.

892

Disseminated Histoplasma capsulatum infection presenting as genital ulcerations. Smith MB, Schnadig VJ, Zaharopoulos P, Van Hook C. Obstet Gynecol. 1997 May;89(5 Pt 2):842-4.

BACKGROUND: Histoplasma capsulatum infection in adults is most often subclinical but can result in disseminated disease with weight loss, fever, hepatosplenomegaly, and oropharyngeal ulcerations. Genital ulceration as the presenting sign of the disease has been reported rarely. CASE: A 63-year-old woman presented with multiple vaginal ulcerations due to chronic disseminated H capsulatum infection. Initial diagnosis was made by Papanicolaou and Giemsa-stained vulvar smears. Ketoconazole therapy resulted in clearing of the lesions in 5 weeks. CONCLUSION: Chronic disseminated histoplasmosis is an insidious and potentially fatal disease that can present rarely as genital mucocutaneous ulcerations in women. Prompt presumptive diagnosis can be accomplished by examination of smears obtained by ulcer abrasion, permitting institution of appropriate therapy.

893

A pulmonary infection caused by Coprinus cinereus (Hormographiella aspergillata) diagnosed after a neutropenic episode. Surmont I, Van Aelst F, Verbanck J, De Hoog GS. Med Mycol. 2002 Apr;40(2):217-9.

In a patient treated for a non-Hodgkin's lymphoma, a lung abscess caused by Hormographiella aspergillata (stat. anamorph. Coprinus cinereus) was diagnosed using an ultrasound-guided puncture of the lesion. The patient appeared to respond to amphotericin B, but at the same time was also recovering from her neutropenic episode. The extent to which each of these two factors explains the complete resolution of the infection is unclear. Expert classical morphological examination and molecular typing methods were needed to identify this filamentous basidiomycetous fungus.

894

Fatal pulmonary infection caused by the basidiomycete Hormographiella aspergillata. Verweij PE, van Kasteren M, van de Nes J, de Hoog GS, de Pauw BE, Meis JF. J Clin Microbiol. 1997 Oct;35(10):2675-8.

A fatal case of a pulmonary infection caused by Hormographiella aspergillata, the anamorph of the mushroom Coprinus cinereus, is reported for a patient receiving treatment for a second relapse of acute lymphoblastic leukemia. The filamentous basidiomycete was identified with restriction fragment length polymorphism patterns of PCR-amplified internally transcribed spacers and small subunit ribosomal DNA with four restriction enzymes. The patient failed to respond to treatment with amphotericin B and itraconazole. The fungus was cultured from the lungs at autopsy: the MIC of amphotericin B for the fungus was low (0.5 mg/liter), and that of itraconazole was high (8 mg/liter).

896

Fatal Hormonema dematioides peritonitis in a patient on continuous ambulatory peritoneal dialysis: criteria for organism identification and review of other known fungal etiologic agents. Shin JH, Lee SK, Suh SP, Ryang DW, Kim NH, Rinaldi MG, Sutton DA. J Clin Microbiol. 1998 Jul;36(7):2157-63.

We report a fatal case a fungal peritonitis caused by the yeast-like dematiaceous mould Hormonema dematioides in a 45-year-old woman. The woman had a 13-year history of insulin-dependent diabetes mellitus and had been on continuous ambulatory peritoneal dialysis for chronic renal failure. H. dematioides was repeatedly isolated from the dialysate culture specimens collected on days 3, 9, 16, and 20 of her hospital stay. Preliminary culture reports on day 7 of the growth of a yeast-like fungus, a probable Candida species, prompted the administration of fluconazole (FLU). Intraperitoneal and intravenous FLU failed to eliminate the mould, and the patient expired on day 21 of her hospital stay. We use this case to present what appears to be the first report of fungal peritonitis due to H. dematioides, to provide laboratorians with criteria for differentiating this organism from the similar mould Aureobasidium pullulans and from various yeast genera, and to provide a review of known fungal taxa inciting peritonitis.

897

Cutaneous phaeohyphomycosis caused by a rare fungal pathogen, Hormonema dematioides: successful treatment with ketoconazole. Coldiron BM, Wiley EL, Rinaldi MG. J Am Acad Dermatol. 1990 Aug;23(2 Pt 2):363-7.

Annular, fungating, ulcerated lesions developed on both hands of a 64-year-old immunocompetent man 2 months after he was cut with barbed wire. A dematiaceous mold, Hormonema dematioides, heretofore not definitively associated with human disease, was grown from two separate tissue specimens during a period of 9 days. Histopathologic examination demonstrated rare small, periodic acid-Schiff-positive, hyaline, yeastlike organisms in tissue. Twelve weeks of empiric therapy with ketoconazole, 400 mg/day, was curative.

898

Fungemia due to Hormonema dematioides following intense avian exposure. Kent D, Wong T, Osgood R, Kosinski K, Coste G, Bor D. Clin Infect Dis. 1998 Mar;26(3):759-60.

903

Endophthalmitis after Lasiodiplodia theobromae corneal abscess. Borderie VM, Bourcier TM, Poirot JL, Baudrimont M, Prudhomme de Saint-Maur P, Laroche L. Graefes Arch Clin Exp Ophthalmol. 1997 Apr;235(4):259-61.

BACKGROUND: Lasiodiplodia theobromae is an exceptional cause of human keratomycosis. PATIENT: We treated a 53-year-old man with fungal keratitis, which had been treated with topical betamethasone and gentamicin for 1 month, and endophthalmitis due to Lasiodiplodia theobromae. Despite intensive systemic, topical and intravitreal fungicidal treatment, enucleation had to be performed. RESULTS: The vitreous aspirate cultures were negative as of the second amphotericin intravitreal injection. However, histology revealed that the fungus was present in the cornea, ciliary body, iris and retina. CONCLUSION: The use of topical steroids may worsen the outcome of the infection.

904

Intrahyphal hyphae in corneal tissue from a case of keratitis due to Lasiodiplodia theobromae. Thomas PA, Garrison RG, Jansen T. J Med Vet Mycol. 1991;29(4):263-7.

Lasiodiplodia theobromae, a recognized plant pathogen, was isolated in culture from a case of human mycotic keratitis. Chemotherapy with a variety of azoles was unsuccessful and the lesion was removed surgically. Electron microscopy of thin sections of the excised corneal tissue revealed several examples of intrahyphal hyphae, a unique process described previously in in vitro cultures of various zoopathogenic fungi. We believe this to be the first report of the presence of intrahyphal hyphae in parasitized animal or human tissue. The demonstration of this process in vivo is thought to be consistent with the hypothesis that intrahyphal hyphae might represent an attempt by the invading fungus to survive in an otherwise unfavourable environment.

905

Lasiodiplodia theobromae panophthalmitis. Slomovic AR, Forster RK, Gelender H. Can J Ophthalmol. 1985 Oct;20(6):225-8.

Lasiodiplodia theobromae is a rare ocular pathogen. We report a case of panophthalmitis caused by this fungus. The patient was a healthy 62-year-old janitor with no history of ocular trauma in whom keratitis developed. Cultures of corneal scrapings identified the fungus. Despite treatment with appropriate antimycotics the keratitis progressed to infectious scleritis and then spontaneous perforation of the globe, which necessitated enucleation. The ultrasonographic, microbiologic and histologic findings are discussed and the results of in-vitro sensitivity testing presented.

906

Lasiodiplodia theobromae as a cause of keratomycoses. Rebell G, Forster RK. Sabouraudia. 1976 Jul;14(2):155-70.

Four cases of human keratitis caused by the tropical fungus Lasiodiplodia theobromae have been encountered in Miami, Florida bringing to 8 the number of cases reported in the world literature. Two of the ulcers were mild. Three patients recovered without severe impairment of vision after topical polyene treatment, but 1 patient with a severe ulcer required therapeutic keratoplasty after 11 days of topical natamycin. Histopathology revealed fungus deep in the cornea, invading Descemet's membrane. L. theobromae appeared to have collagenase activity in vitro. Inoculation of L. theobromae into the corneas of rabbits produced progressive ulcers. The fungus was endemic in Miami on home grown and imported bananas. Polyene antimycotic antibiotics were fungicidal for L. theobromae in vitro. Thiabendazole was effectively fungistatic but varied in fungicidal effect. Clotrimazole and miconazole were only incompletely fungistatic. Of 7 strains of L. theobromae tested, 4 were relatively resistant to 5-flurocytosine.

907

Onychomycosis due to saprophytic fungi. Report of 25 cases. Vélez H, Díaz F. Mycopathologia. 1985 Aug;91(2):87-92.

Twenty five cases of onychomycosis due to filamentous saprophytic agents were diagnosed within the period 1981-1982 in two mycology laboratories in Medellín, Colombia. These cases represented 4.5% and 9.5% respectively of the total fungal nail lesions (FNL) seen at those institutions. No explanation was found for the high frequencies, which sharply contrast with the previous local experience with the disease (0.4% of FNL). The responsible agents belonged to the following genera in decreasing order of frequency: Fusarium, Aspergillus, Scopulariopsis, Penicillium and Lasiodiplodia; two patients were infected with unidentified dematiaceous fungi and two more had the association of a saprophyte and a dermatophyte. In every case direct KOH preparations revealed septate hyphae, associated in 14 patients (56%) with chlamydoconidia. The only predisposing factors that were common to all these patients were age above 20 years and the use of footwear.

908

Lasiodiplodia theobromae isolated from a subcutaneous abscess in a Cambodian immigrant to Australia. Maslen MM, Collis T, Stuart R. J Med Vet Mycol. 1996 Jul-Aug;34(4):279-83.

A patient from Cambodia presented at a hospital in Melbourne with a persistent subcutaneous abscess of the right buttock. Septate fungal hyphae were seen in biopsy tissue. Lasiodiplodia theobromae was isolated and identified by the formation of pycnidia that produced typical conidia. The abscess was managed by drainage and debridement only. We briefly review the history and importance of the fungus as a wound parasite in tropical horticulture and its relatively rare occurrence in human infections. The significance of this fungus in Australian horticulture and its potential as an opportunistic human pathogen is noted. This paper records the first isolation of L. theobromae from a human lesion in Australia and the second isolation from a subcutaneous lesion worldwide.

909

Lecythophora mutabilis endophthalmitis after long-term corneal cyanoacrylate. Marcus DM, Hull DS, Rubin RM, Newman CL. Retina. 1999;19(4):351-3.

910

Fungal peritonitis caused by Lecythophora mutabilis. Ahmad S, Johnson RJ, Hillier S, Shelton WR, Rinaldi MG. J Clin Microbiol. 1985 Aug;22(2):182-6.

Fungal peritonitis caused by Lecythophora mutabilis, a mold rarely isolated from humans, is described. A patient on continuous peritoneal dialysis developed clinical, microbiological, and serological evidence for peritonitis due to this fungus. In vitro susceptibility testing of the fungus revealed marked differences in the activities of various antifungal agents. Although initially responding to treatment with oral ketoconazole, intraperitoneal miconazole, and catheter replacement, the patient had a documented relapse. The patient was eventually cured following the removal of a second catheter in association with prolonged imidazole treatment.

916

Leptosphaeria tompkinsii mycetoma. Venugopal PV, Venugopal TV. Int J Dermatol. 1990 Jul-Aug;29(6):432-3.

917

Mycetoma in Yemen: clinicoepidemiologic and histopathologic study. Khatri ML, Al-Halali HM, Fouad Khalid M, Saif SA, Vyas MC. Int J Dermatol. 2002 Sep;41(9):586-93.

BACKGROUND: Mycetoma is widespread in Yemen, but has not been fully documented. METHODS: A prospective study of 70 patients (53 male, 17 female; from different regions of Yemen) was performed. The clinical profile of the cases was recorded in a special protocol. The diagnosis was based on clinical features, examination of grains, roentgenographic studies, and histopathology (44 cases). RESULTS: Fifty cases were diagnosed as eumycetoma and 20 as actinomycetoma. The identification of the causative species was performed in 44 cases by histopathologic studies. Among the cases of eumycetoma, Madurella mycetomatis was recognized in 27 patients, Leptosphaeria senegalensis in two, and pale-grain fungi in two. Among the cases of actinomycetoma, Streptomyces somaliensis was seen in eight patients, Streptomyces madurae in one, and Nocardia species in four. The treatment of eumycetoma patients with ketoconazole and excision in selected cases controlled the disease activity in the majority. Most of the cases of actinomycetoma were better controlled with drug therapy alone, with a combination of penicillin and cotrimoxazole, or cotrimoxazole alone. CONCLUSIONS: Mycetoma is widespread in Yemen, with a higher incidence of eumycetoma and a maximum number of cases from the Hudaida region. A multicenter study is needed to evaluate the exact extent of disease.

918

Mycetomas in Mali: causative agents and geographic distribution. Mahe A, Develoux M, Lienhardt C, Keita S, Bobin P. Am J Trop Med Hyg. 1996 Jan;54(1):77-9.

Although Mali is situated in the African zone endemic for mycetomas, no report has been published on the characteristics of the disease in this country. We report a series of 54 cases observed in Bamako. The causative agents were Madurella mycetomatis in 20 patients, Leptosphaeria sp. in one patients, Actinomadura madurae in 12 patients, A. pelletieri in 15 patients, and Streptomyces somaliensis in three patients. In this series, the observed geographic distribution of the causative agents was in agreement with data on the causative agents and their geographic distribution in neighboring countries, and with those suggesting a relationship between the type of infectious agent and the annual rainfall.

919

[Mycetoma in Somalia - results of a survey done from 1959 to 1964] Destombes P, Mariat F, Rosati L, Segretain G. Acta Trop. 1977 Dec;34(4):355-73.

The Pasteur Institute studied 103 mycetoma patients in Somalia between 1959 and 1964. Grains were seen in 94 of them and this, added to cultural features, allowed the diagnosis of 60 pathogens as follows: 44 Madurella mycetomi, 1 Leptosphaeria senegalensis, 7 Pyrenochaeta romeroi (or Madurella grisea), 3 Allescheria boydii, 1 Fusarium sp., 3 Neotestudina (Zopfia) rosatii, and 1 unidentified; 34 were actinomycetes: 24 Streptomyces somaliensis, 4 Actinomadura madurae, 3 A. pelletieri and 3 Nocardia spp. The patients delayed too long in consulting their doctors and health education is vital if amputations are to be avoided. The geographical distribution is related to climate and fungal species. In central Somalia the association of M. mycetomi and S. somaliensis, organisms characteristic of desert conditions, was found; white grain mycetomata and those caused by Nocardia spp. occurred in more humid areas. The study revealed 2 new fungi. One, obtained in culture was called Neotestudina (Zopfia) rosatii. The 3 patients affected, lived in Mudugh (2 in El Bur). The other fungus was not identified. It also was recovered from El Bur and one with similar microscopic characters has been seen in Chad and also in "territoire français des Afars et des Issas". Both fungi are desert species.

920

Eumycetoma due to Madurella mycetomatis acquired in Jamaica. Fletcher CL, Moore MK, Hay RJ. Br J Dermatol. 2001 Dec;145(6):1018-21.

We report a case of eumycetoma due to Madurella mycetomatis affecting the left dorsal forefoot in a 35-year-old woman. She had spent her childhood in Jamaica, and had been resident in the U.K. for 20 years prior to her presentation. She gave a highly suggestive history for a mycetoma, having observed the intermittent discharge of black grains from the lesion. The diagnosis was confirmed by histological and mycological analysis of the grains, and a magnetic resonance imaging scan excluded osteomyelitis. She has responded very favourably to treatment with itraconazole. Mycetomas due to M. mycetomatis have not previously been reported from Jamaica.

921

Environmental occurrence of Madurella mycetomatis, the major agent of human eumycetoma in Sudan. Ahmed A, Adelmann D, Fahal A, Verbrugh H, van Belkum A, de Hoog S. J Clin Microbiol. 2002 Mar;40(3):1031-6.

Madurella mycetomatis is the main causative agent of human eumycetoma, a severe debilitating disease endemic in Sudan. It has been suggested that eumycetoma has a soil-borne or thorn prick-mediated origin. For this reason, efforts were undertaken to culture M. mycetomatis from soil samples (n = 43) and thorn collections (n = 35) derived from areas in which it is endemic. However, ribosomal sequencing data revealed that the black fungi obtained all belonged to other fungal species. In addition, we performed PCR-mediated detection followed by restriction fragment length polymorphism (RFLP) analysis for the identification of M. mycetomatis DNA from the environmental samples as well as biopsies from patients with mycetoma. In the case of the Sudanese soil samples, 17 out of 74 (23%) samples were positive for M. mycetomatis DNA. Among the thorn collections, 1 out of 22 (5%) was positive in the PCR. All PCR RFLP patterns clearly indicated the presence of M. mycetomatis. In contrast, 15 Dutch and English control soil samples were all negative. Clinically and environmentally obtained fungal PCR products share the same PCR RFLP patterns, suggesting identity, at least at the species level. These observations support the hypothesis that eumycetoma is primarily environmentally acquired and suggest that M. mycetomatis needs special conditions for growth, as direct isolation from the environment seems to be impossible.

922

Madura's foot: report of a case caused by Madurella mycetomatis. Verdolini R, Amerio P, Bugatti L, Manso E, Cataldi I, Brancorsini D, Nicolini M, Filosa G, Giangioacomi M. Eur J Dermatol. 2000 Dec;10(8):627-9.

We present a case of mycetoma by Madurella mycetomatis on the foot of a Chinese young man, living in Italy for more than ten years. Clinically the lesion closely resembled and was initially misinterpreted as a vascular neoformation. We analyze the histological and morphological features of the Madurella mycetomatis infection through which we managed to type the etiological agent. Our case is worth reporting because of the rarity of this disease in Europe and the unusual clinical presentation. It also offers the opportunity to stress the need for the clinical suspicion of this dermatosis, considering the increase of immigration towards our regions.

923

Eumycetoma by Madurella grisea. Report of the first case observed in the southern Brazilian region. Severo LC, Vetoratto G, Oliveira Fde M, Londero AT. Rev Inst Med Trop Sao Paulo. 1999 Mar-Apr;41(2):139-42.

The first case of eumycetoma by Madurella grisea occurred in Southern Brazilian Region is herein related. In addition, Brazilian literature on this subject was reviewed and, the geographic distribution of this eumycetoma is presented.

924

Mycetoma due to Madurella grisea acquired in Mexico. Southern PM Jr. Trop Doct. 1996 Oct;26(4):187-8.

Mycetomas due to Madurella grisea have been reported from South America, Central America, the Caribbean Islands, Africa and Asia, but only rarely from Mexico. We report a case of mycetoma due to M. grisea acquired in northern Mexico.

929

Epidemiology of Malassezia yeasts associated with pityriasis versicolor in Ontario, Canada. Gupta AK, Kohli Y, Faergemann J, Summerbell RC. Med Mycol. 2001 Apr;39(2):199-206.

The genus Malassezia was recently revised to include seven species, but the clinical significance of each of these species is not clearly understood. To obtain a better understanding of the contribution of individual Malassezia species to the epidemiology of pityriasis (tinea) versicolor, we used Leeming-Notman medium to culture patient skin specimens showing positive evidence of Malassezia infection in direct microscopy. Isolates were identified on the basis of recently published morphological and physiological tests for distinction of the new species. Identification using recently developed molecular criteria was also carried out for the ambiguous cases. Malassezia species were cultured from 111 cases of pityriasis versicolor in the Canadian province of Ontario. The most frequently isolated species were Malassezia sympodialis, M. globosa and M. furfur which respectively made up 59.4%, 25.2% and 10.8% of the isolated etiological agents. M. globosa was commonly isolated from a small number of pityriasis versicolor specimens obtained from investigators outside Canada. A large number of additional Ontario specimens with positive direct microscopy failed to yield a culture; however, it is suggested that this is consistent with the standard sampling practice of scraping the older portions of pityriasis lesions rather than the margins, where viable fungal cells are most likely to occur.

930

[Pityriasis versicolor and Malassezia folliculitis] Katoh T, Irimajiri J. Nippon Ishinkin Gakkai Zasshi. 1999;40(2):69-71.

Pityriasis versicolor and malassezia folliculitis were studied clinically and mycologically. The main results were as follows: 1) The average age of pityriasis versicolor patients has gradually become higher. 2) Negative rates of Malassezia furfur after treatment were very high by direct examination but relatively low by culture. 3) Patients who were negative by culture on completion of treatment seldom recurred within 2 months. 4) We can evaluate the effectiveness of antifungal application by using Malassezia furfur as normal skin flora on the volunteer's back. 5) Malassezia furfur (orbiculare or ovale type) is detected in follicular contents of steroid acne and acne vulgaris, which makes it necessary to establish criteria for diagnosis of malassezia folliculitis.

931

Diagnosis and treatment of tinea versicolor. Savin R. J Fam Pract. 1996 Aug;43(2):127-32.

Tinea versicolor (pityriasis versicolor) is a common superficial fungal infection of the stratum corneum. Caused by the fungus Malassezia furfur, this chronically recurring disease is most prevalent in the tropics but is also common in temperate climates. Treatments are available and cure rates are high, although recurrences are common. Traditional topical agents such as selenium sulfide are effective, but recurrence following treatment with these agents is likely and often rapid. Currently, therapeutic interest is focused on synthetic "-azole" antifungal drugs, which interfere with the sterol metabolism of the infectious agent. Ketoconazole, an imidazole, has been used for years both orally and topically with great success, although it has not been approved by the Food and Drug Administration for the indication of tinea versicolor. Newer derivatives, such as fluconazole and itraconazole, have recently been introduced. Side effects associated with these triazoles tend to be minor and low in incidence. Except for ketoconazole, oral antifungals carry a low risk of hepatotoxicity.

932

Tinea versicolor of the scalp. el-Gothamy Z, Ghozzi M. Int J Dermatol. 1995 Aug;34(8):533-4.

BACKGROUND: Tinea versicolor (TV) is commonly described on the trunk without giving attention to involvement of the scalp. We examined cases with dandruff with and without TV on the body to see how frequent Malassezia furfur (M. furfur) is present in dandruff scales. METHODS: A total of 80 patients were examined mycologically using KOH preparation for the presence of M. furfur in dandruff scales. RESULTS: M. furfur was found in dandruff scales in 7 out of 20 men with TV (35%) and 5 out of 20 women with TV (25%), whereas it was absent in another 40 cases without clinical lesions of TV on the body. CONCLUSIONS: Attention must be paid to TV of the hairy scalp. Cases of dandruff, especially those accompanied with TV of the body, must be examined for the presence of M. furfur because of its prognostic significance. Positive cases should be treated accordingly.

933

Malignant otitis externa caused by Malassezia sympodialis. Chai FC, Auret K, Christiansen K, Yuen PW, Gardam D. Head Neck. 2000 Jan;22(1):87-9.

BACKGROUND: Malignant otitis externa caused by fungal infections is rare. A review of the literature showed only 9 cases, and the causative fungus in all cases was Aspergillus. This article reports an unusual case caused by Malassezia sympodialis. METHODS: A 53-year-old man with non-insulin dependent diabetes presented with malignant otitis externa. He deteriorated despite treatment with intravenous antipseudomonal therapy and surgical debridement. Microbiologic tests revealed M. sympodialis. He responded rapidly to intravenous amphotericin. RESULTS: Systemic human infections caused by M. sympodialis have not been reported. M. furfur systemic infection is rare and has been associated lipid hyperalimentation by means of a central catheter. Only 1 other case of M. fungemia without these associated risk factors has been reported. CONCLUSIONS: The first case of malignant otitis externa caused by M. sympodialis is presented. It highlights the difficulty of initial biologic diagnosis and the need for lipid-enriched media to grow this fastidious organism.

934

Malassezia furfur fungaemia in a ventilator-dependent patient without known risk factors. Chu CM, Lai RW. Hong Kong Med J. 2002 Jun;8(3):212-4.

Malassezia furfur is the lipophilic yeast which causes tinea versicolor and is an uncommon cause of fungaemia. It usually occurs in the context of hyperalimentation with lipid emulsion, immunosuppression, or the presence of a central venous catheter. We report a case of a ventilator-dependent patient who developed Malassezia furfur fungaemia in the absence of these known risk factors. A likely risk factor in this patient was receipt of multiple courses of broad-spectrum antibiotics. This case highlights the importance of recognising Malassezia furfur as a cause of fungaemia, as well as the need for special culture techniques to aid identification.

935

Systemic Malassezia furfur infection in an adult receiving total parenteral nutrition. Shparago NI, Bruno PP, Bennett J. J Am Osteopath Assoc. 1995 Jun;95(6):375-7.

Malassezia furfur sepsis developed in a woman with hyperemesis gravidarum while she was receiving total parenteral nutrition supplemented with lipids. Fever, chills, dyspnea, pleuritic chest pain, and multiple bilateral pulmonary nodular infiltrates were the primary clinical manifestations. Lysis-centrifugation fungal blood cultures supplemented with olive oil grew M furfur. Treatment included removal of the central venous catheter line, discontinuation of the lipid emulsion, and antifungal chemotherapy. Malassezia furfur sepsis complicating total parenteral nutrition may be more common in adults than once suspected. A high index of suspicion is required to diagnose this infection, and the addition of olive oil to the fungal culture medium will provide the necessary growth factors to isolate this fungus.

936

Malassezia furfur colonization of neonates in an intensive care unit. Ahtonen P, Lehtonen OP, Kero P, Tunnela E, Havu V. Mycoses. 1990 Nov-Dec;33(11-12):543-7.

We studied Malassezia furfur colonization of neonates in the neonatal intensive care unit (NICU) and found that the rate was astonishingly high as compared to the previous studies. In very low birth weight (less than 1,000 g) infants we recorded a colonization rate of 80%, and 4% infants with a birth weight greater than 2,000 g. Under 10 day's hospitalization the rate was 11%, and it was 70% after 20 days spent in the unit. Among the infants with the birth weight less than 1,700 g, antibiotic therapy was recorded as a significant risk factor for colonization. In the infants with a greater birth weight, the colonization rate was independent from the risk factors studied. M. furfur colonization could not be linked with occurrence of any symptoms of signs recorded and colonization by M. furfur was so common in NICU that the predictive value of surveillance cultures is poor.

937

Catheter-related infection in infants due to an unusual lipophilic yeast--Malassezia furfur. Long JG, Keyserling HL. Pediatrics. 1985 Dec;76(6):896-900.

Malassezia furfur (Pityrosporum orbiculare, P ovale), a lipophilic yeast that is part of the normal skin flora, causes tinea versicolor but has only rarely been associated with more serious infections. We report five episodes in four infants of catheter-related infection caused by this organism. All episodes occurred in infants who had survived serious neonatal disorders and were receiving prolonged therapy with intravenous fat emulsion. Sudden onset of fever without focal findings was the usual presentation; however, one afebrile patient had recurrent episodes of apnea, bradycardia, and cyanosis. Thrombocytopenia was a prominent finding. Patients were generally treated with amphotericin B. All patients recovered when the colonized catheter was removed or fat emulsion therapy was stopped. The yeast usually grew slowly in blood culture media but grew readily when subcultured onto Sabouraud's medium coated with sterile olive oil. Yeasts were readily identified in all four patients in whom a buffy coat Gram stain was obtained of blood from the central intravenous catheter. M furfur may be a fairly common but unrecognized cause of catheter-related sepsis in infants receiving long-term fat emulsion therapy. This organism should be sought whenever routine blood cultures are negative for bacteria and yeasts are observed in a buffy coat Gram stain.

938

An epidemic outbreak of Malassezia folliculitis in three adult patients in an intensive care unit: a previously unrecognized nosocomial infection. Archer-Dubon C, Icaza-Chivez ME, Orozco-Topete R, Reyes E, Baez-Martinez R, Ponce de León S. Int J Dermatol. 1999 Jun;38(6):453-6.

BACKGROUND: Malassezia is a lipophilic fungus commonly found in normal human skin. Infection of the hair follicle by Malassezia furfur occurs in patients with predisposing factors such as diabetes or immunosuppression, or who are undergoing antibiotic treatment. Malassezia furfur folliculitis is an infrequent nosocomial infection which may be associated with fomite transmission. METHODS: We reviewed the clinical files of three adult patients from an intensive care unit (ICU) who simultaneously developed folliculitis through Malassezia infection. We specifically analysed predisposing factors, possible transmission modes, characteristics of skin lesions, results of biopsies and cultures, treatment, and patient outcome. RESULTS: The three male patients were in neighboring beds and they all had factors that predisposed them to underlying immunosupression. Simultaneously, and within hours of each other, they developed erythematous follicular papules and pustules on the face and chest. The skin biopsies revealed an acute folliculitis with abundant round to oval yeasts of up to 5 microm in diameter. Stains for fungi (Schiff's peryodic acid, Grocott and silver methenamine) revealed numerous unipolar budding yeasts without hyphae, consistent with M. furfur. Conventional cultures were negative. The diagnosis of folliculitis by M. furfur was established and antifinigal treatment initiated, with adequate outcome of the dermatosis. After this outbreak, the aseptic and hygienic measures of the health care personnel of the ICU were reviewed and corrected. CONCLUSIONS: The simultaneous emergence of this superficial infection by M. furfur suggests fomite participation. This dermatomycosis is an infrequent nosocomial infection in adults, which to our knowledge has not been previously reported.

939

11. Human infections due to Malassezia spp. Marcon MJ, Powell DA. Clin Microbiol Rev. 1992 Apr;5(2):101-19.

The genus Malassezia contains three member species: Malassezia furfur and Malassezia sympodialis, both obligatory lipophilic, skin flora yeasts of humans, and Malassezia pachydermatis, a nonobligatory lipophilic, skin flora yeast of other warm-blooded animals. Several characteristics suggest the basidiomycetous nature of these yeasts, although a perfect stage has not been identified. Classically, these organisms are associated with superficial infections of the skin and associated structures, including pityriasis versicolor and folliculitis. Recently, however, they have been reported as agents of more invasive human diseases including deep-line catheter-associated sepsis. The latter infection occurs in patients, primarily infants, receiving parenteral nutrition (including lipid emulsions) through the catheter. The lipids presumably provide growth factors required for replication of the organisms. It is unclear how deep-line catheters become colonized with Malassezia spp. Skin colonization with M. furfur is common in infants hospitalized in neonatal intensive care units, whereas colonization of newborns hospitalized in well-baby nurseries and of older infants is rarely observed. Catheter colonization, which may occur without overt clinical symptoms, probably occurs secondary to skin colonization, with the organism gaining access either via the catheter insertion site on the skin or through the external catheter hub (connecting port). There is little information on the colonization of hospitalized patients by M. sympodialis or M. pachydermatis. Diagnosis of superficial infections is best made by microscopic examination of skin scrapings following KOH, calcofluor white, or histologic staining. Treatment of these infections involves the use of topical or oral antifungal agents, and it may be prolonged. Diagnosis of Malassezia catheter-associated sepsis requires detection of the organism in whole blood smears or in buffy coat smears of blood drawn through the infected catheter or isolation of the organism from catheter or peripheral blood or the catheter tip. Culture of M. furfur from blood is best achieved with Isolator tubes and plating onto a solid medium supplemented with a lipid source. Appropriate treatment of patients requires removal of the infected catheter with or without temporary stoppage of lipid emulsions; administration of antifungal therapeutic agents does not appear to be necessary. Because many patients who develop Malassezia catheter-associated sepsis have severe underlying illnesses, caution must be exercised in attributing all clinical deterioration to Malassezia infection. Our better understanding of how these organisms cause disease awaits the development of a useful typing scheme for epidemiologic studies and further studies on microbial virulence factors and the role of the immune response in pathogenesis.

941

Malbranchea pulchella fungal sinusitis. Benda TJ Jr, Corey JP. Otolaryngol Head Neck Surg. 1994 Jun;110(6):501-4.

Fungal sinus disease is being reported with increasing frequency. We could find no previously reported cases of sinonasal infections with Malbranchea pulchella and only two previously reported cases of human infection of any kind. We now report on a case of suspected sinonasal Malbranchea pulchella in a patient with aspirin-sensitive triad asthma.

955

Fungal keratitis caused by Metarhizium anisopliae var. anisopliae. De Garcia MC, Arboleda ML, Barraquer F, Grose E.J Med Vet Mycol. 1997 Sep-Oct;35(5):361-3.

Metarhizium anisopliae var. anisopliae (Metschnikov) Sorokin 1883 to our knowledge has never been reported as an agent of human or animal mycosis. This fungus has great importance as an agent of biological control of different pests and mosquito larvae in Colombia. It has been isolated as the aetiological agent of keratomycosis for the first time from the eye of a Colombian male.

958

Suppurative cutaneous granulomata caused by Microascus cinereus in a patient with chronic granulomatous disease. Marques AR, Kwon-Chung KJ, Holland SM, Turner ML, Gallin JI. Clin Infect Dis. 1995 Jan;20(1):110-4.

We describe a patient with chronic granulomatous disease who presented with erythematous papular skin lesions on the chest, back, and arm. Examination of biopsy specimens from the lesions on the arm and back showed suppurative granulomata in association with acute and chronic inflammation. Histopathologic examination of a specimen from the lesion on the arm revealed fungal elements, and cultures yielded Microascus cinereus. The patient was treated with 2.5 g of intravenous amphotericin B, and the lesions resolved. We report what is, to our knowledge, the first case of invasive disease due solely to M. cinereus.

959

Onychomycoses due to Microascus cirrosus (syn. M. desmosporus). de Vroey C, Lasagni A, Tosi E, Schroeder F, Song M. Mycoses. 1992 Jul-Aug;35(7-8):193-6.

Microascus cirrosus is very rarely the aetiological agent of onychomycosis. We report two additional cases of toenail infections caused by this fungus.

960

Microascus desmosphorus(Lechmere)Curzi 1931 as causative agent of toe-nail mycosis] Schönborn C, Jahn H. Dermatol Monatsschr. 1970;156(6):615-26.

961

Microascus cinereus infection of human nail. Agarwal GP, Singh SM. Indian J Med Sci. 1980 Nov;34(11):263-5.

962

Maxillary sinusitis from Microascus cinereus and Aspergillus repens. Aznar C, de Bievre C, Guiguen C. Mycopathologia. 1989 Feb;105(2):93-7.

Microascus was associated with Aspergillus repens in a left maxillary sinus. Tissue contained septale filaments of two types, conidia, ostiolate perithecia containing ascospores corresponding to Microascus cinereus which was identified by culture. The abundance of sexual fructifications in the tissue indicates that pathogenicity is due to Microascus cinereus.

963

Microascus cinereus (Anamorph scopulariopsis) brain abscess in a bone marrow transplant recipient. Baddley JW, Moser SA, Sutton DA, Pappas PG. J Clin Microbiol. 2000 Jan;38(1):395-7.

We report the first documented case of brain abscess due to the dematiaceous fungus Microascus cinereus, an organism common in soil and stored grain. M. cinereus was isolated from brain abscess material from a bone marrow transplant recipient. The patient responded well to treatment by amphotericin B lipid complex, itraconazole, and a craniotomy but later died from secondary complications caused by graft-versus-host disease.

964

Early Microascus cinereus endocarditis of a prosthetic valve implanted after Staphylococcus aureus endocarditis of the native valve. Célard M, Dannaoui E, Piens MA, Guého E, Kirkorian G, Greenland T, Vandenesch F, Picot S. Clin Infect Dis. 1999 Sep;29(3):691-2.

969

Microsphaeropsis olivacea as an etiological agent of human skin infection. Guarro J, Mayayo E, Tapiol J, Aguilar C, Cano J. Med Mycol. 1999 Apr;37(2):133-7.

Microsphaeropsis olivacea is reported as the agent of a case of human skin infection in an otherwise healthy woman. This fungus has not been reported previously as causing disease in humans. It was identified on the basis of its production of pycnidia and conidial structures typical of the Coelomycetes, and by its light brown, ellipsoid to cylindrical and thick walled conidia. The in vitro inhibitory activity of amphotericin B, fluconazole, flucytosine, itraconazole, ketoconazole and miconazole was determined.

970

Microsphaeropsis olivacea keratitis and consecutive endophthalmitis. Shah CV, Jones DB, Holz ER. Am J Ophthalmol. 2001 Jan;131(1):142-3.

PURPOSE: To report a case of fungal keratitis with consecutive endophthalmitis caused by Microsphaeropsis olivacea. METHODS: Case report. RESULTS: A 51-year-old man developed fungal keratitis and consecutive endophthalmitis after sustaining a penetrating injury to the right eye. Cultures of the aqueous humor yielded M. olivacea. Infection resolved after intraocular fungal debridement, intravitreous amphotericin B, and aggressive topical natamycin and oral fluconazole. Persistent, low-grade smoldering corneal and intraocular inflammation required topical corticosteroid therapy. CONCLUSION: M. olivacea is an exceedingly rare ocular pathogen. The intraocular portion of the infection responded quickly to intravitreal antifungal treatment; however, the course was prolonged by smoldering corneal inflammation. Prompt recognition of intraocular spread and aggressive treatment may be beneficial in fungal infections caused by unusual organisms with uncertain virulence.

971

Microsporum langeronii dermatophytosis in a newborn infant contaminated in France] Cabon N, Moulinier C, Taieb A, Maleville J. Ann Dermatol Venereol. 1994;121(3):247-8.

Dermatophytosis due to Microsporum langeronii was observed in a 21-day neonate born in Bordeaux, France to a mother of West African origin. A typical misleading manifestations were: non alopecic squamation of the scalp with seborrhoea associated with circineous vesiculo-squamous lesions of the forehead. The source of the contamination was undoubtedly the mother who presented squamation without alopecia of the scalp. M. langeronii were observed in the scales and the hair. Epidemiological search for tinea should be carried out in the family as well as in schools attended by the brothers and sisters. Familial contamination is more frequent.

972

[Microsporum canis tinea ciliaris and blepharitis] Creach P, Auffret N, Buot G, Binet O. Ann Dermatol Venereol. 1995;122(11-12):773-4.

INTRODUCTION: The involvement of eyelashes and eyelids by dermatophytes is unfrequent. CASE REPORT: We describe such a case in a 48 year old woman, who presented with unilateral blepharitis, resistant to topical treatments with antiseptics, antibiotics and corticosteroids. Diagnosis was suspected by magnifying lens and Wood's light examination; Microsporum canis was isolated from broken eyelashes and scales of annular lesions of eyelids. CONCLUSION: This case emphasizes the interest of mycological examination of eyelashes and eyelids in front of a persisting unilateral blepharitis.

973

Microsporum canis infections in children: results of a new oral antifungal therapy. Ginter G. Mycoses. 1996 Jul-Aug;39(7-8):265-9.

Clinical and laboratory data from 22 children with tinea corporis and tinea capitis caused by Microsporum canis (10 tinea corporis, 12 tinea capitis), confirmed by microscopic examination and culture and partly pretreated with griseofulvin or terbinafine, are summarized. The children were treated consecutively with itraconazole in our clinic during 1994/95. The age of the children ranged between 4 and 13 years, with girls being affected much more frequently than boys. Oral, individually adapted, high-dose treatment of 5 mg itraconazole per kg body weight proved to be successful. In all 22 children, although pretreatment with griseofulvin or terbinafine was partly unsuccessful, fungal infections could be cured clinically and also were culture negative at control examinations. In 10 children with tinea corporis treatment was performed only for 4-14 (middle 11) days. In the children with tinea capitis itraconazole treatment was continued for 3-11 weeks. Among the six children without pretreatment, itraconazole solution was administered for 4-11 weeks (average 7.5 weeks). Of the patients in whom pretreatment was unsuccessful, four with griseofulvin and two with terbinafine, the duration of the subsequent oral treatment with itraconazole solution was 3-5 weeks (average 3.6 weeks). The drug seemed to be well tolerated-no significant side-effects occurred, with the exception of possible minor gastrointestinal disturbances in two patients. Laboratory values remained within normal limits.

974

Tinea capitis due to Microsporum gypseum in an adult. Offidani A, Simoncini C, Arzeni D, Cellini A, Amerio P, Scalise G. Mycoses. 1998 May-Jun;41(5-6):239-41.

A case of tinea capitis due to Microsporum gypseum in an adult is described. An otherwise healthy 69-year-old woman presented two large patches of slightly erythematous scaling alopecia localized on the vertex and on the left parietal region of the scalp. The only subjective sign was itching. A mycological culture was positive for Microsporum gypseum. Tinea capitis is uncommon in adults; furthermore, isolation of Microsporum gypseum from this type of lesion is rare.

975

Case report. Tinea corporis purpurea. Veraldi S, Gorani A, Schmitt E, Gianotti R. Mycoses. 1999;42(9-10):587-9.

We report a case of tinea corporis purpurea localized to a calf in a 36-year-old woman. The patient, who was also affected by mild superficial venous insufficiency of lower limbs, complained of intense pruritus. Microsporum canis was the aetiological agent. Clinically atypical varieties of tinea corporis were sometimes reported in the literature, particularly in HIV-positive patients, although they are uncommon in immunocompetent patients; in particular, tinea corporis purpurea is very rare.

976

Tinea faciei due to Microsporum canis abscess formation. Patel G, Mills C. Clin Exp Dermatol. 2000 Nov;25(8):608-10.

Superficial dermatophyte infections are common in children; however, complications are encountered rarely. We describe a child with tinea faciei caused by Microsporum canis, who subsequently developed an abscess. Complete resolution occurred after treatment with oral terbinafine.

977

Microsporum canis tinea capitis in an 8-month-old infant successfully treated with 2 weekly pulses of oral itraconazole. Koumantaki E, Georgala S, Rallis E, Papadavid E. Pediatr Dermatol. 2001 Jan-Feb;18(1):60-2.

We report an 8-month-old girl with tinea capitis caused by Microsporum canis which was successfully treated with two pulses of oral itraconazole 50 mg/day, each of 1 week duration with an interval of 2 weeks. M. canis tinea capitis can be a difficult therapeutic problem in an infant, as the treatment is usually long, lasting up to 4-6 weeks with griseofulvin and 6-12 weeks with terbinafine, and the desire to provide a safe systemic therapy is particularly important. With an intermittent regimen the duration of treatment with active drug can be much shorter compared to continuous therapy. We found that itraconazole pulse therapy for M. canis tinea capitis was a safe and effective treatment in an infant.

978

Subcutaneous infection by Microsporum gypseum. Fernández-Torres B, Mayayo E, Boronat J, Guarro J. Br J Dermatol. 2002 Feb;146(2):311-3.

We report a case of subcutaneous infection caused by the dermatophyte Microsporum gypseum in an immunocompetent host. The patient acquired the infection in the knee through a traumatic inoculation of a splinter. To our knowledge this is the first case of subcutaneous infection caused by this fungus.

979

Case report. Onychomycosis due to Microsporum canis. Romano C, Paccagnini E, Pelliccia L. Mycoses. 2001 May;44(3-4):119-20.

A case of distal subungual onychomycosis of the big toe due to Microsporum canis is reported in a 69-year-old male asthma patient who had been treated with systemic corticosteroids for the last 3 years. The nail infection was contracted from a cat who was a healthy carrier. The patient was treated successfully with intermittent itraconazole therapy.

980

Onychomycosis due to Microsporum gypseum. Romano C. Mycoses. 1998 Sep-Oct;41(7-8):349-51.

The first four cases of onychomycosis due to Microsporum gypseum observed in Italy between 1990 and 1997 are reported. clinical manifestation was distal subungual onychomycosis in all cases. The lesions were asymptomatic in two patients. Three patients were treated with oral itraconazole (pulsed therapy) and the other with ciclopirox 8% nail lacquer. Clinical and mycological recovery was achieved in all cases. The cases are reported because of their rarity.

981

Case of onychomycosis caused by Microsporum racemosum. García-Martos P, Gené J, Solé M, Mira J, Ruíz-Henestrosa R, Guarro J. J Clin Microbiol. 1999 Jan;37(1):258-60.

We report the case of a Spanish 60-year-old female who presented in 1997 with onychomycosis of the left thumbnail following an injury caused by a fresh fish bone. Microsporum racemosum was repeatedly cultured from nail scrapings, and its identity was confirmed by sequencing the isolate's ITS1/ITS2 and 5.8S rRNA regions. The patient was successfully treated with itraconazole, which was administered for 12 weeks. This represents the first case of onychomycosis due to M. racemosum and the first time that this species has been isolated from a human in Europe.

982

[Mycetomas caused by Microsporum canis. Report of one case] Zaror L, Moreno MI, Hering M, Siegmund I, Norambuena L. Rev Med Chil. 1997 Aug;125(8):922-6.

We report an eight years old boy presenting with a pyogenic granuloma of the scalp, generalized alopecia, descamative plates in the neck, trunk and limbs and nail involvement. Cultures for fungus of all these lesions disclosed Microspore canis. The patient was treated with oral griseofulvin, miconazole and topical tolnaftate. Five years later and after several incomplete treatments, the patient returns with a fistulous mass of 15 x 8 cm in the dorsal area whose culture revealed Microspore canis. The mass was excised and oral ketoconazole was indicated. After three months of follow up, the patient was lost from control.

983

[Microsporum canis mycetoma of the scalp] Vezon G, Desbois N, Boisseau-Garsaud AM, Helenon R, Jouannelle A, Saint-Cyr I, Cales-Quist D. Ann Dermatol Venereol. 2000 Aug-Sep;127(8-9):729-31.

BACKGROUND: Mycetoma is a chronic subcutaneous tumefaction with presence of grains or granules. Etiological agents include bacteria or filamentous fungi. Mycetoma due to dermatophytes is uncommon, mainly occurring in Africa. To our knowledge, no case has been reported in the West Indies. Only two observations of Micosporum canis mycetoma in humans have been reported in the literature. We report a third case of mycetoma of the scalp caused by this fungus. CASE REPORT: A 22-year-old woman from Martinique, French West Indies, presented with an indolent tumefaction of the scalp evolving over five years. She had mental retardation due to congenital adrenal hyperplasia with 21-hydroxylase deficiency. The lesion was extracted surgically. Pathology and mycology examinations showed features of Microsporum canis mycetoma. Two months later, the scalp lesion recurred and the patient was treated with griseofulvin after surgical extraction. DISCUSSION: Mycetoma due to dermatophytes is very uncommon, mainly observed on the scalp and nape of the neck. A history of a skin lesion is frequent, leading to transcutaneous penetration of the fungus and mycetoma formation. Several dermatophyte species have been identified as causal agents (Microsporum ferrugineum, Trichophyton rubrum, Trichophyton verrucosum, Trichophyton mentagrophytes, Microsporum audouinii, Microsporum langeronii). Microsporum canis is rarely demonstrated in humans: two cases in children in Africa and Australia. Our observation was similar to the two cases in the literature: indolent and mobile tumefaction of the scalp, in a child or young adult, suggestive of lipoma or epidermal cyst, with excision leading to diagnosis. Association with tinea capitis and skin or nail involvement can also be observed.

984

Occupational asthma caused by a natural food colorant derived from Monascus ruber. Vandenplas O, Caroyer JM, Cangh FB, Delwiche JP, Symoens F, Nolard N. J Allergy Clin Immunol. 2000 Jun;105(6 Pt 1):1241-2.

1001

Primary cutaneous zygomycosis due to Mucor circinelloides. Chandra S, Woodgyer A. Australas J Dermatol. 2002 Feb;43(1):39-42.

A 62-year-old woman with myelodysplastic syndrome presented with a 4-week history of a large indurated ulcer with a black eschar on the forearm following trauma. On biopsy a diagnosis of zygomycosis was made as broad, sparsely septate, thin-walled hyphae were seen in the deep dermis and subcutaneous fat. The zygomycete fungus Mucor circinelloides was cultured from tissue. Further investigation confirmed that the infection was localized to the skin. The 6 x 4 cm lesion was excised and the defect closed with a neurovascular island flap. No other treatment was undertaken. The patient died 6 months later from her haematological disease without recurrence of the fungal infection.

1002

A case of cutaneous mucormycosis in Shanghai, China. Wang JJ, Satoh H, Takahashi H, Hasegawa A. Mycoses. 1990 Jun;33(6):311-5.

A 34-year-old female farmer suffered from localized cutaneous mucormycosis for 17 years. At the first admission, the lesion was a dull red plaque, about 7 x 9 cm in size with ulcerations, surrounded by some nodules on the dorsum of her right hand. General examination did not reveal abnormal findings except the skin lesion. Direct examination of skin scrapings in 10% KOH revealed broad, sparsely septate, branching hyphae. Histopathology showed many intradermal granulomata and microabscesses as well as mycelial elements comprising broad, distorted, ribbon-like strands. Some of them were phagocytized by multi-nucleated giant cells. Cultures revealed rapidly growing yellow colonies on Sabouraud dextrose agar medium at 25 degrees C. Sporangiophores branched in sympodia and the sporangia were globose, 35-60 microns in diameter. Their walls were deliquescent, but some of them were rather persistent. Columellae were mostly globose, 12-17 microns in diameter, up to 35 microns with collars. Sporangiospores were mainly ellipsoidal, 1.5-2.5 x 3-5 microns in size, but sometimes highly variable in size and shape. The maximum growth temperature of the isolate was 37 degrees C. The pathogenic organism isolated was tentatively identified as Mucor lusitanicus, which, as far as we know, has not been reported as a causative agent of cutaneous mucormycosis.

1003

Subcutaneous mucormycosis caused by Mucor hiemalis Wehmer f. luteus (Linnemann) Schipper 1973. Costa AR, Porto E, Tayah M, Valente NY, Lacaz Cda S, Maranhao WM, Rodrigues MC. Mycoses. 1990 May;33(5):241-6.

The authors report a case of subcutaneous mucormycosis in a diabetic patient with verrucous lesions in the fourth finger of the right hand. Initially diagnosed as a fixed cutaneous sporotrichosis case, success was obtained with the use of potassium iodide with healing of the lesion in a period of nearly 5 months. At present the patient remains under clinical observation with no treatment or relapse.

1004

A fatal case of gastric mucormycosis and diabetic ketoacidosis.Paulo De Oliveira JE, Milech A.Endocr Pract. 2002 Jan-Feb;8(1):44-6.

OBJECTIVE: To describe a case of gastric mucormycosis in conjunction with severe bleeding in a young woman, which occurred after an episode of ketoacidosis and had a fatal outcome. METHODS: We present a case report, including detailed clinical and pathologic findings in a woman with gastric mucormycosis associated with severe bleeding. RESULTS: A 17-year-old woman sought medical assistance for diabetic ketoacidosis and severe epigastric pain. Chest radiography showed normal findings, and blood and urine cultures were negative for bacterial growth. Endoscopy disclosed an extensive ulcerated lesion involving the greater curvature and posterior wall of the stomach. Biopsy specimens demonstrated the presence of invasive mucormycosis. Treatment with amphotericin B was initiated, but severe persistent gastrointestinal bleeding resulted in the patient's demise. CONCLUSION: In conjunction with diabetic ketoacidosis, severe infection by Mucor has been reported mainly in the rhino-orbital area. Although uncommon, the gastrointestinal tract can also be involved. In the case described, severe hemorrhage ensued and caused the patient's death.

1005

[Myelodysplastic syndrome developing acute myelocytic leukemia with gastric mucormycosis] Sasaki A, Tsukaguchi M, Takayasu K, Hanai J. Rinsho Byori. 1993 Sep;41(9):1054-8.

80-year-old female was admitted to our hospital because of pancytopenia. Her peripheral and bone marrow examinations were performed. According to the criteria of FAB classification, the diagnosis was myelodysplastic syndrome (refractory anemia with excess of blasts in transformation). Etoposide was administered to decrease leukemic blasts. However, she still had high fever and increasing of CRP. Hematological data also showed the increasing of WBC count, blast cells, and LDH enzyme. Antibiotics and anti fungal drugs were also not effective. She died of respiratory failure, although the cautions and extensive treatment was tried. Autopsy findings revealed proliferation of mucor in the mucosa of stomach. So, we reported here a very rare case of gastric mucormycosis, localizing exclusively in the stomach which was difficult to diagnose while she was alive.

1006

Successful treatment of mucor infection after liver or pancreas-kidney transplantation. Jiménez C, Lumbreras C, Aguado JM, Loinaz C, Paseiro G, Andrés A, Morales JM, Sánchez G, García I, del Palacio A, Moreno E. Transplantation. 2002 Feb 15;73(3):476-80.

OBJECTIVE: To describe a case of gastric mucormycosis in conjunction with severe bleeding in a young woman, which occurred after an episode of ketoacidosis and had a fatal outcome. METHODS: We present a case report, including detailed clinical and pathologic findings in a woman with gastric mucormycosis associated with severe bleeding. RESULTS: A 17-year-old woman sought medical assistance for diabetic ketoacidosis and severe epigastric pain. Chest radiography showed normal findings, and blood and urine cultures were negative for bacterial growth. Endoscopy disclosed an extensive ulcerated lesion involving the greater curvature and posterior wall of the stomach. Biopsy specimens demonstrated the presence of invasive mucormycosis. Treatment with amphotericin B was initiated, but severe persistent gastrointestinal bleeding resulted in the patient's demise. CONCLUSION: In conjunction with diabetic ketoacidosis, severe infection by Mucor has been reported mainly in the rhino-orbital area. Although uncommon, the gastrointestinal tract can also be involved. In the case described, severe hemorrhage ensued and caused the patient's death.

1007

Hepatic and small bowel mucormycosis after chemotherapy in a patient with acute lymphocytic leukemia. Suh IW, Park CS, Lee MS, Lee JH, Chang MS, Woo JH, Lee IC, Ryu JS. J Korean Med Sci. 2000 Jun;15(3):351-4.

Mucormycosis is a rare but invasive opportunistic fungal infection with increased frequency during chemotherapy-induced neutropenia. The clinical infections due to Mucor include rhinocerebral, pulmonary, cutaneous, gastrointestinal and disseminated diseases. The first two are the most common diseases and all entities are associated with a high mortality rate. Still hepatic involvement of Mucor is rarely reported. We experienced a case of hepatic and small bowel mucormycosis in a 56-year-old woman after induction chemotherapy for B-cell acute lymphocytic leukemia. Initial symptoms were a high fever unresponsive to broad spectrum antibiotics and pain in the left lower abdominal quadrant. It was followed by septic shock, deterioration of icterus and progressively elevated transaminase. An abdominal CT demonstrated multiple hypodense lesions with distinct margins in both lobes of liver and pericolic infiltration at small bowel and ascending colon. Diagnosis was confirmed by biopsy of the liver. The histopathology of the liver showed hyphae with the right-angle branching, typical of mucormycosis. The patient was managed with amphotericin B and operative correction of the perforated part of the small bowel was performed. However, the patient expired due to progressive hepatic failure despite corrective surgery and long-term amphotericin B therapy.

1008

Subacute disseminated mucormycosis in a diabetic male. Nolan RL, Carter RR 3rd, Griffith JE, Chapman SW. Am J Med Sci. 1989 Oct;298(4):252-5.

Mucormycosis is an opportunistic invasive infection caused by fungi of the order Mucorales. Rhizopus, Absidia, and Mucor are the most commonly encountered genera. Disease is characterized by vascular invasion, thrombosis, and tissue necrosis. Rhinocerebral disease is the most common manifestation but pulmonary, cutaneous, gastrointestinal, and widely disseminated forms have been reported. Pulmonary and disseminated disease are usually seen in neutropenic patients with leukemia or lymphoma. Both present as fever and unexplained pulmonary infiltrates unresponsive to antibacterials and corticosteroids. Disease is usually fulminant and has a high mortality rate. Diagnosis is most commonly made at autopsy. A single case of disseminated disease is reported that is unusual in its subacute course and its occurrence in an otherwise healthy non-neutropenic diabetic male.

1009

Cerebral mucormycosis after liver transplantation: a case report. Webb M, Dowdy L, Bundschu C, Nery J, Schiff E, Tzakis AG. Clin Transplant. 1998 Dec;12(6):596-9.

A fatal case of cerebral mucormycosis occurring shortly after liver transplantation is described. The patient was a 32-yr-old male with advanced end-stage liver disease manifested by tense ascites, spontaneous bacterial peritonitis, deepening jaundice and anuria requiring hemodialysis. The 3rd day after successful liver transplantation the patient developed acute respiratory failure, then focal motor signs. Computed tomography showed fluid in the left maxillary sinus, partial opacification of the ethmoid and sphenoid sinuses, and diffuse low density lesions in both cerebral hemispheres. Despite treatment for cerebritis and cerebral edema, the patient's pupils became fixed and dilated, and brain death was declared. Autopsy revealed mucor sinusitis and cerebritis. Mucormycosis is an opportunistic fungal infection occurring in patients with diabetic ketoacidosis, malignancy, or immunodeficiency, and in those receiving wide-spectrum antibiotics, corticosteroids, or cytotoxic therapy. Mucor most frequently involves the face, rhinocerebral disease predominating. These infections are difficult to treat, but are curable with aggressive and frequent surgical debridement, discontinuation or reduction of immunosuppressive therapy and amphotericin. The diagnosis of mucormycosis is very difficult to make in cases such as the present one, in which the typical presentation and classical signs are not present. A high index of suspicion based on identified risk factors may assist in more rapid diagnosis of this life-threatening mycosis.

1010

Infection of the postoperative cavity of the ear with the Mucor mucedo fungus] Lev NA. Vestn Otorinolaringol. 1966 Mar-Apr;28(2):87-8.

1013

Fatal aortic Myceliophthora thermophila infection in a patient affected by cystic medial necrosis. Farina C, Gamba A, Tambini R, Beguin H, Trouillet JL. Med Mycol. 1998 Apr;36(2):113-8.

A 22-year-old Italian woman developed fungal aortitis after cardiac surgery for aortic insufficiency. She experienced two episodes of septic embolization and subsequently underwent replacement of the aortic root and initial ascending aorta by a homograft. The lumina of the ascending aorta, aortic arch and the origin of the innominate artery were completely filled with vegetation. From the involved tissue the phaeoid thermophilic hyphomycete Myceliophthora thermophila (Apinis) van Oorschot was isolated in pure culture. This is the second report of isolation of this fungus from humans and the first isolation of a human pathogenic strain of M. thermophila causing fatal vasculitis in a patient affected by cystic medial necrosis. A detailed morphological description of the isolate is also provided.

1014

Fatal disseminated infection caused by Myceliophthora thermophila, a new agent of mycosis: case history and laboratory characteristics. Bourbeau P, McGough DA, Fraser H, Shah N, Rinaldi MG. J Clin Microbiol. 1992 Nov;30(11):3019-23.

We report a case of human infection caused by the hyphomycete Myceliophthora thermophila. A 7-year-old male with neurofibromatosis (type 1) was diagnosed in 1987 with acute myeloblastic leukemia associated with the chromosomal abnormality monosomy 7. The patient experienced multiple serious infections over a three-year period before expiring in 1990 while in the end stage of leukemia. Autopsy findings included fungal vegetations of the left atrium, ascending aorta, and pulmonary arteries and fungal invasion of both lungs. Cultures yielded M. thermophila. We believe that this is the first reported fatality caused by M. thermophila.

1015

Frontal sinusitis caused by Myriodontium keratinophilum. Maran AG, Kwong K, Milne LJ, Lamb D. Br Med J (Clin Res Ed). 1985 Jan 19;290(6463):207.

1024

Mycoleptodiscus indicus: a new etiologic agent of phaeohyphomycosis. Padhye AA, Davis MS, Reddick A, Bell MF, Gearhart ED, Von Moll L. J Clin Microbiol. 1995 Oct;33(10):2796-7.

Mycoleptodiscus indicus, a dematiaceous hyphomycete, was identified as the causal agent of subcutaneous infection in the knee of a 72-year-old male gardener residing in coastal South Carolina. The patient had Wegener's granulomatosis and immunodeficiency. Synovial fluid and biopsy tissue sections from the prepatellar bursa stained with hematoxylin and eosin, periodic acid-Schiff, and Gomori methenamine silver stains revealed branched, septate hyphae and many moniliform hyphal elements. When tissue sections were stained by the Fontana-Masson procedure, melanin pigment in the hyphal cell walls and at the septa was evident. A velvety, dematiaceous mold was isolated from both synovial fluid and the biopsy tissue. Sporulation was induced by exposure of slide cultures on potato dextrose agar to UV light for 12 h at 25 degrees C followed by incubation of the slide cultures at 25 degrees C in the dark for 4 weeks. Clypeate sporodochia consisting of ampulliform, compressed, phialidic conidiogenous cells produced curved, hyaline, one-celled conidia with setulae at one or both ends. Initial treatment with fluconazole for 7 days was not effective, and cultures were positive after treatment. Treatment with amphotericin B with concomitant irrigation and debridement of the affected area followed by treatment with itraconazole resulted in resolution of the infection.

1027

Invasive Nattrassia mangiferae infections: case report, literature review, and therapeutic and taxonomic appraisal. Sigler L, Summerbell RC, Poole L, Wieden M, Sutton DA, Rinaldi MG, Aguirre M, Estes GW, Galgiani JN. J Clin Microbiol. 1997 Feb;35(2):433-40.

We report on a case of subcutaneous infection of the arm caused by the coelomycetous fungus Nattrassia mangiferae (formerly Hendersonula toruloidea) in a steroid-dependent diabetic man with chronic obstructive lung disease. The man was a resident of Arizona, where the fungus is known to be endemic on Eucalyptus camaldulensis and on citrus trees. Diagnosis of fungal infection was made by observation of narrow hyphal filaments by histopathology of biopsy specimens and isolation of a fast-growing black mold which demonstrated hyphae and arthroconidia of varying widths typical of the Scytalidium synanamorph (S. dimidiatum). The formation of pycnidia, which at maturity expressed conidia with a central median dark band, allowed for the confirmation of the isolate as N. mangiferae. Remission of the lesions occurred following intravenous therapy with amphotericin B, followed by topical clotrimazole treatment. We use this patient's case report as an opportunity to review the literature on cases of deep infection caused by Scytalidium species, to evaluate the antifungal susceptibilities of a spectrum of Scytalidium isolates, and to review the taxonomy of Scytalidium species isolated from human infections.

1028

Hendersonula toruloidea infection in Thailand. Kotrajaras R, Chongsathien S, Rojanavanich V, Buddhavudhikrai P, Viriyayudhakorn S. Int J Dermatol. 1988 Jul-Aug;27(6):391-5.

Hendersonula toruloidea infection is present in Thailand, where the clinical picture of tinea pedis is scales 61%, erythema 22%, maceration 10.8%, and hyperkeratosis 9%. The diagnosis was confirmed by repeated isolation of H. toruloidea. The slow-growing type was found more often than the fast-growing in the ratio of 2.8:1. In patients with H. toruloidea infection, skin test with Hs antigen of 1:10 was positive. Griseofulvin sensitivity test revealed that the MIC of 20 cultures was more than 100 micrograms/ml. Only 2 out of 93 cases (0.02%) were cured with half-strength Whitfield ointment for 4 months. Pathomechanism of the infection is being studied.

1029

Hendersonula toruloidea, causative agent of a fungal verrucous dermatitis observed in Algeria] Mariat F, Liautaud B, Liautaud M, Marill FG. Sabouraudia. 1978 Jun;16(2):133-40.

A verrucose dermatitis of the face, accompanied by onychomycosis was observed in a 30 years old male living in Algeria. He was born there and 15 years previously he had been treated successfully for "Dermatophytic disease" due to Trichophyton verrucosum. A deficiency in his cellular immune mechanism was noted at that time. On this occasion Hendersonula toruloidea was isolated from facial lesions and affected nails. The infection of the face, but not the nails, responded to treatment with amphotericin B. In the facial lesions, the fungus was present as single cell units sometimes with a false bud or a short hyphal extension. Cross walls were occasionally present but the cell walls were not pigmented. Intratesticular inoculation of the isolates to guinea pigs resulted in an infection in which the morphology of the fungus conformed to that found in the facial lesions. In cultures, the isolates of H. toruloidea conformed to the descriptions in literature, although pycnidia were not formed.

1030

Hendersonula toruloidea infection of the skin and nails. Eady R, Moore M.

Trans St Johns Hosp Dermatol Soc. 1974;60(1):104-8.

1031

Infection of thefeet and nails with Hendersonula toruloidea. Gentles JC, Evans EG. Sabouraudia. 1970 May;8(1):72-5.

1032

Onychomycosis caused by Scytalidium dimidiatum. Report of two cases. Review of the taxonomy of the synanamorph and anamorph forms of this coelomycete. Lacaz CS, Pereira AD, Heins-Vaccari EM, Cucé LC, Benatti C, Nunes RS, de Melo NT, de Freitas-Leite RS, Hernández-Arriagada GL. Rev Inst Med Trop Sao Paulo. 1999 Sep-Oct;41(5):319-23.

The authors report two cases of onychomycosis in the dystrophic form, one of them involving an HIV-positive patient, provoked by Scytalidium dimidiatum, previously called Scytalidium lignicola. The subject is reviewed from the taxonomic viewpoint, considering the anamorph Hendersonula toruloidea as a synonym of Nattrassia mangiferae, and having Scytalidium dimidiatum as the major synanamorph. According to many mycologists, Scytalidium hyalinum may be a separate species or a hyaline mutant of Scytalidium dimidiatum. Scytalidium lignicola Pesante 1957 was considered to be the type-species of the genus by ELLIS (1971)13 and later to be a "conidial state" of Hendersonula toruloidea by the same author, today known as Nattrassia mangiferae. The microorganism lives only on the roots of certain plants (mainly Platanus and Pinus). It produces pycnidia and is not considered to be a pathogen, although it is considered as a possible emerging agent capable of provoking opportunistic fungal lesions. The importance of this topic as one of the most outstanding in fungal taxonomy, so likely to be modified over time, as well as its interest in the field of dermatologic mycology, are emphasized.

1033

Case report. Nattrassia mangiferae endophthalmitis. Gumbo T, Mkanganwi N, Robertson VJ, Masvaire P. Mycoses. 2002 Apr;45(3-4):118-9.

Nattrassia mangiferae is a plant pathogen that is also known as a cause of skin infection in humans. Reports of invasive human infection are extremely rare. A 60-year-old-immunocompetent patient presented with endophthalmitis one week after the left eye was injured by a piece of grass. Cultures of an aqueous tap grew N. mangiferae. The patient responded to oral ketoconazole. This suggests that N. mangiferae may be an invasive pathogen in plant penetration injuries and that ketoconazole may be an alternative treatment, especially in countries with poor resources.

1041

Disseminated Neocosmospora vasinfecta infection in a patient with acute nonlymphocytic leukemia. Cornely OA, Chemnitz J, Brochhagen HG, Lemmer K, Schütt H, Söhngen D, Staib P, Wickenhauser C, Diehl V, Tintelnot K. Emerg Infect Dis. 2001 Jan-Feb;7(1):149-52.

We report Neocosmospora vasinfecta infection following chemotherapy for acute nonlymphocytic leukemia. N. vasinfecta, a plant pathogen, was identified by culture and genetic sequencing. Susceptibility testing revealed in vitro resistance for common antifungals.

1042

Osteoarthritis caused by Neocosmospora vasinfecta. Kac G, Piriou P, Guého E, Roux P, Trémoulet J, Denis M, Judet T. Med Mycol. 1999 Jun;37(3):213-7.

We report the case of a patient who developed an ankle osteoarthritis due to the Ascomycete Neocosmospora vasinfecta, following accidental multiple trauma to his legs in whilst in Africa. Antifungal susceptibility testing was performed. Despite a low amphotericin B minimal inhibitory concentration, parenteral antifungal therapy failed and amputation was required to resolve the osteoarthritis. Possible reasons for the failure of this antifungal treatment are examined.

1043

Leg granuloma due to Neocosmospora vasinfecta in a renal graft recipient. Ben Hamida F, Achard JM, Westeel PF, Chandenier J, Bouzernidj M, Petit J, Carme B, Fournier A. Transplant Proc. 1993 Jun;25(3):2292.

1050

Cerebral Aspergillosis Caused by Neosartorya hiratsukae, Brazil. Guarro J, Kallas EG, Godoy P, Karenina A, Gené J, Stchigel A, Colombo AL. Emerg Infect Dis. 2002 Sep;8(9):989-91.

We report the first case of infection by Neosartorya hiratsukae, an ascomycete in which the conidial state resembles Aspergillus fumigatus. The fungus caused a brain infection in a Brazilian woman, who died despite itraconazole treatment. Diagnosis was established by direct microscopic examination, computed tomographic scan, and magnetic resonance imaging of the brain, and repeated cultures from the lesions. The in vitro antifungal susceptibility of the isolate is provided.

1051

Neosartorya fischeri: an invasive fungal pathogen in an allogeneic bone marrow transplant patient. Lonial S, Williams L, Carrum G, Ostrowski M, McCarthy P Jr. Bone Marrow Transplant. 1997 Apr;19(7):753-5.

Invasive fungal infections are a complication of allogeneic BMT. We report the first case of a Neosartorya fischeri fungal infection in a patient following allogeneic BMT. Neosartorya fischeri is related to Aspergillus fumigatus, but it is a distinct fungal species. Despite granulocytic engraftment and aggressive anti-fungal therapy with amphotericin B, the patient died of overwhelming fungal infection on day 60 post-BMT. Neosartorya fischeri is a pathogen that grows slowly in culture which can delay or confuse identification. This case further supports the need for more effective prophylaxis and treatment of non-Candida fungal infections in the allogeneic BMT population.

1052

Osteomyelitis caused by Neosartorya pseudofischeri. Padhye AA, Godfrey JH, Chandler FW, Peterson SW. J Clin Microbiol. 1994 Nov;32(11):2832-6.

The first case of osteomyelitis caused by Neosartorya pseudofischeri is reported. The patient, a 77-year-old male with a history of silicosis and tuberculosis, on X-ray examination revealed lytic lesions of L2 and L3 vertebrae suspicious for metastatic lesions. Histologic examination of biopsy specimens from vertebral bodies showed short, distorted, extra- and intracellular, hyaline hyphal fragments. The culture from the biopsy tissue produced numerous, evanescent asci containing eight ellipsoidal ascospores with two distinctive equatorial bands ca. 1 micron wide. When examined by a scanning electron microscope, ascospores exhibited a convex surface ornamented with raised flaps of tissue, in shape resembling triangular projections or long ridge lines. The conidial state (anamorph) was identified as Aspergillus thermomutatus on the basis of conidial columns which were smaller and less tightly packed as well as of a lighter shade of green than those observed in Aspergillus fumigatus. On the basis of the morphologic features of the ascospores, the teleomorph was identified as N. pseudofischeri.

1053

Graft-related endocarditis caused by Neosartorya fischeri var. spinosa. Summerbell RC, de Repentigny L, Chartrand C, St Germain G. J Clin Microbiol. 1992 Jun;30(6):1580-2.

The first case of endocarditis caused by Neosartorya fischeri var. spinosa is reported. The patient was a child who received a calf pericardium graft after removal of a previously inserted Dacron graft associated with deterioration of adjacent tissue. Copious vegetations removed from the heart were found to be composed of septate hyaline fungal filaments. The fungus was recognized in culture by its bivalved, winged, spiny ascospores, its Aspergillus fischerianus anamorph, and its thermotolerance.

1054

Neosartorya fischeri var fischeri (Wehmer) Malloch and Cain 1972 (anamorph: Aspergillus fischerianus Samson and Gams 1985) as a cause of mycotic keratitis. Coriglione G, Stella G, Gafa L, Spata G, Oliveri S, Padhye AA, Ajello L. Eur J Epidemiol. 1990 Dec;6(4):382-5.

The first case of mycotic keratitis caused by Neosartorya fischeri var. fischeri the teleomorph of Aspergillus fischerianus, is described. The patient, a 62-year-old man, had no history of trauma to his infected left eye. The infection progressed despite treatment with ketoconazole and the eye had to be eviscerated. Histological studies revealed the presence of hyaline, septate mycelium in the eye tissue. Cultures gave rise to a thermotolerant mould that developed both its asexual and sexual forms. The isolate was identified on the basis of the morphologic features of its anamorphic and teleomorphic states. In the literature only seven other species of Aspergillus have been unequivocally reported as causing mycotic keratitis.

1055

[Recent contribution to the study of mycetoma in Senegal. Neotestudina rosatii. Pyrenochaeta romeroi. Aspergillus nidulans] Baylet R, Camain R, Chabal J, Izarn R. Bull Soc Med Afr Noire Lang Fr. 1968;13(2):311-3.

1056

[Agents of mycetomas: a bacteriological and parasitological study (author's transl)] Peloux Y, Quilici M. Med Trop (Mars). 1979 Jan-Feb;39(1):9-15.

Microscopic agents responsible of Mycetomas are reviewed. They may be bacteria belonging to the Actinomycetalae order (Nocardia, Actinomadura, Streptomyces) or very various fungi belonging to the classes of Adelomycetes or Ascomycetes (Madurella, Leptosphaeria, Neotestudina, etc.). Though the procedures for collecting and transporting samples are the same, direct microscopic examination gives possibility to choose among the selective culture media the most appropriate ones to isolate either fungi or Actinomycetalae. Technics of identification for the most important bacterial agents are given, but fungi can be identified in only very specialized laboratories. Immunological methods may bring valuable indications for helping diagnosis or treatment supervision.

1057

The histopathological features of pale grain eumycetoma. Hay RJ, Mackenzie DW. Trans R Soc Trop Med Hyg. 1982;76(6):839-44.

Histological findings in 24 cases of pale grain eumycetoma have been compared. The inflammatory response and morphology of grains caused by different organisms are very similar. However the histological appearances of Neotestudina rosatii infections, although reminiscent of dermatophyte mycetomas, are distinctive. The characteristic features include the presence of cement and the short swollen hyphal segments. Petriellidium boydii grains are more likely to contain numerous vesicles or swollen hyphae and be surrounded by a prominent eosinophilic fringe. In contrast, Fusarium and Acremonium grains usually have a minimal fringe and contain a dense mass of intermeshing hyphae. However the features separating P. boydii and Fusarium/Acremonium grains are not invariable and can only be used as an approximate guide to the correct identity of the organism.

1058

Description of a new agent for maduromycosis, Neotestudina rosatii, n. gen., n. sp., isolated in Africa] SEGRETAIN G, DESTOMBES P. C R Acad Sci (Paris) 1961 Nov 27;253:2577-9.

1060

Nigrospora causing corneal ulcer--a case report. Muralidhar S, Sulthana M. Indian J Pathol Microbiol. 1997 Oct;40(4):549-51.

A patient from a rural background developed corneal ulceration following an insect hitting the eye. Corneal scrapings when processed for bacterial and fungal growth yielded Nigrospora, a contaminant fungus. This fungus has been quoted in literature as a common contaminant of no pathogenic significance. Herein, we describe its role as the causative agent of corneal ulcer, which has not been reported thus far.

1064

Isolation of a Nodulisporium species from a case of cerebral phaeohyphomycosis. Umabala P, Lakshmi V, Murthy AR, Prasad VS, Sundaram C, Beguin H. J Clin Microbiol. 2001 Nov;39(11):4213-8.

A fungal infection of the brain of a 55-year-old male patient is reported. The lesion and involved fungus were located exclusively in the right medial temporo-parietal region. The patient was successfully treated with surgical resection of the lesion and antifungal chemotherapy. Few pathogenic dematiaceous fungi exhibit neurotropism and can cause primary infection in the central nervous system (CNS). The etiological agent is described as a Nodulisporium species. To date Nodulisporium has never been reported as an agent of CNS infection in humans.

1068

. Infections due to dematiaceous fungi in organ transplant recipients: case report and review. Singh N, Chang FY, Gayowski T, Marino IR. Clin Infect Dis. 1997 Mar;24(3):369-74.

Dematiaceous fungi are being increasingly recognized as pathogens in organ transplant recipients. We describe a case of invasive esophagitis due to Cladophialophora bantiana in a small bowel transplant recipient and review a total of 34 cases of infections due to dematiaceous fungi in organ transplant recipients. The median time to the onset of fungal infection after transplantation was 22 months. Clinically, two distinct patterns of infections were observed: 79% of the patients had skin and/or soft-tissue infections or joint infections (predominantly due to Exophiala species), and 21% had systemic invasive infections (predominantly brain abscesses due to Ochroconis gallopavum [Dactylaria gallopava, Dactylaria constricta var. gallopava]). The overall mortality rate among the patients with skin and/or soft-tissue infections or joint infections and the patients with systemic invasive disease was 7% and 57%, respectively; two of five patients with brain abscesses were cured with antifungal therapy. Recognition of infections due to dematiaceous fungi is important since these infections, unlike invasive aspergillosis, may be more amenable to therapy.

1069

Successful therapy for cerebral phaeohyphomycosis due to Dactylaria gallopava. Nieto-Rodriguez JA, Kusne S. Clin Infect Dis. 1996 Jul;23(1):211.

1070

Successful therapy for cerebral phaeohyphomycosis due to Dactylaria gallopava in a liver transplant recipient. Vukmir RB, Kusne S, Linden P, Pasculle W, Fothergill AW, Sheaffer J, Nieto J, Segal R, Merhav H, Martinez AJ. Clin Infect Dis. 1994 Oct;19(4):714-9.

A 68-year-old liver transplant recipient who was being treated with FK 506 and immunosuppressive steroid therapy was admitted to our medical center because of a tonic-clonic seizure. Computed tomography of the head revealed multiple discrete cerebral abscesses, and culture of fluid drained intraoperatively yielded a dematiaceous fungus. The isolate was susceptible to amphotericin B and itraconazole but was resistant to flucytosine and fluconazole. The patient was successfully treated with a prolonged course of amphotericin B colloidal dispersion and itraconazole, as evidenced by both clinical and radiographic resolution of disease over a 2-year follow-up.

1071

Phaeohyphomycosis caused by Dactylaria (human dactylariosis): report of a case with review of the literature. Kralovic SM, Rhodes JC. J Infect. 1995 Sep;31(2):107-13.

Phaeohyphomycosis due to Dactylaria (Ochroconis) spp. is a rare infection of man. It was first reported in 1986. All patients have had significant immunosuppression. To our knowledge, this is the second case of phaeohyphomycosis caused by Dactylaria constricta var. gallopava in a liver transplant patient and it developed even though he had been receiving fungal prophylaxis with fluconazole. Moreover, this case may represent nosocomial acquisition. In addition, we have reviewed the English language literature of previously reported patients with phaeohyphomycosis caused by Dactylaria spp.

1072

Subcutaneous abscesses caused by Ochroconis gallopavum. Fukushiro R, Udagawa S, Kawashima Y, Kawamura Y. J Med Vet Mycol. 1986 Jun;24(3):175-82.

A subcutaneous fungus infection that occurred in a patient with an acute myeloblastic leukemia was found to be caused by Ochroconis gallopavum (Dactylaria gallopava). In histological sections dematiaceous, septate hyphae were present. A darkly pigmented fungus was isolated on Sabouraud glucose medium. The mycological features of the causative agent were typical of O. gallopavum. The patient died after 6 months of treatment with antileukemic drugs and 5-fluorocytosine. At autopsy, tissue sections revealed leukemic infiltrates in most of the internal organs but fungal invasion was not detected.

1073

A case report of a dactylaria fungal infection in a lung transplant patient. Mazur JE, Judson MA. Chest. 2001 Feb;119(2):651-3.

Dematiaceous fungi such as Dactylaria gallopava are becoming more prevalent in transplant patients, with 50% of outcomes being fatal. In this report, we describe a 32-year-old woman who presented with swelling in the right shoulder area and right lateral neck. On further investigation with a CT scan, a fluid collection in the shoulder was identified, drained, and subsequently grew D gallopava. We report the successful treatment of an invasive Dactylaria infection in a lung transplant patient predominantly by medical chemotherapy, although surgical incision and drainage was performed on one of the fungal lesions.

1074

Multiple lung abscesses due to Ochroconis gallopavum, a dematiaceous fungus, in a nonimmunocompromised wood pulp worker. Odell JA, Alvarez S, Cvitkovich DG, Cortese DA, McComb BL. Chest. 2000 Nov;118(5):1503-5.

An occurrence of multiple chronic lung abscesses managed by lobectomy is described. These abscesses were present for 13 years in the patient, a nonimmunocompromised wood pulp worker. The patient had hemoptysis at presentation. The organism isolated was Ochroconis gallopavum, a dematiaceous fungus known to cause disease in immunocompromised patients and epidemic encephalitis in poultry. The fungus is typically found in warm environments and in decaying compost; for this reason, we postulate that his illness was occupationally acquired.

1075

Pulmonary infection due to Ochroconis gallopavum treated successfully after orthotopic heart transplantation. Jenney A, Maslen M, Bergin P, Tang SK, Esmore D, Fuller A. Clin Infect Dis. 1998 Jan;26(1):236-7.

1076

Dactylaria gallopava infection presenting as a pulmonary nodule in a single-lung transplant recipient. Burns KE, Ohori NP, Iacono AT. J Heart Lung Transplant. 2000 Sep;19(9):900-2.

We describe the first case of a pulmonary nodule caused by Dactylaria gallopava in a lung-transplant recipient. An asymptomatic lung-allograft recipient was found to have a 2-cm nodule in the native lung 450 days after transplantation. Culture of a transthoracic needle biopsy of the solitary pulmonary nodule revealed Dactylaria gallopava. Treatment was initiated with amphotericin B for a period of 21 days followed by oral itraconazole for an 8-month period.

1077

Dactylaria infection of a human being: pulmonary disease in a heart transplant recipient. Mancini MC, McGinnis MR. J Heart Lung Transplant. 1992 Jul-Aug;11(4 Pt 1):827-30.

We describe a case of pulmonary abscess caused by Dactylaria constricta in a heart transplant recipient. A 30-year-old man with a 1-month history of fever and cough was found by computed tomographic scan to have a cavitary lesion in the lingular segment in the upper lobe of his left lung. Culture of a needle biopsy specimen yielded a pure culture of D. constricta. The patient was successfully treated with systemic amphotericin B therapy, which resulted in resolution of the clinical symptoms and of the cavitary lesion.

1078

Disseminated Dactylaria gallopava infection in a diabetic patient with chronic lymphocytic leukemia of the T-cell type. Terreni AA, DiSalvo AF, Baker AS Jr, Crymes WB, Morris PR, Dowda H Jr. Am J Clin Pathol. 1990 Jul;94(1):104-7.

A 62-year-old male with a 20-year history of diabetes and three-year history of adult T-cell lymphocytic leukemia developed a systemic infection with Dactylaria gallopava. At autopsy the fungus was found in the brain, lungs, liver, spleen, and kidney. The organism has caused disease in chickens and turkey poults and has been found in chicken litter, hot springs, and the effluent of a thermonuclear reactor. This report documents the second human infection and the first case of disseminated human dactylariosis.

1079

Disseminated Dactylaria constricta infection in a renal transplant recipient. Malani PN, Bleicher JJ, Kauffman CA, Davenport DS. Transpl Infect Dis. 2001 Mar;3(1):40-3.

We report the case of a 32-year-old renal transplant recipient who developed disseminated Dactylaria constricta infection. The patient died despite treatment with amphotericin B, itraconazole, and fluconazole.

1084

Oidiodendron cerealis isolated from neurodermitis nuchae. Blomqvist K, Salonen A. Dermatologica. 1969;139(2):158-60.

1085

Ovadendron sulphureo-ochraceum endophthalmitis after cataract surgery. Lee BL, Grossniklaus HE, Capone A Jr, Padhye AA, Sekhon AS. Am J 1995 Mar;119(3):307-12.

PURPOSE: We examined an 82-year-old woman with delayed-onset endophthalmitis caused by an opportunistic pathogen, Ovadendron sulphureo-ochraceum. METHODS: Tissue obtained during vitrectomy was cultured and examined by light and electron microscopy. An enucleation specimen was examined by light microscopy. RESULTS: The patient had fungal endophthalmitis, with O. sulphureo-ochraceum present in the lens capsule. The eye developed a necrotizing scleritis secondary to O. sulphureo-ochraceum. The patient failed to respond to intravitreous, subconjunctival, and systemic amphotericin B, and the eye was enucleated. CONCLUSION: In this case of O. sulphureo-ochraceum as a human pathogen, the organism caused endophthalmitis after cataract extraction.

1094

Growing incidence of cutaneous and ungual infections by non-dermatophyte fungi at Jabalpur (M.P.). Naidu J. Indian J Pathol Microbiol. 1993 Apr;36(2):113-8.

A random survey of skin and nail infections was done at Jabalpur (M.P.). Out of the 80 suspected cases 60 were culture positive. Out of these 25 were of dermatophyte infection followed by 21 cases of phaeohyphomycosis, 7 of aspergillosis, 4 of hyalohyphomycosis, 2 of mixed infection in which a non-dermatophyte was associated with a dermatophyte and 1 had yeast infection. Trichophyton rubrum was the only dermatophyte isolated. Among the non-dermatophyte infections cases of Alternaria chlamydospora, Cladosporium sphaero-spermum, Curvularia senegalensis, Chaetomium globosum, Scopulariopsis brumptii, Paecilomyces variotii and Aspergillus chevalieri are for the first time documented as etiologic agent of cutaneous and ungual mycosis from India.

1095

Paecilomyces variotii. An unusual cause of isolated sphenoid sinusitis. Thompson RF, Bode RB, Rhodes JC, Gluckman JL. Arch Otolaryngol Head Neck Surg. 1988 May;114(5):567-9.

Isolated fungal sphenoid sinusitis is an unusual head and neck infection. We describe the first reported case (to our knowledge) of Paecilomyces variotii sphenoid sinusitis. In addition, it represents one of the few reported cases of isolated fungal sphenoid sinusitis. Diagnosis and management of this condition are described. Aggressive surgical management is advocated when fungal sphenoid sinusitis is suspected.

1096

Paecilomyces fungus infection of the paranasal sinuses. Nayak DR, Balakrishnan R, Nainani S, Siddique S. Int J Pediatr Otorhinolaryngol. 2000 Apr 15;52(2):183-7.

Fungal infections caused by Paecilomyces species are very rare and occur in adult patients with impaired host defences or following foreign body implants. They are found worldwide in soil and decaying vegetation. We describe a case of an 8 year old child who came with complaints of left sided nasal obstruction and discharge, telecanthus, diplopia and epiphora. On examination and investigation he had pansinusitis caused by P. lilacinus. An endoscopic sinus surgery was done and the patient was on oral Itraconazole for 6 months. To our knowledge, this is the first case reported in the paediatric age group.

1097

Complicated soft tissue infection with prepatellar bursitis caused by Paecilomyces lilacinus in an immunocompetent host: case report and review. Westenfeld F, Alston WK, Winn WC. J Clin Microbiol. 1996 Jun;34(6):1559-62.

Documented Paecilomyces lilacinus infections are quite rare. Most reports involve immunocompromised patients or implanted objects. We report the first case of complicated soft tissue infection caused by P. lilacinus in an immunocompetent host. The spectrum of infections involving this fungus is reviewed.

1098

Paecilomyces pyelonephritis complicating nephrolithiasis and review of Paecilomyces infections. Sherwood JA, Dansky AS. J Urol. 1983 Sep;130(3):526-8.

We report a case of Paecilomyces variotii isolated from the renal pelvis at ureterolithotomy. The patient presented with nephrolithiasis, acute flank pain, fever and pyuria, which resolved postoperatively. Paecilomyces has infected the cornea, prosthetic lens implants, lacrimal sac, maxillary sinuses, prosthetic mitral and aortic valves, skin and a ventriculoperitoneal shunt.

1099

Paecilomyces marquandii cellulitis in a kidney transplant patient. Naldi L, Lovati S, Farina C, Gotti E, Cainelli T. Br J Dermatol. 2000 Sep;143(3):647-9.

1100

Paecilomyces lilacinus cellulitis in an immunocompromised patient. Jade KB, Lyons MF, Gnann JW Jr. Arch Dermatol. 1986 Oct;122(10):1169-70.

Paecilomyces lilacinus, a saprophytic soil fungus, is an uncommon human pathogen. An immunocompromised patient developed a deep cellulitis due to P lilacinus. The infection responded poorly to intravenous amphotericin B but eventually resolved after combination therapy with amphotericin B and flucytosine (5-fluorocytosine). Previous in vitro studies have suggested that miconazole is the most active antifungal agent against P lilacinus.

1101

Chronic suppurative otitis media caused by Paecilomyces variotii. Dhindsa MK, Naidu J, Singh SM, Jain SK. J Med Vet Mycol. 1995 Jan-Feb;33(1):59-61.

A case of chronic suppurative otitis media is described in a patient with a chronic cold and cough. The presenting symptoms were otorrhoea, perforation of the tympanic membrane and granulation in the air cells of the left mastoid cavity. X-ray showed sclerotic mastoid and partial cellular obliteration. Histologic sections revealed aggregated fungal masses, filamentous hyphae and single-celled structures of Paecilomyces variotii. The infection responded to topical ketoconazole therapy. This is the first reported case of chronic suppurative otitis media caused by P. variotii.

1102

Paecilomyces javanicus endocarditis of native and prosthetic aortic valve. Allevato PA, Ohorodnik JM, Mezger E, Eisses JF. Am J Clin Pathol. 1984 Aug;82(2):247-52.

A 41-year-old diabetic woman developed endocarditis of the aortic valve caused by Paecilomyces javanicus six years after insertion of a porcine mitral valve heterograft. The patient died shortly after aortic valve replacement. Autopsy revealed vegetations of the aortic heterograft, valve ring abscess and ascending aortitis due to Paecilomyces. There was no involvement of the mitral valve heterograft. Lesions due to mycotic emboli were found in the kidneys, spleen, and brain. Cultures of the surgically removed aortic valve and of the kidney at autopsy produced rapid growth of P. javanicus. The gross and microscopic pathologic and cultural characteristics of this organism are described with a review of the literature. Previously reported cases of Paecilomyces endocarditis occurred only in prosthetic heart valves. This is the first known report of P. javanicus endocarditis of a native valve and its prosthetic heart valve heterograft.

1103

Infective endocarditis caused by Paecilomyces varioti. Kalish SB, Goldschmidt R, Li C, Knop R, Cook FV, Wilner G, Victor TA. Am J Clin Pathol. 1982 Aug;78(2):249-52.

The first reported case of Paecilomyces varioti endocarditis occurring on a porcine heterograft prosthesis is presented and the clinical and pathological features described in the four previously reported cases of prosthetic valvular endocarditis caused by this organism are reviewed. In each case, infection became apparent more than two months after cardiac surgery. Three of the four patients with infected aortic prosthesis developed outflow obstruction secondary to valvular vegetations. All patients died regardless of medical or surgical intervention. Appropriate therapy remains unknown.

1104

Multifocal osteomyelitis caused by Paecilomyces varioti in a patient with chronic granulomatous disease. Cohen-Abbo A, Edwards KM. Infection. 1995 Jan-Feb;23(1):55-7.

This report describes an 18-year-old male patient with chronic granulomatous disease who developed cutaneous nodules and multifocal osteomyelitis with the saprophytic fungus Paecilomyces varioti. After several biopsies the organism was identified. Anti-fungal susceptibility testing was performed. Combination therapy with amphotericin B and gamma-interferon followed by long-term therapy with itraconazole and gamma-interferon resulted in a clinical response.

1105

Cerebral Paecilomyces javanicus infection. An ultrastructural study. Ho KL, Allevato PA, King P, Chason JL. Acta Neuropathol (Berl). 1986;72(2):134-41.

A 41-year-old diabetic woman developed Paecilomyces javanicus endocarditis and subsequent cerebral fungal embolism and vasculitis with massive infarction and hemorrhage 6 years after a mitral valve replacement with porcine heterograft. The organism was identified by the culture from the infected brain tissue and aortic valve. Cerebral infection due to fungus Paecilomyces is rare. This report documents the cerebral manifestations of fungus Paecilomyces javanicus and describes for the first time the ultrastructure of such an organism obtained from the infected tissue. Their ultrastructural findings, similar to those described in Paecilomyces farinosus derived from culture, include a double-layered cell wall, a triple unit plasma membrane, abundant cytoplasmic lipid droplets, vacuoles, membranous profiles and septal formation. This report further demonstrates hyphae with packed 50A filaments and granulofibrillary material and features suggestive of intrahyphal hyphae, not previously described in fungus Paecilomyces.

1106

Lung abscess caused by Paecilomyces lilacinus. Ono N, Sato K, Yokomise H, Tamura K. Respiration. 1999;66(1):85-7.

We report the case of a 57-year-old man who was referred to our department for further investigation of an abnormal chest shadow. Radiography on admission demonstrated a coin lesion in the right hilum. To make a final diagnosis, right middle lobectomy was performed and the mass was revealed to be a fungal abscess. Further examination confirmed that the fungus was Paecilomyces lilacinus. This is the first reported case of lung abscess caused by P. lilacinus in an otherwise healthy person.

1107

Paecilomyces varioti pneumonia in a patient with diabetes mellitus. Byrd RP Jr, Roy TM, Fields CL, Lynch JA. J Diabetes Complications. 1992 Apr-Jun;6(2):150-3.

Paecilomyces is a saprophytic soil fungus that is an uncommon human pathogen. We report a diabetic patient who developed an upper lobe pulmonary infection due to Paecilomyces varioti. This pneumonia responded poorly to oral imidazole therapy with ketoconazole. Eventual treatment of the chronic infiltrating process required administration of intravenous amphotericin B. This experience emphasizes the potential pathologic nature of this fungus when immunity is compromised by poorly controlled diabetes.

1108

Progressive cutaneous hyalohyphomycosis due to Paecilomyces lilacinus: rapid response to treatment with caspofungin and itraconazole. Safdar A. Clin Infect Dis. 2002 May 15;34(10):1415-7.

A case of rapidly progressive cutaneous infection due to Paecilomyces lilacinus developed in a woman with advanced pancreatic cancer who did not have granulocytopenia. The infection responded favorably to caspofungin and itraconazole combination therapy.

1109

Case report. Successful treatment of cutaneous Paecilomyces lilacinus infection with oral itraconazole in an immune competent host. Gottlieb T, Atkins BL. Mycoses. 2001 Dec;44(11-12):513-5.

A 59-year-old woman presented to us with an eight-month history of Paecilomyces lilacinus soft tissue infection. She was treated with a six-month course of oral itraconazole. The lesion resolved fully without the need for adjunctive surgery. Susceptibility testing confirmed susceptibility to itraconazole. This is the second case of confirmed P. lilacinus soft tissue infection in an immunocompetent host treated with oral itraconazole alone.

1110

Cutaneous hyalohyphomycosis caused by Paecilomyces lilacinus in a renal transplant patient. Blackwell V, Ahmed K, O'Docherty C, Hay RJ. Br J Dermatol. 2000 Oct;143(4):873-5.

We describe a renal transplant recipient with cutaneous hyalohyphomycosis due to Paecilomyces lilacinus and highlight the increasing importance of such opportunistic fungal infections in immunosuppressed patients.

1111

Cutaneous hyalohyphomycosis caused by Paecilomyces lilacinus in an immunocompetent host successfully treated with itraconazole: case report and review. Gutiérrez-Rodero F, Moragón M, Ortiz de la Tabla V, Mayol MJ, Martín C. Eur J Clin Microbiol Infect Dis. 1999 Nov;18(11):814-8.

Paecilomyces lilacinus is an emerging fungal pathogen that is highly resistant to many antifungal drugs. Skin and subcutaneous soft tissue infections caused by this organism are very unusual. Most cases occur in patients with impaired host defenses or following surgical procedures. There has been only one previous report of a histologically confirmed cutaneous infection due to Paecilomyces lilacinus in a patient without predisposing factors. Described here is the second histopathologically proven case of Paecilomyces lilacinus cutaneous infection in a healthy patient without any apparent portal of entry. Prolonged antifungal chemotherapy with itraconazole led to resolution of the skin lesion. This case of sporadic cutaneous infection due to Paecilomyces lilacinus is believed to be the first reported in Europe and the first histopathologically proven case successfully treated with itraconazole.

1112

Outbreak of invasive mycoses caused by Paecilomyces lilacinus from a contaminated skin lotion. Orth B, Frei R, Itin PH, Rinaldi MG, Speck B, Gratwohl A, Widmer AF. Ann Intern Med. 1996 Nov 15;125(10):799-806.

BACKGROUND: Invasive mycoses are an important cause of illness and death in immunocompromised patients. Infections with molds other than aspergilli have been increasingly seen in patients with hematologic cancers, but epidemics of these infections have not yet been reported. OBJECTIVE: To describe an outbreak of invasive mycoses with Paecilomyces lilacinus in severely neutropenic patients. DESIGN: An outbreak investigation. SETTING: The hematology-oncology isolation and bone marrow transplantation unit of the University Hospital, Basel, Switzerland. PATIENTS: 25 consecutive patients admitted between 17 August 1993 (the date of the first manifestation of P. lilacinus infection) and 31 October 1993 (when the unit was closed). MEASUREMENTS: Clinical and microbiological data, including histologic findings; cultures from several patient sites; and environmental examinations of potential airborne, parenteral, enteric, and horizontal routes of transmission. Infections were defined by the isolation of P. lilacinus from clinically evident skin eruptions. RESULTS: 12 of the 25 patients (48%) were infected or colonized. Nine patients (36%), including all bone marrow transplant recipients, had documented invasive P. lilacinus infections. All 9 infected patients had papular, pustular, or necrotic skin eruptions. Two patients with severe graft-versus-host disease died with refractory fungal disease; 1 also had microbiologically documented endophthalmitis and kidney infiltrates. Seven affected patients no longer had P. lilacinus after recovery of bone marrow function. The organism was resistant in vitro to amphotericin B, itraconazole, and fluconazole. Patients did not respond clinically to these agents. The outbreak was ultimately traced to a contaminated, commercially available, pharmaceutically prepared skin lotion. The outbreak ended after the skin lotion was recalled and has not recurred after a follow-up period of 2 years. CONCLUSION: Contaminated skin lotion is a potential cause of opportunistic fungal infections in immunocompromised hosts. Paecilomyces lilacinus is a common saprophytic mold that can cause, by direct cutaneous inoculation, invasive infections associated with illness and death.

1113

Paecilomyces lilacinus fungemia in an adult bone marrow transplant recipient. Chan-Tack KM, Thio CL, Miller NS, Karp CL, Ho C, Merz WG. Med Mycol. 1999 Feb;37(1):57-60.

Paecilomyces lilacinus is a rare fungal pathogen in humans. We report a case of fungemia caused by P. lilacinus in a non-neutropenic adult, 120 days after bone marrow transplant. The patient's primary risk factor was the presence of an indwelling vascular catheter. Her initial clinical course was characterized by fever, chills, and rigors. Blood cultures from the central line and peripheral veins were positive, as was a peripheral specimen drawn after removal of the catheter. Two initial peripheral specimens were positive for P. lilacinus only by blind subculture and/or sustained incubation. She developed peripheral pulmonary nodules following the fungemia, thus raising the possibility of disseminated disease, but definitive diagnosis was confounded by Pseudomonas bacteremia. The nodules cleared and she recovered following removal of the central line and treatment with amphotericin B and 5-fluorocytosine, despite in vitro resistance to these antifungal drugs. This case underscores the increasing importance of P. lilacinus as a human pathogen capable of producing disease in immunocompetent, as well as in immunocompromised hosts. Also of note is that blood culture systems may require extended incubation or subcultures in order to detect fungi.

1114

Paecilomyces varioti fungemia in a bone marrow transplant patient. Shing MM, Ip M, Li CK, Chik KW, Yuen PM. Bone Marrow Transplant. 1996 Feb;17(2):281-3.

Paecilomyces varioti, a fungus resembling penicillium spp, has been described in conjunction with impaired host defence or foreign body implants. We report a case of Paecilomyces varioti catheter-related fungemia that occurred during neutropenia in an allogeneic BMT patient receiving antifungal prophylaxis with fluconazole. Successful treatment was achieved by removal of central venous catheter, intravenous amphotericin B and oral itraconazole.

1115

Paecilomyces lilacinus catheter-related fungemia in an immunocompromised pediatric patient. Tan TQ, Ogden AK, Tillman J, Demmler GJ, Rinaldi MG. J Clin Microbiol. 1992 Sep;30(9):2479-83.

Paecilomyces lilacinus catheter-related fungemia in an immunocompromised child is reported. The presence of a central venous catheter and the patient's immunocompromised status were felt to be predisposing factors for this unusual infection. To our knowledge, this is the first description of P. lilacinus catheter-related fungemia, and our patient may be the youngest reported patient with this mycosis who was cured.

1119

Ocular and central nervous system paracoccidioidomycosis in a pregnant woman with acquired immunodeficiency syndrome. Luiz V; Belfort, Rubens Jr. Finamor LP, Muccioli C, Martins MC, Rizzo LV, Belfort R Jr. Am J Ophthalmol. 2002 Sep;134(3):456-9.

PURPOSE: To describe an atypical case of central nervous system and ocular paracoccidioidomycoses simulating ocular toxoplasmosis in a pregnant woman with acquired immunodeficiency syndrome (AIDS). DESIGN: Interventional case report. METHODS: Case report. RESULTS: A 25-year-old pregnant woman with AIDS, presented with a severe ocular inflammation in the right eye involving the choroid, retina, and the optic disk, which rapidly progressed to retinal detachment, iris neovascularization, and neovascular glaucoma. The left eye was normal. Magnetic resonance imaging (MRI) showed a focal hypodense contrast-enhanced ring lesion in the brain. Serum antibody titers were negative for Toxoplasma gondii, but the polymerase chain reaction was positive for the parasite in the vitreous sample. The patient responded partially to specific treatment for toxoplasmosis, and there was a small reduction in size of the brain lesion. She progressed to a blind painful eye, which was enucleated. Paracoccidioides brasiliensis was found in the histopathological studies of the eye and oropharynx. With the diagnosis of disseminated ocular paracoccidioidomycoses, the patient was treated with trimethoprim-sulfamethoxazole with a satisfactory outcome and reduction in size of the brain lesion. CONCLUSION: Although ocular infection with ocular paracoccidioidomycoses is rare, this diagnosis should be considered when investigating ocular inflammation in a patient with AIDS.

1120

The pathobiology of Paracoccidioides brasiliensis. Borges-Walmsley MI, Chen D, Shu X, Walmsley AR. Trends Microbiol. 2002 Feb;10(2):80-7.

Paracoccidioides brasiliensis causes one of the most prevalent systemic mycoses in Latin America--paracoccidioidomycosis. It is a dimorphic fungus that undergoes a complex transformation in vivo, with mycelia in the environment producing conidia, which probably act as infectious propagules upon inhalation into the lungs, where they transform to the pathogenic yeast form. This transition is readily induced in vitro by temperature changes, resulting in modulation of the composition of the cell wall. Notably, the polymer linkages change from beta-glucan to alpha-glucan, possibly to avoid beta-glucan triggering the inflammatory response. Mammalian oestrogens inhibit this transition, giving rise to a higher incidence of disease in males. Furthermore, the susceptibility of individuals to paracoccidioidomycosis has a genetic basis, which results in a depressed cellular immune response in susceptible patients; resistance is conferred by cytokine-stimulated granuloma formation and nitric oxide production. The latency period and persistence of the disease and the apparent lack of efficacy of humoral immunity are consistent with P. brasiliensis existing as a facultative intracellular pathogen.

1121

metropolitan area of Rio de Janeiro. Nogueira SA, Guedes AL, Wanke B, Capella S, Rodrigues K, Abreu TF, Morais JC, Lambert JS. J Trop Pediatr. 2001 Oct;47(5):311-5.

The authors describe a case of paracoccidioidomycosis in a 7-year-old girl from the city of Rio de Janeiro who initially presented to her physician with a lesion in her calcaneous which was misdiagnosed and treated as bacterial osteomyelitis. Later, cutaneous manifestations, lymph node enlargement, and hepatosplenomegaly developed and biopsy of the skin and cervical lymph nodes showed the fungus which was also present in the sputum. It is emphasized that Paracoccidioides brasiliensis can be the cause of bone lesions in endemic areas of Latin America and that response to treatment with amphotercin B is good.

1122

Paracoccidioidomycosis of the central nervous system: case report] da Silva CE, Cordeiro AF, Gollner AM, Cupolilo SM, Quesado-Filgueiras M, Curzio MF. Arq Neuropsiquiatr. 2000 Sep;58(3A):741-7.

The involvement of the central nervous system in paracoccidioidomycosis is more frequent than previously thought. The first reference to the possibility that Paracoccidioides brasiliensis could affect the central nervous system was by Pereira & Jacobs in 1919. Since then, a great number of other studies has showed this form of clinical behavior and, in some of them, the frequency has ranged 27.27%. We report a clinical case of a 34-year-old white Brazilian woman admitted because of bacterial pneumonia. In the sixth day of admission, the patient developed cerebellar symptomatology with nausea, vomiting, dysmetria and gait disturbance. Central nervous system computer tomographic scanning disclosed a hypodense lesion in the right cerebellar hemisphere. The patient was submitted to surgery with total excision of the lesion. Histopathological examination confirmed the diagnosis of neuroparacoccidioidomycosis. Coadjuvant treatment with sulfamethoxazole-trimetoprim was introduced. The patient had a good outcome and was discharge 30 days after surgery.

1123

Endemic regions of paracoccidioidomycosis in Brazil: a clinical and epidemiologic study of 584 cases in the southeast region. Blotta MH, Mamoni RL, Oliveira SJ, Nouér SA, Papaiordanou PM, Goveia A, Camargo ZP. Am J Trop Med Hyg. 1999 Sep;61(3):390-4.

This paper describes the clinical-seroepidemiologic characteristics of patients with paracoccidioidomycosis (PCM) who visited the University Hospital at the State University of Campinas (Campinas, Sao Paulo, Brazil). The study group consisted of 584 individuals (492 males and 92 females) with ages ranging from 5 to 87 years. The highest incidence of the disease occurred between the ages of 41 and 50 years for men and between 11 and 40 years for women. Rural activities were the principal occupation of 46% of the patients. The diagnosis was confirmed by histopathologic examination and demonstration of fungus in scrapings, secretions, or in the sputum. Serologic test results for PCM were positive in 80% of the 584 patients studied. The significant number of patients, including 33 children less than 14 years old, indicates the presence of the fungus in the area and that this region is an important endemic area for PCM.

1124

Paracoccidioidomycosis. Bethlem EP, Capone D, Maranhao B, Carvalho CR, Wanke B. Curr Opin Pulm Med. 1999 Sep;5(5):319-25.

Paracoccidioidomycosis is a systemic infection caused by the dimorphic fungus Paracoccidioides brasiliensis. It is commonly an endemic disease in Latin America, but several cases have been reported outside this area, particularly now in this time of world globalization. Primary pulmonary infection occurs commonly in the first and second decades of life and usually has a benign, self-limited respiratory infection course. The adult chronic manifestation of the disease is usually the result of reactivation of quiescent lesions with diffuse lung infiltrates, predominately of the interstitial pattern, with or without involvement of various other organs. The finding of this disease in a patient is an important step for the large differential diagnosis of the interstitial lung diseases group.

1125

Palpebral paracoccidioidomycosis. Burnier SV, Sant'Anna AE. Mycopathologia. 1997;140(1):29-33.

This paper describes two cases of eyelid paracoccidioidomycosis (South American blastomycosis) in which it was the first signal of the disease. In both cases the first clinical diagnosis made was not a fungal infection, but a neoplastic disease that was not confirmed by the pathology study. In the first patient we suspected a primary infection on the eyelid, because there was no other systemic signs of the disease, and in the second patient we noted a very advanced pulmonary lesions caused by the Paracoccidioides brasiliensis. We believe that, in endemic areas, the histopathological study should be made before every excisional procedures to avoid unnecessary palpebral mutilation.

1126

Paracoccidioidoma: case record and review. dos Santos JW, Michel GT, Londero AT. Mycopathologia. 1997;137(2):83-5.

A case of solitary pulmonary paracoccidioidal lesion-paracoccidioidoma-is related. It is the first reported case in Brazil. The literature on spontaneously regressive lesion of paracoccidioidomycosis is commented upon.

1153

Penicillium marneffei infection and solitary pulmonary nodule. Chang C, Chan CK, Chow KC, Lam CW. Hong Kong Med J. 1998 Mar;4(1):59-62.

We report on a patient infected with human immunodeficiency virus who presented with fever, a solitary pulmonary nodule, and cervical lymphadenopathy. The diagnosis of Penicillium marneffei infection was made from an excisional lymph node biopsy and a sputum culture. The microbiology, pathology, diagnosis, and treatment of the case are discussed. A high level of clinical suspicion is necessary for making an early diagnosis and improving the outcome of infection.

1154

Fatal Penicillium citrinum pneumonia with pericarditis in a patient with acute leukemia. Mok T, Koehler AP, Yu MY, Ellis DH, Johnson PJ, Wickham NW. J Clin Microbiol. 1997 Oct;35(10):2654-6.

We report here a case of fatal Penicillium citrinum infection. The patient, who suffered from acute myeloid leukemia, developed signs and symptoms typical of fungal pneumonia and pericardial tamponade after undergoing standard induction chemotherapy. Despite attaining complete remission of her leukemia, the patient succumbed 8 weeks after presentation. At autopsy, multiple nodular cavitary pulmonary lesions with invasion by fungal hyphae were found. Pericardial and lung tissue obtained at autopsy grew P. citrinum, a fungus ubiquitous in the environment but seldom reported as a pathogen. The microbiological findings were consistent with the histopathological features and confirmed this as a case of true P. citrinum infection causing fatal pulmonary and pericardial complications in an immunocompromised host.

1155

Unusual lung mycosis: Penicillium++ marneffei infection] Breton P, Bani Sadr F, Germaud P, Leautez S, Morin O, Raffi F. Rev Pneumol Clin. 1998 May;54(2):85-7.

We report an uncommon radiographic finding which led to the diagnosis of Penicillium marneffei pulmonary mycosis in an HIV positive woman. The patient who lived in France had travelled several times to her native country. Thailand, prior to the development of fever, weight loss, skin lesions with a macular aspect around the umbilicus. The chest x-ray demonstrated non-excavated round opacities. Penicillium marneffei was isolated from alveolar lavage fluid and blood samples. This rare fungus is usually found in immunodepressed subjects, especially HIV+ patients (CD4 < 50) should be suspected in subjects who have travelled to endemic zones (Southeast Asia). Penicillium marneffei is considered as a criteria for AIDS. P. marneffei is the only dimorphic member of the Penicillium genus and has a particular affinity for the reticuloendothelial system. Clinical manifestations vary, usually with skin lesions. Mycology diagnosis is usually made on blood samples as well as alveolar lavage or pleural fluids. Antifungals (amphotericin B. itraconazole, ketoconazole) are generally effective but the risk of relapse underlines the importance of secondary prophylaxis in immunodepressed subjects.

1156

Imported penicilliosis marneffei in the United States: report of a second human infection. Pautler KB, Padhye AA, Ajello L. Sabouraudia. 1984;22(5):433-8.

The first natural infection due to Penicillium marneffei in a human was reported in the United States in 1973. We describe a second case of penicilliosis marneffei that was diagnosed in Florida. In both instances, the patients had a history of travel in Southeast Asia where P. marneffei is endemic. The Florida patient had recurrent episodes of hemoptysis attributed to bronchitis and bronchiectasis. In spite of therapy with various antibacterial antibiotics for tuberculosis, the granulomatous lesions in the left upper lobe of the lungs persisted. The diagnosis of penicilliosis marneffei was established by isolating and identifying the dimorphic species of Penicillium, P. marneffei. The histopathologic features of the lung tissue included granulomata with central areas of necrosis and neutrophilic infiltration with many yeast-like, tissue-form cells of P. marneffei, which multiplied by a fission rather than a budding process.

1157

[Onychopathy due to Penicillium (green nails): topical treatment with econazole nitrate] Rotoli M, Capizzi R, Tulli A. G Ital Dermatol Venereol. 1982 May-Jun;117(3):XV-XVII

1158

A case of invasive penicilliosis in Hong Kong with immunologic evaluation. So SY, Chau PY, Jones BM, Wu PC, Pun KK, Lam WK, Lawton JW. Am Rev Respir Dis. 1985 Apr;131(4):662-5.

A 53-yr-old Chinese sailor developed prolonged pyrexia with unresolved lobar pneumonia, cervical lymphadenopathy, generalized subcutaneous abscesses, and pericardial effusion. Penicillium marneffei was isolated from pericardial fluid and subcutaneous pus and was demonstrated on histologic sections of lymph nodes and lung tissue. The penicilliosis was treated successfully with amphotericin B, ketoconazole, and 5-fluorocytosine. Subsequently, he also developed other T-lymphocyte-related opportunistic infections such as disseminated cutaneous herpes zoster and chronic osteomyelitis of sternum caused by Salmonella typhimurium. He was also a chronic carrier of cytomegalovirus. Further investigations showed that he had persistent depression of T-lymphocyte function and enhancement of B-lymphocyte activity, the cause of which was undetermined.

1159

Cutaneous manifestations of disseminated Penicillium marneffei mycosis in five HIV-infected patients. Chiewchanvit S, Mahanupab P, Hirunsri P, Vanittanakom N. Mycoses. 1991 May-Jun;34(5-6):245-9.

Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Thailand.

Five cases of disseminated Penicillium marneffei mycosis of Thai HIV patients, presented between November 1990 and April 1991, have been investigated. All patients were male and had bone marrow involvement. They showed mucocutaneous lesions with papules predominantly on the faces and upper extremities (5 cases), palatal papules (3 cases), and chronic genital ulcer (2 cases). P. marneffei was cultured, and the specific tissue form of the fungus was demonstrated histopathologically from skin and bone marrow specimens. In future, with increasing awareness of mucocutaneous lesions, disseminated penicilliosis in HIV-infected patients might be diagnosed sooner, thus leading to earlier therapy and better prognosis of the disease.

1160

Case report: cutaneous penicilliosis due to Penicillium chrysogenum. López-Martínez R, Neumann L, González-Mendoza A. Mycoses. 1999;42(4):347-9.

A case of cutaneous penicilliosis in a young man, without immunological compromise is reported. The lesions in the neck were characterized by two exudative reddish-purple pruriginous and painless spots. Penicilliosis was diagnosed after serial laboratory studies based on the observation of hyphae by direct microscopic examination and histopathology. Cultures of the tissue obtained from the lesions, developed mould colonies with typical conidia of Penicillium chrysogenum, which was thermotolerant at 37 degrees C. The treatment with itraconazole was successful, and 15 days after cessation of therapy, no recurrence of infection was observed. The epidemiology of this type of mycosis is commented upon, as well as the rarity of infections produced by Penicillium, even as opportunistic pathogens. The isolation of P. chrysogenum from skin lesions is exceptional.

1161

Case report. Fungaemia due to Penicillium piceum, a member of the Penicillium marneffei complex. Horré R, Gilges S, Breig P, Kupfer B, de Hoog GS, Hoekstra E, Poonwan N, Schaal KP. Mycoses. 2001 Dec;44(11-12):502-4.

Due to the inability of most Penicillium species to grow at 37 degrees C, systemic non-marneffei infections are very rare in the human host. We describe a case of fungemia due to Penicillium piceum in a female patient, who died a few days after repeated isolation of this fungus from blood cultures. The species is a member of the section Biverticillata of Penicillium, as was confirmed by rDNA Internal Transcribed Spacer (ITS) sequence data, and hence may share virulence factors with P. marneffei.

1162

Systemic Penicillium marneffei infection in a child with common variable immunodeficiency. Lin WC, Dai YS, Tsai MJ, Huang LM, Chiang BL. J Formos Med Assoc. 1998 Nov;97(11):780-3.

Penicillium marneffei is rarely pathogenic in humans. Most previously reported cases of P. marneffei infection were from Southeast Asia where patients were usually in an immunocompromised state due to human immunodeficiency virus (HIV) infection. The majority of the patients reported in Western countries were immunocompromised by malignancy, especially Hodgkin's lymphoma. In Taiwan, the first case of P. marneffei infection was reported in 1994 and involved an adult with HIV infection. We report a case of systemic P. marneffei infection in a child with common variable immunodeficiency (CVID). The patient, a 4-year, 5-month-old boy, had a 1-year history of oligoarthritis resembling juvenile rheumatoid arthritis (JRA). He developed a low grade fever (38 degrees C) and hepatosplenomegaly 1 month before admission to the hospital. Although cultures of synovial fluid obtained at the time of onset of oligoarthritis did not grow any organisms, cultures of blood, bone marrow, synovial fluid, and lymph node biopsy samples taken during this admission were positive for P. marneffei. Further immunologic studies revealed a profile characteristic of CVID. The fungal infection was finally eradicated by combined therapy with amphotericin B, fluconazole, itraconazole, and regular immunoglobulin replacement. This case reminds us that JRA or JRA-like arthritis should be differentiated from septic arthritis caused by rare pathogens in immunocompromised patients.

1163

Penicillium marneffei fungemia in an AIDS patient: the first case report in Taiwan. Chiang CT, Leu HS, Wu TL, Chan HL. Changgeng Yi Xue Za Zhi. 1998 Jun;21(2):206-10.

We report a 36-year-old man with acquired immunodeficiency syndrome (AIDS), presenting systemic Penicillium marneffei (PM) infection. Fungal culture from the blood isolated PM. PM-induced enteritis was also suspected in this patient although there was no direct evidence. He also had other manifestations of immunocompromised status, including military tuberculosis and oral candidiasis. He died of respiratory failure in spite of prompt treatment for infection. This is the first confirmed case of PM infection in Taiwan.

1164

Systemic infection caused by Penicillium decumbens in a patient with acquired immunodeficiency syndrome. Alvarez S. J Infect Dis. 1990 Jul;162(1):283.

1165

Penicillium marneffei osteomyelitis. Chan YF, Woo KC. J Bone Joint Surg Br. 1990 May;72(3):500-3.

We report a case of systemic Penicillium marneffei infection in a Chinese woman who presented with multiple osteolytic lesions and radiographic changes similar to those seen in other fungal osteomyelitides. This infection is often misdiagnosed as tuberculosis and has a high mortality rate. The correct diagnosis is important since early antifungal therapy is life-saving.

1166

A case of Penicillium marneffei osteomyelitis involving the axial skeleton. Pun TS, Fang D. Hong Kong Med J. 2000 Jun;6(2):231-3.

Fungal infection of bone by Penicillium marneffei is rare. We report on a case of Penicillium marneffei infection in a Filipino woman, which involved multiple soft-tissue abscesses and infection of the axial skeleton. Early diagnosis and treatment of this potentially reversible disease is emphasised. Such an approach is essential to prevent bony destruction from becoming too advanced and, more importantly, to prevent any damage to the spinal cord from occurring.

1167

Fungal infections of ear with special reference to chronic suppurative otitis media. Talwar P, Chakrabarti A, Kaur P, Pahwa RK, Mittal A, Mehra YN. Mycopathologia. 1988 Oct;104(1):47-50.

Fungus were found to take important role in ear infections of the 344 patients (CSOM 286, Otomycosis 44, Otitis externa 14), significant fungal infections (with positive smear and culture) were detected on 49%, 79.5%, 66.6% patients respectively. 84.8% patients were detected both by smear and culture, 14.1% patients by culture and 0.1% patients in smear preparation only. In CSOM patients, age predominated in 20-27 yrs group, sex in male below 30 yrs, and Aspergillus flavus, A. niger, Penicillium, A. fumigatus in mycelial fungus, Candida albicans, C. parapsillosis in yeast. But in 18 post antibiotic fungus infected patients Penicillium and A. niger were the important isolates. In otomycosis and otitis externa patients A. niger took the main role.

1168

Fatal necrotizing esophagitis due to Penicillium chrysogenum in a patient with acquired immunodeficiency syndrome. Hoffman M, Bash E, Berger SA, Burke M, Yust I. Eur J Clin Microbiol Infect Dis. 1992 Dec;11(12):1158-60.

Although blue-green molds of the genus Penicillium are ubiquitous in the human environment, invasive penicilliosis is uncommon and primarily encountered among immunosuppressed patients. A patient with HIV infection who died of severe necrotizing esophagitis caused by Penicillium chrysogenum is reported and the relevant English language literature on human penicilliosis is reviewed. Although infectious esophagitis is commonly associated with AIDS, Penicillium esophagitis has not been described in such patients.

1169

Successful management of Penicillium endocarditis. DelRossi AJ, Morse D, Spagna PM, Lemole GM. J Thorac Cardiovasc Surg. 1980 Dec;80(6):945-7.

Penicillium endocarditis involving an aortic valvular tissue prosthesis (Ionescu-Shiley) was successfully managed. This is the fourth reported case of Penicillium endocarditis, and the first survivor. A review of the literature shows that this fungus is ubiguitous though rarely pathogenic. The management of this rare type of infection is outlined.

1174

Phaeomycotic cyst caused by Phaeoacremonium parasiticum] Kitamura K, Mochizuki T, Ishizaki H, Fukushiro R. Nippon Ishinkin Gakkai Zasshi. 2000;41(2):89-95.

Division of Dermatology, Kanazawa National Hospital, Kanazawa, Ishikawa, Japan.
Phaeoacremonium parasiticum was identified as the causative agent of a phaeomycotic cyst seen just below the right knee of a 59-year-old healthy woman. She had no history of trauma. Direct KOH examination of the pus aspirated from the subcutaneous nodule revealed abundant mycelia, which were not too deeply brown in color. The nodule was surgically excised, and there was no recurrence during a half year of observation. Tissue section of the excised material revealed rather a large cavity extending from the cutis to the subcutis. The cavity had a thick wall composed of granulomatous tissues. Mycelial and yeast-like fungal elements were seen within the cavity and the granulomatous tissues. A dematiaceous fungus was cultured from both pus and the excised material. The isolates were characterized by a dark green to black colony, unbranched or infrequently branched, brownish conidiophores bearing an aculeate monophialide with a narrow funnel-shaped collarette, and slimy, hyaline, one-celled, ellipsoid to allantoid conidia.

1175

Subcutaneous phaeohyphomycosis caused by Phaeoacremonium rubrigenum in an immunosuppressed patient. Matsui T, Nishimoto K, Udagawa S, Ishihara H, Ono T. Nippon Ishinkin Gakkai Zasshi. 1999;40(2):99-102.

BACKGROUND: Phaeohyphomycosis refers to infection by dematiaceous fungi with pigmented hyphae or yeast-like cells in the tissue. In humans, this disease is usually considered to be an opportunistic infection. The causal agents of phaeohyphomycosis include numerous species belonging to different genera and they are increasing as a result of the development of intensive medical therapy. OBSERVATION: We report the case of a 61-year-old Japanese female under corticosteroid treatment for malignant rheumatoid arthritis. An asymptomatic subcutaneous tumor developed on the back of her left foot. Histological examination of the excised material revealed mixed cell granuloma (H&E) and the presence of branched hyphal elements (periodic acid-Schiff). A fungus grown in pure culture was identified as Phaeoacremonium rubrigenum. CONCLUSION: The hyphomycete genus, Phaeoacremonium, was proposed in 1996 by Crous et al. Three species belonging to this genus have been isolated from clinical specimens: P. inflatipes, from a human toenail, human synovial fluid and human mycetoma of the foot, P. parasiticum, from a subcutaneous lesion on a kidney transplant patient and several other sources, and P. rubrigenum, from a human patient with pneumonia. To our knowledge, however, this is the first report of phaeohyphomycosis caused by Phaeoacremonium rubrigenum.

1176

Phaeohyphomycosis caused by Phaeoacremonium inflatipes. Padhye AA, Davis MS, Baer D, Reddick A, Sinha KK, Ott J. J Clin Microbiol. 1998 Sep;36(9):2763-5.

Phaeoacremonium inflatipes, one of three species previously classified as strains of Phialophora parasitica, was identified as the causal agent of a subcutaneous infection of the left foot of an 83-year-old woman from South Carolina. The patient had a granulomatous growth over the anteromedial aspect of her left foot. It was surgically excised, which led to complete healing without complications. Tissue sections of the excised mass stained with hematoxylin and eosin and Gomori's methenamine silver strains showed many septate hyphal elements of various lengths, some exhibiting brownish pigment in the cell walls of the hyphae. Portions of the tissue, when cultured, yielded many colonies which were initially glabrous, off white becoming velvety, greyish brown on aging. Microscopically, their hyphae were septate, branched, and phaeoid and bore lateral and terminal, erect, septate conidiophores. The conidiogenous cells (phialides) were terminal or lateral, mostly monophialidic, subcylindrical to spinelike in shape, and constricted at their bases and bore funnel-shaped, inconspicuous collarettes at their tips. The conidia were subhyaline, oblong, and ellipsoid to allantoid.

1177

Phaeoacremonium parasiticum infective endocarditis following liver transplantation. Heath CH, Lendrum JL, Wetherall BL, Wesselingh SL, Gordon DL. Clin Infect Dis. 1997 Nov;25(5):1251-2.

1178

Dermoscopy in the diagnosis of tinea nigra plantaris. Smith SB, Beals SL, Elston DM, Meffert JJ. Cutis. 2001 Dec;68(6):377-80.

Tinea nigra is a relatively uncommon dermatiaceous fungal infection, usually caused by Phaeoannellomyces werneckii, that may mimic a melanocytic lesion. We describe the value of epiluminescent dermoscopy of tinea nigra plantaris compared with other common diagnostic tools and procedures available (clinical appearance, potassium hydroxide [KOH], culture, culture mount preparation, and biopsy). A case of tinea nigra plantaris was evaluated clinically, microscopically with KOH, and dermatoscopically. Dermatoscopic findings were evaluated according to the Stolz system. Dermoscopy, clinical presentation, and microscopy with KOH all confirmed the diagnosis, with dermoscopy being the fastest and simplest procedure. Dermoscopy is a useful clinical adjuntive tool in differentiating tinea nigra from a melanocytic lesion.

1179

Bilateral tinea nigra plantaris and tinea nigra plantaris mimicking melanoma. Tseng SS, Whittier S, Miller SR, Zalar GL. Cutis. 1999 Oct;64(4):265-8.

Tinea nigra, a superficial fungal infection caused by Phaeoannellomyces werneckii, presents as a hyperpigmented, nonscaling macule of variable size and shape. Typically lacking induration, erythema, or pruritus, these "ink spot" lesions may resemble junctional nevi or malignant melanoma. Rapid, noninvasive diagnosis can be provided by potassium hydroxide examination, demonstrating numerous large, dematiaceous hyphae.

1180

Tinea nigra palmaris. Hughes JR, Moore MK, Pembroke AC. Clin Exp Dermatol. 1993 Sep;18(5):481-2.

Tinea nigra is a clinically distinctive superficial mycosis of the palms, and occasionally the soles, caused by Phaeoannellomyces werneckii. A patient, resident in the United Kingdom, is described who acquired the infection in Thailand. The condition cleared after treatment with topical miconazole cream 2%.

1181

Phaeohyphomycotic cyst caused by a recently described species, Phaeoannellomyces elegans. Engleberg NC, Johnson J 4th, Bluestein J, Madden K, Rinaldi MG. J Clin Microbiol. 1987 Apr;25(4):605-8.

An 81-year-old man presented with a chronic, painful nodule on the palmar surface of the left fourth finger. As a former farm worker, the patient acknowledged frequent soil-contaminated wounds of the left hand 4 to 12 years previously, but he denied any recent trauma. The patient's other medical problems included a history of chronic immunoglobulin A gammopathy and a new pleural mass eroding into adjacent ribs on chest X-ray. The finger nodule was excised and consisted of an intact phaeohyphomycotic cyst which yielded growth of a darkly pigmented fungus. At 25 degrees C, the isolate formed annellidic yeast cells having dark-brown walls consistent with the recently described species Phaeoannellomyces elegans. In vitro antifungal susceptibility tests indicated resistance to amphotericin B and variable susceptibility to imidazoles. The lesion was excised, and the patient received no antifungal therapy. After 9 months of follow-up, the fungal infection shows no signs of recurrence.

1182

Phaeoisaria clematidis as a cause of keratomycosis. O, Zorat-Yu C, Figueras MJ. J Clin Microbiol. 2000 Jun;38(6):2434-7.

We report the first case of human infection by Phaeoisaria clematidis. This fungus caused a corneal ulcer in a Brazilian man who had previously suffered an eye injury. Diagnosis was established by positive direct examination and repeated cultures. The isolate was clearly resistant in vitro to the six antifungal agents tested.

1183

Phaeohyphomycosis due to Alternaria spp. and Phaeosclera dematioides: a histopathological study. Pec J, Palencarova E, Plank L, Straka S, Pec M, Jesenska Z, Filo V. Mycoses. 1996 May-Jun;39(5-6):217-21.

A case of phaeohyphomycosis caused by strains of both Alternaria spp. and Phaeosclera dematioides is presented. The biopsy material was studied using histological, immunohistochemical and transmission electron microscopy techniques. The agent's dematiaceous mycelia are composed of thick-walled hyphae, branched and unbranched, with terminal vesicular formations. All the described structures occur alone or in chains within multinuclear giant foreign body-type cells or invading an abscess. Also present are budding forms. Immunostaining of histiocytic inflammatory cells in either. diffuse or granulomatous infiltrates revealed cytoplasmic positivity for lysozyme and Ki-MIP antibody. The lymphocytic infiltrates of the upper corium show predominantly small T lymphocytes (CD3 and CD45RO positive) and absence of CD20-positive B cells. Plasma cells occurring within the infiltrates of the deeper parts show polyclonal expression of both Ig light chains.

1184

Phaeohyphomycosis caused by Alternaria species and Phaeosclera dematioides Sigler, Tsuneda and Carmichael. Palencarova E, Jesenska Z, Plank L, Straka S, Baska T, Hajtman A, Pec J. Clin Exp Dermatol. 1995 Sep;20(5):419-22.

A case of phaeohyphomycosis caused by strains of both Alternaria spp. and Phaeosclera dematioides is presented. First clinical signs of mycosis appeared on the patient's face, after an injury with a straw stalk during the wheat harvest in Germany in 1942. Further signs developed in 1955 at one forearm, and again in 1968 in the mouth, leading to perforation of the palate. After treatment with amphotericin B (1973-75) she went into a 13-year-long, clinically asymptomatic remission. She relapsed in 1988, when eight foci of the disease developed, mostly on both forearms. Diabetes mellitus and asthma developed at this time. After pulse therapy with itraconazole the patient remains in a good clinical condition.

1185

Chromomycosis caused by Fonsecaea compacta (Carrion 1940) with secondary phaeohyphomycotic infection caused by Phaeosclera dermatioides (Sigler 1981)] Krempl-Lamprecht L, Luderschmidt C, Wehrmann W. Mykosen. 1987 Oct;30(10):454-60, 463-7.

1186

Mycotic keratitis caused by Phaeotrichoconis crotalariae. New report. Shukla PK, Jain M, Lal B, Agrawal PK, Srivastava OP. Mycoses. 1989 May;32(5):230-2.

A case of mycotic keratitis caused by Phaeotrichoconis crotalariae (IMI 275955) is described for the first time. Experimental corneal lesions in albino rabbits and the histopathology are also presented.

1187

Phialemonium curvatum infection after bone marrow transplantation. Heins-Vaccari EM, Machado CM, Saboya RS, Silva RL, Dulley FL, Lacaz CS, Freitas Leite RS, Hernandez Arriagada GL. Rev Inst Med Trop Sao Paulo. 2001 May-Jun;43(3):163-6.

We report a case of cutaneous infection caused by Phialemonium curvatum GAMS et COOKE, 1983, after bone marrow transplantation. The genus Phialemonium was created by GAMS & MCGINNIS in 1983 including three new species: Ph. obovatum, Ph. curvatum and Ph. dimorphosporum, and represents an intermediate genus between Acremonium and Phialophora. Nowadays, the genus Phialemonium is considered to be a pheoid fungus which may cause the eventual lesions observed in pheo- and hyalohyphomycosis. Species of this genus have been described as opportunistic agents in humans and animals, mainly as a result of immunosuppression. In the present case, the patient had multiple myeloma and received an allogenic bone marrow transplant from his HLA-compatible brother. Two months after transplantation, he developed purplish and painful nodular lesions on the right ankle. Some of these lesions drained spontaneously and apparently hyaline mycelial filaments were observed, whose culture was initially identified as Acremonium sp. Subsequent studies showed that the fungus was Phialemonium curvatum. The infection was treated with amphotericin B, followed by ketoconazole. The patient was submitted to surgical debridement followed by two skin grafts to repair the bloody area. The duration of the treatment was 4 months and secondary prophylaxis with ketoconazole alone was maintained for one additional month. No recurrence was observed after discontinuation of treatment. The authors comment on the pathogenicity of the genus Phialemonium.

1188

A phaeohyphomycotic cyst and peritonitis caused by Phialemonium species and a reevaluation of its taxonomy. King D, Pasarell L, Dixon DM, McGinnis MR, Merz WG. J Clin Microbiol. 1993 Jul;31(7):1804-10.

Two cases of human fungal infections caused by members of the genus Phialemonium, a genus proposed by Gams and McGinnis (1983) for fungi intermediate between the genera Acremonium and Phialophora, are presented. The first case was a phaeohyphomycotic cyst on the foot of a renal transplant recipient. The fungus was detected by direct examination and histopathology and was recovered by several procedures over 4 months. It was flat, glabrous, and white becoming yellow with the production of a diffusible yellow pigment; it had conidiophores that were mostly solitary and lateral and terminal phialides and adelophialides with distinct collarettes producing cylindrical to curved conidia. The isolate resembled both Phialemonium dimorphosporum and Phialemonium curvatum, although its characteristics were more consistent with those of the latter. The second case was peritonitis in a renal transplant recipient. The fungus was white-to-cream colored and yeast like, but later became black with a green diffusible pigment, and produced obovoid conidia; it was easily identified as Phialemonium obovatum. Difficulties encountered in the identification and taxonomy of members of this genus highlight the need for standardized conditions, e.g., potato dextrose agar culture incubated at 24 to 25 degrees C for morphologic comparisons, to control significant variations due to culture conditions.

1189

Phialemonium obovatum infection in a burned child. McGinnis MR, Gams W, Goodwin MN Jr. J Med Vet Mycol. 1986 Feb;24(1):51-5.

Phialemonium obovatum is reported for the first time as an opportunistic fungal pathogen of man. The fungus was recovered from biopsy specimens consisting of cutaneous and subcutaneous tissue obtained from thermal burn wounds antemortem and from spleen tissue and three burn sites postmortem. The hyaline hypae of P. obovatum were seen invading viable tissue and blood vessels. The taxonomy of the genus Phialemonium and the criteria for determining fungal burn wound invasion are discussed.

1190

Fatal endocarditis in a neonate caused by the dematiaceous fungus Phialemonium obovatum: case report and review of the literature. Gavin PJ, Sutton DA, Katz BZ. J Clin Microbiol. 2002 Jun;40(6):2207-12.

Phialemonium species are grouped by most authorities among the dematiaceous fungi. Like several other darkly pigmented fungi, they appear to be an emerging cause of human disease, especially in the immunocompromised host. As numbers of immunocompromised patients increase, the trend of unusual fungi emerging as new pathogens is set to continue. Previous experience suggests that reports of rare fungal infections among selected patients often heralds the emergence of infection in a wider population of patients. We report a case of fatal endocarditis caused by Phialemonium obovatum in a premature neonate. To our knowledge this is the first documented case of native valve endocarditis due to this species, and we review the literature on invasive disease caused by the species. Unfamiliar fungal isolates are frequently misidentified or mistaken for environmental contaminants, and because of their relative rarity, data upon which to base antifungal treatment are limited. Thus, the diagnosis and treatment of unusual fungal pathogens present a significant challenge to clinicians and microbiologists alike. Early referral of such isolates to a specialist reference laboratory is advisable.

1191

Late bioprosthetic valve endocarditis caused by Phialemonium aff. curvatum and Streptococcus sanguis: a case report. Schønheyder HC, Jensen HE, Gams W, Nyvad O, Van Nga P, Aalbaek B, Stenderup J. J Med Vet Mycol. 1996 Jun-Jul;34(3):209-14.

Dual fungal and Streptococcus sanguis endocarditis is reported in a 63-year-old woman 7 months after placement of a porcine aortic valve prosthesis. Both micro-organisms were isolated by blood cultures, and the patient succumbed after a full course of antibacterial chemotherapy without having received antifungal chemotherapy. The best possible designation of the fungus was Phialemonium aff. curvatum W. Gams & W. B. Cooke, as represented by CBS 331.93. At autopsy hyphae were revealed in the porcine valve tissue by conventional staining. A hyperimmune rabbit antiserum raised towards strain CBS 331.93 and extensively absorbed with heterologous fungal antigens reacted strongly with hyphae in the valve tissue by indirect immunofluorescence technique. We consider it most likely that the Phialemonium infection evolved insidiously from the time of open heart surgery and led to a haematogenous streptococcal infection of a more fulminant course.

1192

Osteolytic phaeohyphomycosis caused by Phialemonium obovatum. Magnon KC, Jalbert M, Padhye AA. Arch Pathol Lab Med. 1993 Aug;117(8):841-3.

Phialemonium obovatum was found to be the cause of nosocomial osteomyelitis in a 41-year-old man after sustaining a nonpenetrating injury to his lumbar and cervical region. Histologic examination of fragments of disk and bone from L3-4 hemilaminectomy showed multiple fragments of fibrocartilage with focal necrosis, chronic inflammation, and granulation tissue formation. Sections stained with Gomori's methenamine silver procedure showed multiple fungal elements in necrotic areas consisting of irregularly branched, hyaline septate hyphae having swollen cells, and occasional yeastlike cells. The use of Fontana-Masson silver stain showed the presence of melanin in cells walls and septa of the hyphae. Phialemonium obovatum was isolated when the ground tissue from disk and bone from L3-4 was cultured on biphasic brain-heart infusion medium. Colonies were moist, off-white to ochraceous with a characteristic green, diffusible pigment on the reverse side. The isolate grew well up to 40 degrees C. It formed characteristic adelophialides without conspicuous collarettes and basal septa and produced smooth, one-celled, hyaline, and obovate conidia.

1193

Phialemonium fungemia: two documented nosocomial cases. Guarro J, Nucci M, Akiti T, Gené J, Cano J, Barreiro MD, Aguilar C. J Clin Microbiol. 1999 Aug;37(8):2493-7.

Two fungal isolates recovered from the blood of two immunosuppressed patients are described as Phialemonium curvatum. One patient died, while the other, who was infected with Exophiala jeanselmei at the same time, survived after successful treatment with itraconazole. Analysis of internal transcribed spacer sequences demonstrated that the isolates belonged to the same strain and that the source of infection was probably a catheter. The taxonomic position of P. curvatum is discussed, and Phialemonium dimorphosporum is considered a synonym. The in vitro inhibitory activities of six antifungal agents (amphotericin B, itraconazole, ketaconazole, miconazole, flucytosine, and fluconazole) were determined against seven isolates of Phialemonium. Except for flucytosine, all of them were remarkably effective. Phialemonium should be added to the list of potential causes of nosocomial fungemia in cancer patients.

1195

Phaeohyphomycosis due to Phialophora richardsiae. Tam M, Freeman S. Australas J Dermatol. 1989;30(1):37-40.

Phaeohyphomycosis, an infection characterised by dematiaceous yeast-like cells, hyphae and pseudohyphae in tissue, is an uncommon condition, often affecting immunosuppressed patients. A sixty four year old boat-builder, receiving treatment with prednisone and azathioprine developed multiple cutaneous nodules on the extremities. Histology showed a mixed dermal inflammatory infiltrate with scattered spores and hyphae. Culture revealed two organisms, Phialophora richardsiae and Exophiala jeanselmei. Fluorocytosine was initially given but the organism was found to be resistant. Since side effects have been associated with long term ketoconazole therapy, a less toxic and more potent triazole compound, itraconazole, was used. After three months, the lesions had completely resolved without adverse clinical or biochemical changes.

1196

Phialophora repens, an emerging agent of subcutaneous phaeohyphomycosis in humans. Hironaga M, Nakano K, Yokoyama I, Kitajima J. J Clin Microbiol. 1989 Mar;27(3):394-9.

A 63-year-old Japanese man had phaeohyphomycosis that occurred as a solitary subcutaneous nodule on the dorsal aspect of his left hand. In the nodule there were foci of mixed granulomatous and suppurative infiltrations circumscribed by thick fibrous tissue reaction. The foci contained short septate hyphae and occasionally small rounded aggregates of irregularly branched septate hyphae, both of which were nonpigmented or rarely weakly pale brown. Fungal culture from the nodule was positive for a dematiaceous mold. The mycologic features of the mold were typical of Phialophora repens. The infection was successfully treated by excision of the nodule. This is the second reported case of infection due to P. repens.

1197

Case report. Phaeohyphomycosis caused by Phialophora verrucosa developed in a patient with non-HIV acquired immunodeficiency syndrome. Ohira S, Isoda K, Hamanaka H, Takahashi K, Nishimoto K, Mizutani H. Mycoses. 2002 Feb;45(1-2):50-4.

A 53-year-old woman had asymptomatic multiple nodules on her gluteal region for 6 months. She had a history of systemic corticosteroid treatment for Evans' syndrome. Recently she had developed an immunodeficiency condition with CD4+ cell depletion without an HIV infection and a normal serum gamma globulin level. A smear from the purulent exudate of the nodules revealed many brown-coloured hyphae, spores and few large dark-brown cells. A short, hairy, dark-brown coloured colony was cultivated on Sabouraud glucose agar. Slide culturing revealed only a Phialophora-type conidia formation, and the fungus was diagnosed as Phialophora verrucosa. Severe immunosuppressive condition (non-HIV acquired immunodeficiency syndrome) of this patients after systemic corticosteroid treatment for Evans' syndrome predisposed an opportunistic cutaneous fungal infection due to P. verrucosa. Cases with cutaneous infection due to P. verrucosa reported in Japan are summarized and discussed.

1198

A case of chromoblastomycosis due to Phialophora verrucosa responding to treatment with fluconazole. Guerriero C, De Simone C, Tulli A. Eur J Dermatol. 1998 Apr-May;8(3):167-8.

We report the case of a 40-year-old Filippino woman, with a 5-year history of a slowly spreading, painful skin lesion on her left foot. Histological examination showed a dermal, granulomatous infiltrate consisting of neutrophils, histiocytes and lymphocytes, with "sclerotic bodies" in the cytoplasm of phagocytic cells. Mycological culture revealed the presence of Phialophora verrucosa and confirmed the histopathological diagnosis of chromo-blastomycosis. Association of surgical curettage of the exuberant, infected tissue with systemic fluconazole administration gave good therapeutic results with no relevant side effects.

1199

Phialophora mutabilis endocarditis. Slifkin M, Bowers HM Jr. Am J Clin Pathol. 1975 Jan;63(1):120-30.

This is the first reported case of fungal endocarditis due to vegetative growth of Phialophora mutabilis on a prosthetic mitral valve. The patient had rheumatic heart disease with mitral and aortic stenosis. Four months after the mitral and aortic valves had been replaced by prostheses the patient developed congestive failure. Because of increased left atrial pressure, the mitral prosthesis was replaced. A large matted obstructive fungal vegetation was found on the prosthesis. Culture of this vegetation grew Phialophora mutabilis. The patient died postoperatively, and at autopsy the fungus was not found in other tissues. Culturally and morphologically, P. mutabilis shows wide variation in pigmentation, colonial and microscopic appearance. Conidia formation from intercalary cells along the hyphae is somewhat similar to that of Aureobasidium spp. P. mutabilis was injected into mice. Mice pretreated with cortisone died 3 to 5 weeks after intraperitoneal inoculation, while the majority of untreated mice died within 20 weeks of inoculation.

1200

Phialophora verrucosa: a new cause of mycetoma. Turiansky GW, Benson PM, Sperling LC, Sau P, Salkin IF, McGinnis MR, James WD. J Am Acad Dermatol. 1995 Feb;32(2 Pt 2):311-5.

A 29-year-old Thai woman had draining sinus tracts, tumefaction, and granules on the plantar aspect of the foot. Phialophora verrucosa was isolated from the lesion. P. verrucosa is a major agent of chromoblastomycosis, which is known to rarely cause subcutaneous phaeohyphomycosis. This dematiaceous fungus has not been previously reported to cause mycetoma. This case illustrates the clinical spectrum of disease of this fungus. The salient features of mycetoma and management options are presented.

1201

Subcutaneous chromomycotic abscesses caused by Phialophora gougerotii. Kotrajaras R, Chongsathien S. Int J Dermatol. 1979 Mar;18(2):150-4.

Subcutaneous chromomycotic absesses due to phialophora gougerotii in a 50-year-old woman were characterized by subcutaneous abscesses adhering together through fistulous tracts, rupturing and leaving black crusts over multiple sinuses mimicking mycetoma. Reinfection occurred in contaminated excised lesions. Intradermal inoculation in different anemic patients caused abscesses in 14 days and healed without therapy in eight weeks. No spreading to other organs was found after intraperitoneal inoculation of mice for eight weeks.

1202

Study of mold allergy in asthmatic children in Hungary. Szánthó A, Osváth P, Horváth Z, Novák EK, Kujalek E. J Investig Allergol Clin Immunol. 1992 Mar-Apr;2(2):84-90.

We studied the change in sensitivity to propagating aerogenic fungi (spores, conidia) in extrinsic asthmatic children living in an urban environment from 1977 to 1988. According to the skin test, 10.6% of those examined in 1977 were sensitive to the fungi, the proportion being 30.4% in 1985 and 38.5% in 1987/88. The increase may be explained by the increasing frequency of sensitivity to Alternaria alternata and Phoma betae. In skin tests with Bencard allergens, reaction to both types was frequently observed. Of those sensitive to P. betae, 83% were also sensitive to A. alternata, and 87.5% of those sensitive to A. alternata were also sensitive to P. betae. The frequency of cross-reactions observed both with skin tests and specific IgE determinations suggests the presence of a common allergen, or epitope. The effect of environmental factors was analyzed with computer techniques. P. betae allergy was not related to detectable mold, humidity or number of pot plants in the home. The living conditions changed during the study period as follows: 1) housing conditions improved; 2) energy-saving building technologies were generally accepted; and 3) air pollution increased, also affecting the vegetation. The sensitizing masses of spores and conidia originated most likely from molds living on plants weakened and diseased by environmental pollution.

1204

Subcutaneous phaeohyphomycosis caused by Phoma cava. Report of a case and review of the literature. Zaitz C, Heins-Vaccari EM, de Freitas RS, Arriagada GL, Ruiz L, Totoli SA, Marques AC, Rezze GG, Müller H, Valente NS, Lacaz Cda S. Rev Inst Med Trop Sao Paulo. 1997 Jan-Feb;39(1):43-8.

We report a case of subcutaneous phaeohyphomycosis observed in a male patient presenting pulmonary sarcoidosis and submitted to corticosteroid treatment. He presented nodular erythematous-violaceous skin lesions in the dorsum of the right hand. Histopathological examination of the biopsied lesion revealed dematiaceous hyphae and yeast-like cells, with a granulomatous tissual reaction. The isolated fungus was identified as Phoma cava. A review of the literature on fungal infection caused by different Phoma species, is presented. The patient healed after therapy with amphotericin B. followed by itraconazole.

1205

Subcutaneous phaeohyphomycosis caused by an unusual pathogen: Phoma species. Hirsh AH, Schiff TA. J Am Acad Dermatol. 1996 Apr;34(4):679-80.

1206

First report of subcutaneous phaeohyphomycosis of the foot caused by Phoma minutella. Baker JG, Salkin IF, Forgacs P, Haines JH, Kemna ME. J Clin Microbiol. 1987 Dec;25(12):2395-7.

Phoma minutella, a dematiaceous hyphomycete, was isolated to the exclusion of all other fungi from a subcutaneous inflammatory process on the foot of a farmer undergoing corticosteroid therapy for myasthenia gravis. Isolation was achieved on several nutrient media. Examination of stained smears and sections revealed dematiaceous fungal elements consistent with the mold. This is the first reported association of P. minutella with a human infection and only the second reported case involving a Phoma sp. as the etiologic agent of a subcutaneous infection.

1207

The isolation of Phoma eupyrena from a human lesion. Bakerspigel A, Lowe D, Rostas A. Arch Dermatol. 1981 Jun;117(6):362-3.

A strain of the soil-borne fungus Phoma eupyrena was isolated from the skin of an 18-month-old boy who had a crusting, erythematous, perioral eruption of one month's duration. Treatment with clotrimazole, 15% zinc oxide paste, and dimethicone resulted in eradication of the fungus and in complete healing of the lesions in eight weeks.

1210

Ultrastructural aspects of hair digestion in black piedra infection. Figueras MJ, Guarro J, Zaror L. J Med Vet Mycol. 1997 Jan-Feb;35(1):1-6.

The ultrastructural pattern of human hair infection by Piedraia hortae in vivo has been studied. The fungus destroyed the cuticular layers of the hair and was able to penetrate deeply into the cortex. The course of destruction of human hair is described and compared with that produced by other fungi. Two well-defined types of cortex digestion were characterized. The slow rate of keratin degradation at the cortex together with the compacted stromatic organization of the nodules are argued as the main reasons that guarantee the long survival of the fungus, and therefore the chronic course of the disease. The data provided in this paper may help to understand the mechanisms that regulate the pathogenicity of this fungus.

1211

Black piedra: the first case treated with terbinafine (Lamisil). Gip L. Br J Dermatol. 1994 Apr;130 Suppl 43:26-8.

A 23-year-old Swedish Caucasian man presented with typical clinical signs of black piedra of his scalp after his return from 4-months' stay in India. There were black nodules around the hair shafts, and the crushed nodules revealed numerous asci and ascospores on microscopy. Piedraia hortae was isolated from the concretions. He was treated with oral terbinafine 250 mg daily for 6 weeks. At the end of treatment no nodules were visible, but 16 days later a few 'new' black concretions appeared. Microscopy of these nodules revealed markedly degenerated fungal elements, and cultures were negative. No further signs of the disease were seen 2 months after cessation of therapy. In vitro susceptibility tests showed that Piedraia hortae was sensitive to terbinafine. This case demonstrates that terbinafine is effective in the treatment of black piedra.

1212

Facultative and obligate pathogenic moulds in skin affections] Rieth H. Hautarzt. 1978 Jan;29(1):22-6.

Molds are vegetable microorganisms, which differ from dermatophytes sensitive to griseofulvin, and from yeasts, which do not form aerial mycelium. Most of the molds, phytopathogenic or which live from dead organic substances, are apathogenic to humans. Only a couple of dozen species can parasitize on the skin, usually together with dermatophytes or yeasts. Onychomycoses with molds appear mostly in elderly people, and fungus affections of external auditory passage in seborrheic eczema of the ear. The hair can be infected by Piedraia hortae, resulting in hard black nodules. After the identification of molds on the skin, criticism is necessary, since in more than 95% of the cases they are accidental germs. Several cultures and microscopic tests are necessary to assure the diagnosis. Broad-spectrum antimycotics is the predominant choice for treatment, but also amphotericin B, nystatin and pimaricin.

1218

Cutaneous lesions due to Pleurophoma (Phoma) complex. Rosen T, Rinaldi MJ, Tschen JA, Stern JK, Cernoch P. South Med J. 1996 Apr;89(4):431-3.

We report a case of striking and disfiguring facial mycosis due to an organism belonging to the Pleurophoma complex of Coelomycetes. This condition was likely acquired through repeated contact with infected soil and exacerbated by prolonged applications of topical corticosteroid preparations. Antifungal drug susceptibility testing was used to direct a therapeutic choice in this unusual infection.

1219

Phaeohyphomycotic cutaneous disease caused by Pleurophoma in a cardiac transplant patient. Dooley DP, Beckius ML, Jeffery BS, McAllister CK, Radentz WH, Feldman AR, Rinaldi MG, Bailey SR, Keeling JH. J Infect Dis. 1989 Mar;159(3):503-7.

A 56-y-old female cardiac transplant patient treated with cyclosporine and prednisone noted the onset of three nontender red nodules on the legs and arms after gardening. Biopsy of all lesions revealed inflammatory cells and hyphal elements in the dermis. The dematiaceous fungus cultured from biopsy tissue was a pycnidial-forming organism of the genus Pleurophoma. The lesions responded to the topical application of miconazole.

1220

Phaeohyphomycotic soft tissue disease caused by Pleurophomopsis lignicola in a kidney transplant patient. Farina C, Punithaligham E, Ruggenenti P, Goglio A. J Med Microbiol. 1997 Aug;46(8):699-703.

A 44-year-old immunocompromised man presented with multiple tissue abscesses, covering the entire left limb. A dematiaceous fungus compatible with Pleurophomopsis lignicola Petrak was isolated from the diseased tissue in pure culture. This is the second reported isolation of this fungus from man and the first report of fatal soft tissue infection. A detailed morphological description of the isolate is provided.

1221

Maxillary sinusitis caused by Pleurophomopsis lignicola. Padhye AA, Gutekunst RW, Smith DJ, Punithalingam E. J Clin Microbiol. 1997 Aug;35(8):2136-41.

In immunocompetent 59-year-old man developed sinusitis over a 6- to 8-month period after cutting down a rotted maple tree (Acer sp.). A polypoid obstruction with a bloody drainage was evident in his right nasal cavity. A computed tomographic scan showed an opacification of the maxillary sinus. Surgery was performed to remove a fungus ball that had extended into the patient's medial sinus cavity. Sections of the sinonasal mucosa revealed marked acute and chronic sinusitis with inflammation, congestion, and hemorrhage. Sections from the pasty brown to black debrided material revealed a fungus ball consisting of an extensive network of brown-pigmented, septate, profusely branched hyphae. When grown on oat agar, the phaeoid fungus produced pycnidia and was identified as Pleurophomopsis lignicola. The genus Pleurophomopsis includes seven species, which are all known from plant material. This report documents for the first time a coelomycetous fungus, P. lignicola, causing sinusitis in an immunocompetent patient.

1222

Subcutaneous abscess caused by Pleurophomopsis lignicola Petr: first case. Chabasse D, de Bievre C, Legrand E, Saint-Andre JP, de Gentile L, Cimon B, Bouchara JP. J Med Vet Mycol. 1995 Nov-Dec;33(6):415-7.

The dematiaceous coelomycete Pleurophomopsis lignicola Petr. was isolated repeatedly in pure culture from a subcutaneous abscess of the left leg in a farmer undergoing corticosteroid therapy for asthma gravis. To our knowledge, we report the first case involving this fungus as an aetiological agent of subcutaneous phaeohyphomycosis.

1223

Polycytella hominis gen. et sp. nov., a cause of human pale grain mycetoma. Campbell CK. J Med Vet Mycol. 1987 Oct;25(5):301-5.

A hyphomycete isolated from a pale-grain eumycetoma in an indian male patient is described as a species of a new form-genus, Polycytella hominis. The fungus is characterized by elongate multiseptate conidia in which only the apical compartment becomes thick-walled and retains viable cytoplasm. The appearance of P. hominis in the host tissues is described and compared with other pale-grain eumycetomas.

1224

Polypaecilum insolitum (=Scopulariopsis divaricata) isolated from cases of otomycosis. Yamashita K, Yamashita T. Sabouraudia. 1972 Jul;10(2):128-31

1226

Pseudallescheria boydii knee arthritis in a young immunocompetent adult two years after a compound patellar fracture. Lavy D, Morin O, Venet G, Maugars Y, Prost A, Berthelot JM. Joint Bone Spine. 2001 Dec;68(6):517-20.

Pseudallescheria boydii arthritis of the knee developed in a 32-year-old immunocompetent man 2 years after a compound patellar fracture contaminated with soil. No other potential portal of entry was identified, suggesting that the fungus remained latent for 2 years. Pseudallescheria arthritis often occurs after a prolonged latency period, causing minimal symptoms that contrast with the frequently severe radiological changes. Although this organism often shows limited sensitivity to most antifungal agents, our patient achieved a full recovery after surgical synovectomy and 6 months of itraconazole therapy (400 mg/ d). This case illustrates the importance of testing for fungi in patients with torpid arthritis, particularly when mild clinical symptoms contrast with severe bone and joint destruction.

1227

Pseudallescheria boydii osteoarthritis in a patient with acute lymphoblastic leukemia: a case report] Le Gouill SL, Morineau N, Miégeville M, Milpied N, Harousseau JL, Moreau P. Rev Med Interne. 1999 May;20(5):434-8.

INTRODUCTION: The outcome of neutropenic patients with Pseudallescheria boydii infection is poor. EXEGESIS: We report the first case of Pseudallescheria boydii hip arthritis in a patient treated for acute lymphoblastic leukemia. In vitro susceptibility testing showed that the strain was resistant to amphotericin B, fluorocytosine and nystatin, but susceptible to itraconazole. The patient received oral itraconazole (600 mg/day) and clinical symptoms initially resolved. Two months later, after a course of chemotherapy and high-dose steroids while receiving oral itraconazole treatment, the patient developed fever, skin lesions and disseminated lung infiltrates due to Pseudallescheria boydii and finally died. CONCLUSION: This case illustrates the severity of fungal infections due to Pseudallescheria boydii despite a presumably well-conducted antifungal therapy.

1228

Arthritis without grains caused by Pseudallescheria boydii. Ginter G, de Hoog GS, Pschaid A, Fellinger M, Bogiatzis A, Berghold C, Reich EM, Odds FC. Mycoses. 1995 Sep-Oct;38(9-10):369-71.

Severe infection of the knee joint by Pseudallescheria boydii in a 23-year-old female resulted in complete destruction of the cartilaginous surface. The possibility of entry of the fungus through mild abrasions of unperforated skin is discussed. The clinical appearance is compared with that of Scedosporium prolificans. Antimycotic miconazole-itraconazole treatment, applied during a period of 4 months, was successful; no side-effects were noted.

1229

Vertebral osteomyelitis secondary to Pseudallescheria boydii. Lonser RR, Brodke DS, Dailey AT. J Spinal Disord. 2001 Aug;14(4):361-4.

Because Pseudallescheria boydii vertebral osteomyelitis is rare and frequently resistant to available antifungal agents, the proper treatment of this lesion has not been defined. To better determine the best treatment of this lesion, the authors evaluated a case P. boydii vertebral osteomyelitis and reviewed the literature. A 48-year-old man had isolated thoracic vertebral osteomyelitis resulting from P. boydii and associated severe thoracic back pain and proximal lower extremity pain and weakness. Magnetic resonance imaging studies revealed continued collapse of the T6--T7 vertebrae despite previous posterior debridement and appropriate antifungal chemotherapy. On admission to the authors' institution, the patient underwent a right thoracotomy, anterior debridement with transthoracic T6--T7 corpectomies and strut grafting, followed by posterior fusion and stabilization with pedicle screws. After operation, the patient's pain, hyperalgesia, and lower extremity symptoms resolved. He was treated with a 12-month course of itraconazole. Imaging and laboratory studies show no evidence of recurrence. P. boydii vertebral osteomyelitis can have devastating neurologic sequelae if not treated properly. The frequent lack of response of this unusual fungal infection to systemic therapy requires frequent serial follow-up examinations. Patients with evidence of progression on imaging studies or neurologic findings should undergo early and aggressive surgical debridement.

1230

Osteomyelitis due to Pseudallescheria boydii. Hung LH, Norwood LA. South Med J. 1993 Feb;86(2):231-4.

This report describes an unusual opportunistic fungal infection in an immunocompetent young man who had no cutaneous involvement and whose infection was diagnosed 6 years after an accident. The unusual clinical presentation and difficulties in making a correct diagnosis are discussed and prophylactic antifungal chemotherapy is suggested.

1231

Pseudallescheria boydii mycetoma in northern New England. Stierstorfer MB, Schwartz BK, McGuire JB, Miller AC. Int J Dermatol. 1988 Jul-Aug;27(6):383-7.

Mycetoma is a chronic subcutaneous fungal infection characterized by tumefaction, draining sinuses, and grains. It is most common in the tropics but occasionally occurs in the United States. We report a case of a mycetoma affecting the foot of a 38-year-old mentally retarded man from northern New England. The causal organism was identified as Pseudallescheria boydii, the most common cause of mycetoma in the United States. The patient showed a partial response to 8 months of ketoconazole therapy.

1232

Case report. Atypical cutaneous pseudallescheriosis refractory to antifungal agents. Ginter G, Petutschnig B, Pierer G, Soyer HP, Reischle S, Kern T, de Hoog S. Mycoses. 1999;42(7-8):507-11.

We report on a 65-year-old male heart transplant recipient who was otherwise in good condition. The patient was immunocompromised secondarily due to cyclosporin, prednisolone and azathioprine when widespread pustular skin lesions with erythematous margins subsequently developed on his left forearm. There was no history of trauma or septic temperature. Bacterial cultures were sterile and the results of native and cultural investigation studies were negative. A biopsy specimen of the lesion demonstrated hyalohyphomycosis with numerous septate hyphae within granulomas throughout the dermis. Subcutaneous tissues were not involved. Culture plates inoculated with pus and skin from the punch biopsy showed growth of a mould yielding Pseudallescheria boydii. Sensitivity testing was performed with miconazole, ketoconazole and itraconazole showing the best in vitro activity against P. boydii. In spite of treatment with itraconazole, the erythema and pustules continued to spread and therapy was changed to intravenous miconazole. Due to ongoing progression after 3 months of antifungal therapy surgical debridement was required. After 2 years of follow up, he had no recurrence.

1233

Pseudallescheriasis in northern Britain. Milne LJ, McKerrow WS, Paterson WD, Petrie GR, Postlethwaite R. J Med Vet Mycol. 1986 Oct;24(5):377-82.

Five cases of Pseudallescheria boydii infection are reported from the northern part of the United Kingdom. None of the patients had travelled abroad. Three cases of otitis in which P. boydii was associated with bacterial infections were diagnosed within a 6-month period. A lady who had diabetes mellitus presented with a pulmonary fungus ball in a pre-existent cavity caused by a previous bacterial infection. After minor trauma at the site of an old skin graft, a farmer's wife developed an ulcer on the dorsum of the right ankle. Precipitating antibodies were demonstrated except in two of the cases of ear infection. The management of the individual cases is discussed.

1234

Pseudallescheria boydii infection of the brain: imaging with pathologic confirmation. Albernaz V, Huston B, Castillo M, Mukherji S, Bouldin TW. AJNR Am J Neuroradiol. 1996 Mar;17(3):589-92.

Pseudallescheria boydii is a rare opportunistic microorganism that usually infects immunosuppressed hosts. In this patient with cerebral infection by P boydii, imaging findings included enhancement of the ependyma of a lateral ventricle and of the caudate nucleus.

1235

Pseudallescheria boydii infection of the central nervous system. Kershaw P, Freeman R, Templeton D, DeGirolami PC, DeGirolami U, Tarsy D, Hoffmann S, Eliopoulos G, Karchmer AW. Arch Neurol. 1990 Apr;47(4):468-72

Pseudallescheria boydii is a rare cause of central nervous system infection characteristically presenting as a neutrophilic meningitis or multiple brain abscesses. Factors predisposing to central nervous system infection with this fungus include immunosuppression and near drowning. The organism is infrequently cultured from fluid obtained by lumbar puncture, delaying clinical recognition and appropriate antifungal therapy. All untreated patients with P boydii infection of the central nervous system died. We describe a patient who developed a persistent neutrophilic meningitis with focal neurologic deficits due to P boydii 6 months after a freshwater aspiration pneumonia. We also review the characteristic clinical and pathologic features of previously reported cases and emphasize the importance of early detection and treatment in the management of this frequently intractable disease.

1236

The first case of Pseudallescheria boydii meningitis in China--electron microscopic study and antigenicity analysis of the agent. Huang HJ, Zhu JY, Zhang YH. J Tongji Med Univ. 1990;10(4):218-21.

Reported in this paper is the first case of isolation of Pseudallescheria boydii from cerebral spinal fluid of a boy with meningitis in China. Morphology and culture were observed by light microscopy, electron scanning microscopy and transmission electron microscopy. In addition, mycelium antigen prepared by SDS-PAGE was compared with that of the other strain of Scedosporium apiospermum. Both of the strains showed more than 40 peptide lines. Their molecular weight was very similar. On the CS-930 Dual-Wavelength TLC Scanner the peaks of both antigens showed to lie in nearly the same position. It could be concluded that Pseudallescheria boydii and Scedosporium apiospermum belong to the same genus, but they are of different strains and reproductive phases.

1237

Meningitis caused by Pseudallescheria boydii treated with voriconazole. Poza G, Montoya J, Redondo C, Ruiz J, Vila N, Rodriguez-Tudela JL, Ceron A, Simarro E. Clin Infect Dis. 2000 Jun;30(6):981-2.

Meningitis caused by Pseudallescheria boydii is an uncommon infection of the CNS that usually has a poor prognosis and a difficult treatment. We describe a case of chronic meningitis caused by P. boydii in an immunocompetent host that was successfully treated with voriconazole, a new antifungal agent.

1238

Isolated sphenoid sinusitis due to Pseudallescheria boydii. Watters GW, Milford CA. J Laryngol Otol. 1993 Apr;107(4):344-6.

A case of sphenoid sinusitis due to Pseudallescheria boydii is described in a 52-year-old non-immunocompromised woman. Treatment should always involve surgical drainage, and antifungal chemotherapy may be of benefit if there is histological evidence of invasion of surrounding tissue. For P. boydii infection miconazole should be the agent of choice, rather than amphotericin B. For this reason it is important to obtain culture and histological examination of sinus contents if fungal infection is suspected.

1239

Superior sagittal sinus infection with Petriellidium boydii: case report. Fessler RG, Brown FD. Neurosurgery. 1989 Apr;24(4):604-7.

A case of infection of the superior sagittal sinus with Petriellidium boydii is reported. This relatively common fungal pathogen rarely invades the central nervous system. Immunological compromise and poor personal hygiene seem to be common attributes shared by this patient and the 4 previous patients reported to have suffered invasion of the central nervous system by this organism. This report is unique in that it is the first demonstrating apparent hematogenous dissemination of this organism to the central nervous system.

1240

Maxillary sinusitis from Pseudallescheria boydii. Efficacy of surgical therapy. Winn RE, Ramsey PD, McDonald JC, Dunlop KJ. Arch Otolaryngol. 1983 Feb;109(2):123-5.

Pseudallescheria boydii is a ubiquitous mold of soil and is a frequent cause of mycetoma in the United States. Involvement of the sinuses is extremely rare. The necessity of medical and/or surgical management is largely unknown but appears to be dependent on variables of host defense mechanisms, as the fungus is relatively avirulent. Chronic maxillary sinusitis secondary to P boydii developed in a noncompromised woman. Evidence of erosion of the bony wall of the orbit was encountered at operation. Successful eradication of this infection was accomplished with surgical drainage alone.

1241

Pulmonary pseudallescheriasis in a patient with diabetes mellitus and alcoholic liver cirrhosis] Saito Y, Mikami M, Nakamura S, Hashimoto N, Abe Y, Baba M, Takizawa J, Kawakami M, Kamei K. Nihon Kokyuki Gakkai Zasshi. 1998 May;36(5):498-502.

A 62-year-old man with diabetes mellitus and alcoholic liver cirrhosis was admitted to the hospital because of hemoptysis. Chest X-ray films and computed tomograms showed a dense infiltrative lesion and a healed tuberculous cavity with a possible fungus ball in the upper lobe of the right lung. Bronchoscopy revealed that the hemoptysis originated from the right upper-lobe bronchus. The bleeding stopped after thrombin was applied into the bronchus. Filamentous fungi were seen in lavage fluid from the right upper-lobe bronchus. The fungi were identified as Pseudallescheria boydii, and pulmonary pseudallescheriasis was diagnosed. the patient was treated successfully with miconazole (400 mg/day) for 2 months. Pseudallescheriasis should be taken into account in the differential diagnosis of aspergilloma-like lesions.

1242

Invasive pulmonary pseudallescheriasis with direct invasion of the thoracic spine in an immunocompetent patient. Hung CC, Chang SC, Yang PC, Hsieh WC. Eur J Clin Microbiol Infect Dis. 1994 Sep;13(9):749-51.

Most invasive pseudallescheriasis infections have occurred in immunocompromised patients. The case of an immunocompetent patient with invasive pulmonary pseudallescheriasis and subsequent contiguous extension to the ribs and spine is reported. Aspergillosis was mistakenly diagnosed on histopathologic examination of the debrided tissue. Culture of the debrided tissue yielded Pseudallescheria boydii.

1243

Pseudallescheria boydii endocarditis of the pulmonic valve in a liver transplant recipient. Welty FK, McLeod GX, Ezratty C, Healy RW, Karchmer AW. Clin Infect Dis. 1992 Nov;15(5):858-60.

We describe a case of Pseudallescheria boydii endocarditis involving the pulmonic valve in an orthotopic liver transplant recipient. The patient required transplantation because of hepatic failure secondary to chronic active hepatitis B. His postoperative course was complicated by surgery for gastric and duodenal ulcers, persistent fever, and, ultimately, sepsis leading to oliguric renal failure. Two days before death, the patient experienced complete heart block, and an echocardiogram revealed pulmonic valve thickening and an endocardial mass along the left side of the septum. At autopsy the patient was found to have a vegetation on the pulmonic valve and a septal abscess. There were multiple fungal emboli found throughout other organs, and P. boydii was obtained on culture. This unique association between pulmonic valve endocarditis and myocardial septal abscess is discussed. In addition, review of the five previous cases of P. boydii endocarditis reveals that this rare infection is associated with immunosuppression and prosthetic devices.

1244

Native valve endocarditis due to Pseudallescheria boydii in a patient with AIDS: case report and review. Raffanti SP, Fyfe B, Carreiro S, Sharp SE, Hyma BA, Ratzan KR. Rev Infect Dis. 1990 Nov-Dec;12(6):993-6.

A 53-year-old man with AIDS developed mitral valve endocarditis due to infection with the fungus Pseudallescheria boydii. A limited number of cases of prosthetic valve endocarditis caused by this organism have been described. We report a unique case of pseudallescheria infection of a native valve and describe this disease in a patient with AIDS.

1245

Disseminated Petriellidium boydii and pacemaker endocarditis. Davis WA, Isner JM, Bracey AW, Roberts WC, Garagusi VF. Am J Med. 1980 Dec;69(6):929-32.

Clinical and morphologic findings are described in a 62 year old woman with "mixed connective tissue disease" who received corticosteroid therapy, and in whom disseminated and fatal Petriellidium boydii infection with right-sided endocarditis developed. The patient was a gardener. The organism is ubiquitous in soil in many part of the United States; therefore, it is likely that the infection was introduced by this means. Endocarditis due to P. boydii has not been reported previously. In the patient described, massive vegetations nearly obliterated the tricuspid valve orifice, encasing a pacemaker catheter which had been inserted eight years earlier. Although never previously isolated from blood cultures, P. boydii was isolated from 11 consecutive blood cultures. P. boydii is a true fungus and has only recently been appreciated as an opportunistic pathogen in a compromised host.

1246

Disseminated Pseudallescheria boydii infection in a nonimmunocompromised host. Khurshid A, Barnett VT, Sekosan M, Ginzburg AS, Onal E. Chest. 1999 Aug;116(2):572-4.

We present a highly unusual case of pulmonary Pseudallescheria boydii infection in a nonimmunocompromised host with a cavitating mass lesion. The diagnosis was confirmed by open lung biopsy. The patient was treated at another institution with course of amphotericin B, considered an ineffective therapy for this infection, and presented to us with direct extension and invasion of the left atrial appendage and the pulmonary artery, followed by massive pulmonary embolization and hematogenous dissemination to the liver, spleen, kidney, pancreas, and brain.

1247

Disseminated cutaneous Pseudallescheria boydii. Bernstein EF, Schuster MG, Stieritz DD, Heuman PC, Uitto J. Br J Dermatol. 1995 Mar;132(3):456-60.

As increasingly aggressive chemotherapeutic regimens are used to treat malignancy, more patients will become susceptible to various opportunistic pathogens. Specifically, several fungal organisms previously viewed as relatively non-pathogenic are more frequently causing serious disease in these patients. Identification of these organisms is of paramount importance, as some are relatively resistant to standard antifungal therapies. We report a patient with disseminated cutaneous Pseudallescheria boydii, diagnosed from histopathological examination and culture of a skin biopsy specimen. Identification of the organism was achieved shortly before the patient died. Clinicians must be aware of the numerous emerging opportunistic pathogens, which may require special culture techniques for diagnosis and varied or combined modes of therapy.

1248

Allergic bronchopulmonary mycosis caused by Pseudallescheria boydii. Miller MA, Greenberger PA, Amerian R, Toogood JH, Noskin GA, Roberts M, Patterson R. Am Rev Respir Dis. 1993 Sep;148(3):810-2.

Two cases of allergic bronchopulmonary pseudallescheriosis (ABPP) are described. These are the first cases of this allergic bronchopulmonary mycosis (ABPM) reported in which the clinical and serologic criteria are described. The first case was in a patient with mild asthma, and it resolved spontaneously after expectoration of a mucous plug. The second was in a patient with recurrent allergic bronchopulmonary aspergillosis with an exacerbation of ABPM caused by Pseudallescheria boydii. The total serum IgE, IgG, and IgE antibodies against P. boydii and the clinical picture well define ABPP. This diagnosis may be important to recognize in order to prevent a progression of the patient's lung disease.

1249

Mixed allergic bronchopulmonary fungal disease due to Pseudallescheria boydii and Aspergillus. Lake FR, Tribe AE, McAleer R, Froudist J, Thompson PJ. Thorax. 1990 Jun;45(6):489-91.

A 24 year old asthmatic woman with mixed allergic bronchopulmonary fungal disease due to Pseudallescheria boydii and Aspergillus is reported. No previous cases due to P boydii have been described. This patient provides evidence that fungi other than Aspergillus species may cause the condition.

1252

Pseudeurotium ovalis in toenails. Some problems of mycological diagnosis of nail infections. English MP, Harman RR, Turvey JW. Br J Dermatol. 1967 Oct;79(10):553-6.

1253

A clinical trial of itraconazole in the treatment of deep mycoses and leishmaniasis. Borelli D. Rev Infect Dis. 1987 Jan-Feb;9 Suppl 1:S57-63.

Itraconazole was administered orally to two patients with sporotrichosis, 10 patients with paracoccidioidomycosis, three with mycetomas (due to Madurella grisea, Streptomyces madurae, and Pseudochaetosphaeronema larense, respectively), nine with chromomycosis due to Cladosporium carrionii, five with chromomycosis due to Fonsecaea pedrosoi and five with leishmaniasis (including one with the nodular disseminated form). The clinical and laboratory tests showed excellent tolerance to the drug with a total absence of adverse reactions. Satisfactory results were achieved against paracoccidioidomycosis, sporotrichosis, and chromomycosis due to C. carrionii (apparent cure was achieved in a short time). Encouraging improvement was noted in the treatment of mycetoma due to M. grisea. Among the five cases of leishmaniasis, a complete clearing was achieved in one and an encouraging improvement in two, including the one with the nodular disseminated form. Two patients with F. pedrosoi infection were apparently cured after the addition of thermotherapy and flucytosine, respectively, to the treatment regimen.

1256

Pyrenochaeta romeroi causing mycetoma pedis in India. Thammayya A, Sanyal M, Basu N. J Indian Med Assoc. 1979 Aug;73(3-4):66-7.

1257

. Infection of the finger-nail by Pyrenochaeta unguis-hominis. English MP. Br J Dermatol. 1980 Jul;103(1):91-3.

Infection of the finger-nail of an elderly woman by Pyrenochaeta unguis-hominis is reported. The small lesion was extending slowly into the healthy nail plate. The fungus has been isolated from diseased toe-nails on two previous occasions but its extra-human habitat is unknown.

1259

Pythium insidiosum keratitis confirmed by DNA sequence analysis. Badenoch PR, Coster DJ, Wetherall BL, Brettig HT, Rozenbilds MA, Drenth A, Wagels G. Br J Ophthalmol. 2001 Apr;85(4):502-3.

1260

Human pythiosis. Thianprasit M, Chaiprasert A, Imwidthaya P. Curr Top Med Mycol. 1996 Dec;7(1):43-54.

Pythiosis is a cosmopolitan granulomatous disease caused by an aquatic fungus Pythium insidiosum which usually occurs in horses, cattle, dogs, cats or fishes. There have been 28 cases of human pythiosis published in the literature. Twenty three patients have been reported from all over Thailand. Human pythiosis presents in one of three clinical forms: cutaneous or subcutaneous, systemic or vascular and ophthalmic (e.g., corneal ulcer or keratitis). Systemic antibiotics or antimycotics are not effective in the treatment of this infection. A saturated solution of KI gives a beneficial result only in the subcutaneous form. Surgical removal of the source of infection is the method of therapy of vascular and ophthalmic forms.

1261

Pythium insidiosum keratitis. Murdoch D, Parr D. Aust N Z J Ophthalmol. 1997 May;25(2):177-9.

A case of Pythium insidiosum keratitis is described. It is an unusual organism that is difficult to isolate. Cases in animals and humans have been reported from tropical and subtropical parts of the world but this is the first case from a temperate region and was acquired from a hot pool. Although resembling a fungus, it is insensitive to all antifungals and requires wide surgical excision for cure.

1262

Successful medical therapy for deeply invasive facial infection due to Pythium insidiosum in a child. Shenep JL, English BK, Kaufman L, Pearson TA, Thompson JW, Kaufman RA, Frisch G, Rinaldi MG. Clin Infect Dis. 1998 Dec;27(6):1388-93.

Pythiosis occurs in animals and humans who encounter aquatic habitats that harbor Pythium insidiosum. Drug therapy for deeply invasive infections with this organism has been ineffective in humans and animals; patients have been cured only by radical surgical debridement. A 2-year-old boy developed periorbital cellulitis unresponsive to antibiotic and antifungal therapy. The cellulitis extended to the nasopharynx, compromising the airway and necessitating a gastrostomy for feeding. P. insidiosum was isolated from surgical biopsy specimens of the affected tissue. On the basis of in vitro susceptibility studies of the isolate, the patient was treated with a combination of terbinafine and itraconazole. The infection resolved over a period of a few months. The patient remained well 1.5 years after completing a 1-year course of therapy. Cure of deep P. insidiosum infection is feasible with drug therapy.

1263

Human subcutaneous pythiosis. Triscott JA, Weedon D, Cabana E. J Cutan Pathol. 1993 Jun;20(3):267-71.

Two cases of subcutaneous infection caused by the primitive aquatic hyphal organism Pythium are described. Pythium is an important pathogen of horses in the U.S.A. and Australia. Cases of human subcutaneous pythiosis have been cited in the literature, but clinical and histopathological features have not been described previously. Both cases occurred in young immunocompetent males in the periorbital region and showed rapid growth, clinically mimicking a tumor and requiring operative biopsy. In both cases there was a history of exposure to either swampy water or horses. The tissue reaction was distinctive, closely resembling that seen in equine pythiosis, comprising well-defined granular eosinophilic islands bordered by macrophages, multinucleate giant cells, fibrosis and numerous eosinophils. Hyphae were well demonstrated with the Grocott stain but only poorly with the PAS method. Identity of the organisms was confirmed with an immunoperoxidase technique employing a polyclonal antiserum to Pythium. Both patients responded well to amphotericin B.

1264

Human pythiosis in Thailand. Imwidthaya P. Postgrad Med J. 1994 Aug;70(826):558-60.

Pythium insidiosum is a protoctista and causes diseases in plants and animals. In Thailand it can cause a unique human infection of three types. The first type is a subcutaneous lesion in thalassaemic patients, with the pathological findings of a granulomatous reaction, diffuse infiltration, and oedema of the vessel walls. The patients responded to a saturated solution of potassium iodide. The second type is chronic inflammation and occlusion of blood vessels mainly in the lower extremities which results in gangrene or aneurysm formation. This type of infection is only found in thalassaemic patients and leads to amputation of the affected extremities or resection of the involved arteries. The third type is keratitis. This type of infection may or may not be associated with thalassaemia. The clinical signs and symptoms do not differentiate it from other types of myocotic keratitis. The patients end up with keratoplasty, evisceration or enucleation. Thailand is an agricultural country, and there are plenty of swampy areas and several plants to support the life cycle of Pythium. Moreover, many people suffer from thalassaemia, and there is no drug available for Pythium. Pythiosis plays an important role in medicine in Thailand.

1265

Additional case of Ramichloridium mackenziei cerebral phaeohyphomycosis from the Middle East. Khan ZU, Lamdhade SJ, Johny M, Al-Khalidi J, Thussu A, Yossef HN, Al-Obaid I, Nasser AA. Med Mycol. 2002 Aug;40(4):429-33.

In this report we describe a case of cerebral phaeohyphomycosis involving a 56-year-old Egyptian male who worked as a mason in Kuwait for 6 years. Computerized tomography scan of the brain revealed presence of a large abscess in the left occipital lobe. Aspirated pus from the abscess showed branched, septate, hyphae with light brown pigmentation. Cultured pus grew the fungus Ramichloridium mackenziei. Despite amphotericin B (1 mg kg(-1) per day) therapy for 2 weeks, the patient expired. The isolate was later found to be resistant to amphotericin B ( > 32 microg ml(-1)). Antifungal susceptibility testing to other agents was also performed.

1266

Ramichloridium mackenziei brain abscess: report of two cases and review of the literature. Kanj SS, Amr SS, Roberts GD. Med Mycol. 2001 Feb;39(1):97-102.

We report two cases of brain abscesses caused by Ramichloridium mackenziei, a neurotropic dematiaceous fungus that seems to be geographically restricted to the Middle East. One of the patients had chronic myelomonocytic leukemia but did not receive any chemotherapeutic agents. The other patient was a normal host. Both cases had a fatal outcome despite aggressive antifungal therapy and surgical intervention. Herein, we review all previously described cases in the literature, and discuss the epidemiology, mycology and histopathology of this life-threatening organism.

1267

Cerebral phaeohyphomycosis caused by Ramichloridium obovoideum (Ramichloridium mackenziei): case report. Podnos YD, Anastasio P, De La Maza L, Kim RB. Neurosurgery. 1999 Aug;45(2):372-5.

OBJECTIVE AND IMPORTANCE: Only a few cerebral infections with the dark-walled mold Ramichloridium obovoideum (Ramichloridium mackenziei) have been reported in the literature. Central nervous system infections caused by this fungus have poor prognoses; the optimal medical and surgical treatments have not yet been established. We report a case of cerebral R. obovoideum infection for which a combination of medical and surgical treatments failed. CLINICAL PRESENTATION: A 58-year-old Kuwaiti woman, with a history of chronic renal failure requiring hemodialysis, presented with a 3-day history of left frontal headache, blurry vision, dizziness, and right-sided clumsiness. Computed tomography demonstrated multiple, ring-enhancing, cerebral lesions (the largest of which measured 2-3 cm) in the deep left parieto-occipital region. INTERVENTION: A computed tomography-guided needle biopsy of the parieto-occipital lesion yielded 10 ml of dark caseous fluid. Stains demonstrated long, branching, septate hyphae. Fungal cultures grew R. obovoideum. The patient was treated with a combination of amphotericin B and itraconazole. The condition of the patient continued to deteriorate, and stereotactic aspiration of the largest lesion was performed. Despite this approach, the lesion progressed and the patient died. CONCLUSION: R. obovoideum is being increasingly recognized as a cause of cerebral abscesses in patients residing in the Middle East. Prognoses are poor, and responses to antifungal therapy are generally short-lived. Until more effective therapies are found, the greatest chance for adequate treatment involves early recognition, prompt treatment with antifungal agents, and attempts at complete resection.

1268

S. case report of cerebral phaeohyphomycosis caused by Ramichloridium obovoideum (R. mackenziei): criteria for identification, therapy, and review of other known dematiaceous neurotropic taxa. Sutton DA, Slifkin M, Yakulis R, Rinaldi MG. J Clin Microbiol. 1998 Mar;36(3):708-15

We report a case of cerebral phaeohyphomycosis in a 36-year-old male caused by the neurotropic fungus Ramichloridium obovoideum (Matushima) de Hoog 1977 (Ramichloridium mackenziei Campbell et Al-Hedaithy 1993). This man resided in the Middle East, where the fungus appears to be endemic and, possibly, geographically restricted, since all previous reports of brain abscesses due to this organism have been for patients indigenous to this area. As a servant of the Saudi Arabian royal family, he appeared in the United States seeking treatment for chronic weight loss, fatigue, decreased memory, and a more recent 2-week history of right-hand weakness which worsened to involve the entire right upper extremity. On the day prior to his admission, he had a focal motor seizure with rotation of the head and eyes to the right, followed by secondary generalization. A computerized tomogram showed a ring-enhancing hypodense lesion in the left parietal subcortical region with associated edema and mass effect. Diagnosis of a fungal etiology was made following a parietal craniotomy and excisional biopsy by observation of septate, dematiaceous hyphal elements 2 to 3 microm in width on hematoxylin-and-eosin-stained sections from within areas of inflammation and necrosis. Culture of the excised material grew out a dematiaceous mould which was subsequently identified as R. obovoideum. At two months postsurgery and with a regimen of 200 mg of itraconazole twice a day, the patient was doing well and returned to Saudi Arabia. His condition subsequently deteriorated, however, and following a 7-month course of itraconzole, he expired. We use this case to alert clinicians and personnel in clinical mycology laboratories of the pathogenicity of this organism and its potential occurrence in patients with central nervous system signs and symptoms who have resided in the Middle East and to review and/or compare R. obovoideum with other neurotropic, dematiaceous taxa and similar nonneurotropic, dematiaceous species.

1269

Fatal brain abscesses caused by Ramichloridium obovoideum: report of three cases. Naim-ur-Rahman, Mahgoub ES, Chagla AH. Acta Neurochir (Wien). 1988;93(3-4):92-5.

Three cases of brain abscesses caused by Ramichloridium obovoideum are reported. Inspite of adequate antifungal chemotherapy and multiple surgical procedures, all the three patients died of the rupture of a recurrant abscess into the ventricles. Ramichloridium obovoideum was identified as the causative fungus of these brain abscesses. Clinical, histological and mycological features of these cases are described. To our knowledge this is the first time that this fungus is isolated from a brain abscess in Saudi Arabia. The possibility that this life threatening cerebral mycosis may be endemic in this part of the world is considered.

1270

Golden tongue' syndrome caused by Ramichloridium schulzeri. Rippon JW, Arnow PM, Larson RA, Zang KL. Arch Dermatol. 1985 Jul;121(7):892-4.

A 54-year-old woman entered the hospital for induction chemotherapy for acute lymphocytic leukemia. On hospital day 23, while the patient was neutropenic, an erosive lesion appeared on the left side of the tongue. During the next several days the lesion extended over the dorsum of the tongue and was golden orange. Surface scrapings were obtained; the involved site underwent a biopsy and was cultured. Branching septate mycelia of varying diameters were seen on microscopic examination of direct mounts and a biopsy specimen of the tongue. Eight to ten colonies of a fungus grew out in culture. The fungus was golden orange on Sabouraud's glucose agar and brown-gray on corn-meal agar, and was identified as Ramichloridium schulzeri. The lesion regressed during the next two weeks while the patient received amphotericin B therapy and showed an increased granulocyte count. This case seems to be the first authenticated infection caused by this uncommonly encountered soil saprophyte.

1272

Auricular chromoblastomycosis caused by Rhinocladiella aquaspersa. Arango M, Jaramillo C, Cortés A, Restrepo A. Med Mycol. 1998 Feb;36(1):43-5.

An unusual case of chromoblastomycosis localized in the ear and caused by R. aquaspersa is presented. The patient was a 60-year-old male urban resident, who had had the disease for 5 years. The lesion was darkly pigmented, infiltrative and crusty. Sclerotic cells were seen on direct examinations and the fungus was recovered in culture and identified on the basis of the characteristic sporulation. Itraconazole therapy at a dose of 200 mg day-1 for 7 months produced complete healing.

1274

Rhinosporidiosis and peripheral keratitis. Bhomaj S, Das JC, Chaudhuri Z, Bansal RL, Sharma P. Ophthalmic Surg Lasers. 2001 Jul-Aug;32(4):338-40.

Report of a case of peripheral keratitis caused by Rhinosporidium seeberi. The patient was seen in a referral practice. Corneal scraping was performed on a middle-aged female patient presenting with peripheral keratitis and progressive nasal obstruction that revealed spores suggestive of rhinosporidiosis. The patient was started on topical amphotericin B 0.15% eye drops. Ear, nose, and throat (ENT) examination showed presence of a polypoid lesion in the left nostril for which a polypectomy was performed. Histopathological examination confirmed rhinosporidiosis. Complete resolution of the keratitis was observed. Topical amphotericin B is an effective drug in the management of this condition. Keratitis secondary to rhinosporidial infection has not been described although occasional patients with limbal and scleral involvement have been reported. Corneal scraping was effective in helping us make a tentative diagnosis.

1275

Rhinosporidiosis presenting with two soft tissue tumors followed by dissemination. Angunawela P, De Tissera A, Dissanaike AS. Pathology. 1999 Feb;31(1):57-8.

Rhinosporidiosis is caused by Rhinosporidium seeberi. Most mycologists believe that R. seeberi is either a Chytridium related to the Olpidiaceae (order Chytridialis, class Chytridiomycetes) or a Synchytrium. This is the first documented case of tumoral rhinosporidiosis in a Sri Lankan and the third documented case in the world literature. A 44 year old male presented with a large mass above the thigh and a similar mass over the anterior chest wall, both masses contained R. seeberi. Later examination of the patient revealed nasal polyps, confirming that the tumors were due to systemic spread of this infection.

1276

[Nasal rhinosporidiosis] Soler Lluch E, Ruiz González M, González García J, Ruiz Martín F, García Linares C. Acta Otorrinolaringol Esp. 1998 Aug-Sep;49(6):498-500.

Rhinosporidiosis is a granulomatous disease of uncertain mycotic origin that is characterized by polypoid lesions, predominantly of the nasal mucous membrane and conjunctiva. It is endemic to India and Sri Lanki, but occasionally occurs in other regions of the world. We report a case in Spain. The modes of infection and transmission, as well as treatment, are discussed.

1277

Rhinosporidiosis. Report of a case with an unusual presentation with bony involvement. Adiga BK, Singh N, Arora VK, Bhatia A, Jain AK. Acta Cytol. 1997 May-Jun;41(3):889-91.

BACKGROUND: Rhinosporidiosis, a fungal infection due to Rhinosporidium seeberi, frequently produces polypoidal lesions in the nose. Sites like the conjunctiva, larynx, trachea, nasopharynx, skin and genitourinary tract are less frequently involved. Generalized rhinosporidiosis with skin and visceral involvement is extremely rare. This report describes the fine needle aspiration cytology (FNAC) of rhinosporidiosis occurring as a solitary lesion with erosion of cortical bone. CASE REPORT: FNAC of a soft tissue swelling overlying a lytic lesion on the anterior aspect of the tibia was performed in a 40-year-old male. Smears revealed numerous sporangia and spores of R seeberi. There were no mucocutaneous lesions. Histologic examination confirmed the bony involvement. CONCLUSION: The FNAC diagnosis of rhinosporidiosis is specific. Preoperative diagnosis is possible even in cases with unusual clinical presentations.

1278

Infection of the conjunctiva by Rhinosporidium seeberi. Reidy JJ, Sudesh S, Klafter AB, Olivia C. Surv Ophthalmol. 1997 Mar-Apr;41(5):409-13.

Rhinosporidiosis is an unusual fungal disease that rarely affects the eye. It was first described as a pathogen in humans at the turn of the century. The etiologic agent, Rhinosporidium seeberi, commonly produces granulomatous inflammation of the upper respiratory mucosa. Most reported ocular infections have occurred in hot, dry climatic regions. We present a case of conjunctival rhinosporidiosis in an 11-year-old boy from western New York state, the first such report from the temperate zones of North America. The clinical characteristics, histopathologic features, and recommended therapeutic measures are discussed.

1279

Rhinosporidiosis: presentation of 4 cases] González Núñez MA, Rodríguez Fernández AM, Méndez Vega AR, Martí Peña J, Pérez Toril Galán J, Carapeto Márquez de Prado R. Med Clin (Barc). 1990 May 12;94(18):689-92.

We report 4 cases of rhinosporidiosis in the province of Cáceres. Two had nasal localization and in two ocular conjunctiva was involved. Three patients, two of which came from the same village, had the antecedent of bathing in the same stagnant water. The diagnosis was made by the microscopic observation of characteristic sporangia of Rhinosporidium seeberi in the histopathological study. The lesions did not respond to antibiotic and antiinflammatory treatment. After excision there were no recurrences, and the patients are asymptomatic after 1 1/2 year follow up.

1282

Mycotic keratitis due to Rhizoctonia sp. Srivastava OP, Lal B, Agrawal PK, Agarwal SC, Chandra B, Mathur IS. Sabouraudia. 1977 Jul;15(2):125-31.

A case of mycotic keratitis due to Rhizoctonia sp. is reported for the first time. Fungal hyphae were detected in corneal scrapings and cultures were found positive for Rhizoctonia sp. on two occasions. Species could not be identified and it has been disposed in Herb. IMI as Rhizoctonia sp. (IMI 200029). The isolate grew faster at 37 degrees C than at 28 degrees C and its pathogenicity was established in rabbit's eye.

1284

Zygomycosis: review of 16 cases] González A, del Palacio A, Cuétara MS, Gómez C, Carabias E, Malo Q. Enferm Infecc Microbiol Clin. 1996 Apr;14(4):233-9.

BACKGROUND. Zygomycosis (mucormycosis or phycomycosis) is the infection caused by zygomycetes (non partitioned mycelial fungi, usually saprophytes). All cases of zygomycosis diagnosed in the Hospital 12 de Octubre in Madrid, Spain, from 1976 to 1994 were reviewed. METHODS. The underlying diseases of the patients, the factors favoring infection (alteration of the cutaneous barrier and administration of antimicrobians and corticosteroids) and the possible nosocomial origin of infection were analyzed. RESULTS. Over this period of time, 16 cases of zygomycosis were diagnosed with different clinical forms depending on the route of entry (rhino-orbital-cerebral, cutaneous or disseminated). The species isolated were Rhizopus oryzae, Rhizomucor pusillus, Absidia corymbifera and Rhizopus stolonifer. The species could not be determined in two cases. CONCLUSIONS. The diagnosis of zygomycosis should be based on a combined histological and microbiological study which allows both, differentiation between colonization and infection and isolation of the implicated species. Treatment is that of the underlying diseases, extensive surgical resection and amphotericin B.

1285

Cellulitis caused by Rhizomucor pusillus in a diabetic patient receiving continuous insulin infusion pump therapy. Wickline CL, Cornitius TG, Butler T. South Med J. 1989 Nov;82(11):1432-4.

We have reported a case of primary cutaneous zygomycosis in a diabetic patient receiving continuous insulin infusion pump therapy. We believe this to be the first reported case of a fungal infection associated with the use of an insulin pump. The infection itself was an unusually mild and chronic zygomycosis, possibly due to a low production rate of proteolytic enzymes by a rare opportunistic human pathogen, Rhizomucor pusillus.

1286

Diabetic ketoacidosis and rhino-orbital mucormycosis. Dokmetas HS, Canbay E, Yilmaz S, Elaldi N, Topalkara A, Oztoprak L, Yildiz E. Diabetes Res Clin Pract. 2002 Aug;57(2):139-42.

Mucormycosis often develops in immunocompromised patients, particularly in patients with diabetic ketoacidosis. Unless early diagnosis and treatment is established mucormycosis leads rapidly to death. A 38-year-old woman was admitted to the hospital with a severe diabetic ketoacidosis. Her clinical status improved in 4 days as a result of aggressive medical treatment. She has complained left cheek pain on the 10th day and had a swelling of her left cheek, facial edema, a black eschar on the palate and nasal cavity in association with visual disturbance and total ophthalmology in a short time. CT scan revealed left orbital cellulitis and pansinusitis. Excessive surgical treatment was performed and liposomal amphotericin-B, 4 mg/(kg day) was applied. Extensive fungal invasion of the orbit and the sinuses was demonstrated in the pathological species and Rhizomucor species were yielded with culture. Repeated superficial debridement was also performed. After 10 weeks, she was discharged with suggestion of insulin treatment and liposomal amphotericin-B with progressively decreasing doses. At the 13th month following the presentation, the patient was free of disease as confirmed by serial imaging and under good glycaemic control with insulin treatment. Although mucormycosis is a fatal infection, early diagnosis and aggressive treatment may decrease mortality.

1287

Nosocomial infection by Rhizomucor pusillus in a clinical haematology unit. del Palacio Hernanz A, Fereres J, Larregla Garraus S, Rodriguez-Noriega A, Sanz Sanz F. J Hosp Infect. 1983 Mar;4(1):45-9.

Three patients suffering from acute leukaemia were treated with cytotoxic agents and broad-spectrum antibiotics and received blood transfusion and nasal packing for severe epistaxis. All developed necrosis of nasal and facial tissues, with facial swelling an oedema; two biopsies showed typical phycomycete mycelium, and Rhizomucor pusillus was grown from one biopsy. Air and surfaces in the unit and the air intake and ducting were all heavily colonized by Rh. pusillus and other phycomycetes. It is suggested that Rh. pusillus spores from the air invaded the tissues in the conditions promoted by the nasal packing in these patients with impaired defences.

1288

Cure of pulmonary Rhizomucor pusillus infection in a patient with hairy-cell leukemia: role of liposomal amphotericin B and GM-CSF. Ma B, Seymour JF, Januszewicz H, Slavin MA. Leuk Lymphoma. 2001 Nov-Dec;42(6):1393-9.

We describe a case of successfully treated multifocal pulmonary Rhizomucor pusillus, a condition which has previously been universally fatal. A 77 year-old man had a background of chronic neutropenia due to hairy-cell leukemia, splenectomy, corticosteroid therapy and an obstructing left ureteric transitional-cell carcinoma. He was successfully treated with 3 months of high-dose liposomal amphotericin B and 7 months of granulocyte-macrophage colony-stimulating factor. Treatment was complicated by mild reversible deterioration of renal function. There was a near complete radiological response to the therapy at 6 months and the patient remains well 20 months following diagnosis of R. pusillus and 13 months following cessation of treatment.

1289

Infection due to Rhizomucor pusillus: report of four cases in patients with leukemia and review. St-Germain G, Robert A, Ishak M, Tremblay C, Claveau S. Clin Infect Dis. 1993 May;16(5):640-5.

Rhizomucor pusillus, a thermophilic fungus of the order Mucorales, is a rare cause of human infection. A search of the literature has produced only seven reports describing nine cases of infection caused by this organism. Recently, over a period of 17 months, four cases of R. pusillus infection in patients with leukemia were diagnosed: a cluster of three cases in a Montreal hospital and one isolated case from Quebec City. All four cases were proven both by histopathologic examination and by culture of tissues. In three cases, pulmonary involvement was confirmed following lung surgery, and in one case, disseminated infection was observed at autopsy. All patients received amphotericin B, and two underwent surgical debridement; however, none of the patients survived.

1290

[Disseminated aspergillosis and mucormycosis. A case report] Molle M, Blaschke-Hellmessen R, Schuler U, Nowak R, Ehninger G. Mycoses. 1996;39 Suppl 1:59-64.

This paper reports a simultaneous pulmonary infection due to Aspergillus fumigatus and Rhizomucor pusillus which evolved to disseminated aspergillosis and mucormycosis in a leukaemic and neutropenic 40-year-old woman. Both fungi were cultured ante mortem from bronchial secretion. Although high doses of intravenous amphotericin B were administered, the course of the infection was fatal. At autopsy, aspergilli were demonstrated by histology in lungs and brain, and zygomycetes were found to have invaded liver and kidneys.

1293

Rhinocerebral zygomycosis in a patient with acute lymphoblastic leukemia. Lerchenmüller C, Göner M, Büchner T, Berdel WE. Ann Oncol. 2001 Mar;12(3):415-9.

We report a case of a 28-year-old man with acute lymphoblastic leukemia who developed rhinocerebral zygomycosis during induction chemotherapy. This life-threatening fungal infection is an infrequent cause of neutropenic fever, and is occasionally found in patients with leukemia and lymphoma, or patients with severely compromised defence mechanisms due to other diseases. It is caused by moulds belonging to the Mucoraceae family, and is characterized by local destruction of the affected organ. In our patient, the infection spread from the paranasal sinuses to the right orbit, destroyed intraorbital structures and resulted in blindness within days. Biopsy from the right maxillary sinus was performed and mucormycosis was suspected through microscopic examination. Culture of the resected specimen identified Rhizopus arrhizus as the causing agent. Treatment of zygomycosis should consist of radical surgical debridement of the infected tissue, together with intensive broad-spectrum antimycotic therapy with amphotericin B. What could be learned from this case is, that aggressive approaches to identify the cause of infection is necessary, and that aggressive treatment strategies are inevitable to overcome the infection. Furthermore, treatment of the underlying disease should be continued as soon as possible.

1294

Fatal rhino-orbital-cerebral zygomycosis. Kameh DS, Gonzalez OR, Pearl GS, Walsh AF, Gambon T, Kropp TM. South Med J. 1997 Nov;90(11):1133-5.

Rhinocerebral zygomycosis is usually an aggressive, fulminant and, at times, fatal disease most often affecting poorly controlled diabetics of all ages. We report the case of a 13-month-old white boy, a previously undiagnosed diabetic. He came to our hospital with recurrent epistaxis, decreasing consciousness, and a small visible infection at the inner canthus of the left eye. Initial evaluation revealed that the patient was in diabetic ketoacidosis. Despite aggressive medical and surgical treatment, his condition deteriorated rapidly, including the development of diabetes insipidus, and he died 4 days after admission. At autopsy, he was found to have fungal cerebritis (Rhizopus) with multiple areas of infarction and massive cerebral edema.

1295

Chiasmal infarction and sudden blindness caused by mucormycosis in AIDS and diabetes mellitus. Lee BL, Holland GN, Glasgow BJ. Am J Ophthalmol. 1996 Dec;122(6):895-6.

PURPOSE: To report rapidly progressive rhino-orbitocerebral mucormycosis in a 47-year-old woman with both diabetes mellitus and the acquired immunodeficiency syndrome (AIDS). METHOD: Case report including postmortem examination of the eyes, orbit, and brain of a patient with rhino-orbitocerebral mucormycosis, diabetes mellitus, and AIDS. RESULTS: Invasion by hyphae of the Rhizopus species produced an occlusive vasculitis and massive infarction of the optic chiasm. Fungal organisms were discovered in multiple granulomata of the optic nerve. CONCLUSION: Infarction at the optic chiasm probably caused sudden blindness in this patient.

1296

Orbitofacial mucormycosis with unusual pathological features. Albert DM, Lesser RL, Cykiert RC, Zakov ZN. Br J Ophthalmol. 1979 Oct;63(10):699-703.

A 52-year-old man with mild diabetes and acute stem cell leukaemia developed an orbitofacial mucormycosis. Cultures showed the fungus to be Rhizopus oryzae. Vigorous treatment with amphotericin B and other bactericidal and bacteriostatic antibiotics for a concurrent sepsis failed to suppress the infections, and the patient died. On post-mortem examination characteristic haematoxylin-staining, broad, aseptate fungal hyphae were found in the right eye, orbit, and lung. A striking and unusual feature of this case is the presence of brightly birefringent crystals within the severely degenerated eye. These were found by histochemical staining and x-ray diffraction studies to be calcium salts of fatty acids, apparently liberated from necrotic adipose tissue of the orbit.

1297

[A case of abrupt pulmonary infection by Rhizopus microsporus var. rhizopodiformis during treatment for bronchial asthma] Maniwa K, Tanaka E, Taguchi Y, Oida K, Inoue T, Kato T, Sakuramoto M, Maeda Y, Terada K, Aihara M. Kansenshogaku Zasshi. 2002 May;76(5):396-9.

We presented a case of pulmonary Rhizops microsporus var. rhizopodiformis infection which developed abruptly during treatment of bronchial asthma by systemic corticosteroids. The patient, an 85 year-old-woman, was given systemic steroid therapy for 15 days. She suddenly became febrile two days after the therapy and was coughing up yellow sputum. Chest X-ray film showed multiple nodules with cavities which became worsened rapidly. A specimen of sputum culture gave a growth of Mucoraceae, which was identified to be Rhizopus microsporus var. rhizopodiformis. She was given amphotericin B and miconazole was added on the basis of MIC value of the strain. Although she improved initially, her clinical course showed neutropenia, pseudomembranous enterocolitis, malnutrition, and then died after about six months. Because the diagnosis of pulmonary mucormycosis is difficult and prognosis is poor, further studies for investigating clinical features would be necessary.

1298

Pulmonary mucormycosis in a diabetic patient. Vincent L, Biron F, Jardin P, Piens M, Dannaoui E, Isaac S, Guibert B, Pacheco Y. Ann Med Interne (Paris). 2000 Dec;151(8):669-72.

We present the case of a 54 year-old male from Moldavia with diabetes mellitus (type II diabetic), admitted to hospital in January 1999, with ketoacidosis and consolidation of the lower left lobe. The diagnosis of mucormycosis was confirmed by identification of large, nonseptate hyphae of the order Mucorales. A strain of Rhizopus oryzae (Rhizopus arrhizus) was isolated from culture on sabouraud medium. The patient was treated by systemic amphotericin B, associated with surgical debridement (lobectomy).The treatment with amphotericin B was stopped after ten days and the patient was completely asymptomatic and returned to Moldavia. Mucormycoses are rare, and tend to be encountered in individuals with predisposing factors such as malignant blood disorders (immunocompromised patients) or diabetes mellitus. Prognosis is poor, resembling infection with Aspergillus, despite aggressive treatment as in the present case. The gravity of the condition can be accounted for by the thrombotic and necrosing nature of the fungal invasion of lung vessels.

1299

Pulmonary Rhizopus infection in a diabetic renal transplant recipient. Demirag A, Elkhammas EA, Henry ML, Davies EA, Pelletier RP, Bumgardner GL, Dorner B, Ferguson RM. Clin Transplant. 2000 Feb;14(1):8-10.

Infectious complications after renal transplantation remain a major cause of morbidity and mortality. Mucormycosis is a rare infection in renal transplant recipients; however, mortality is exceedingly high. Risk factors predisposing to this disease include prolonged neutropenia, diabetes, and patients who are immunosuppressed (Singh N, Gayowski T, Singh J, Yu LV. Invasive gastrointestinal zygomycosis in a liver transplant recipient: case report and review of zygomycosis in solid-organ transplant recipients, Clin Infect Dis 1995: 20: 617). Life-threatening infections can occur, as this fungus has the propensity to invade blood vessel endothelium, resulting in hematological dissemination. We report a case of cavitary Rhizopus lung infection, 2 months after renal transplantation, where the patient was treated successfully with Amphotericin B and surgical resection of the lesions with preservation of his allograft function. In this era of intensified immunosuppression, we may see an increased incidence of mucormycosis in transplant population. Invasive diagnostic work-up is mandatory in case of suspicion; Amphotericin B and, in selected cases, surgical resection are the mainstays of therapy.

1300

Pulmonary Rhizopus rhizopodiformis cavitary abscess in a cardiac allograft recipient. Tan HP, Razzouk A, Gundry SR, Bailey L. J Cardiovasc Surg (Torino). 1999 Apr;40(2):223-6.

Pulmonary mucormycosis is rare in solid organ transplant recipients. Only one case has been reported previously in a cardiac allograft recipient. However, the Rhizopus species in that study was not identified. We report a case of successful surgical treatment of pulmonary cavitary mucormycosis due to Rhizopus rhizopodiformis in a cardiac allograft transplant recipient. A review of the literature on pulmonary mucormycosis occurring in solid organ transplant recipients is also presented.

1301

Rhizopus lung abscess in renal transplant patient successfully treated by lobectomy. Gribetz AR, Chuang MT, Burrows L, Teirstein AS. Chest. 1980 Jan;77(1):102-4.

A 46-year-old man with diabetes mellitus and cadaveric kidney transplant, maintained on a regimen of prednisone and azathioprine, developed a necrotizing pneumonia. The abscess cavity became secondarily infected with Rhizopus and was cured by surgical resection. Secondary invasion of an abscess cavity by Rhizopus and the successful surgical treatment of pulmonary phycomycosis in an immunosuppressed patient have not previously been reported.

1302

Fatal genitourinary mucormycosis in a patient with undiagnosed diabetes. Williams JC, Schned AR, Richardson JR, Heaney JA, Curtis MR, Rupp IP, von Reyn CF. Clin Infect Dis. 1995 Sep;21(3):682-4.

We present what we believe is the first report in the world literature of penile necrosis due to mucormycosis, a rare and often fatal fungal infection. This case of rhizopus mucormycosis began with a penile lesion in a 27-year-old patient with undiagnosed diabetes; it led to necrosis of the phallus, lower urinary tract, rectum, and pelvic musculature and finally to death. Despite repeated aggressive surgical debridement in conjunction with medical therapy, we were unable to halt the progression of the fungal and synergistic bacterial infections.

1303

Cutaneous zygomycosis: a case report and review of Japanese reports. Kobayashi M, Hiruma M, Matsushita A, Kawai M, Ogawa H, Udagawa S. Mycoses. 2001;44(7-8):311-5.

A 69-year-old man, a carpenter with idiopathic thrombopenic purpura and interstitial pneumonia, was treated with steroid pulse therapy and antibiotics. On the seventh day of steroid therapy, a conglomeration of papules, vesicles and pustules appeared in an area of the left buttock in contact with his napkin. In a Parker KOH specimen of the crust of the lesion, many non-septate hyphae were seen, and culture of material obtained by biopsy yielded Rhizopus microsporus var. microsporus. Ketoconazole cream was applied topically for 1 week, and the exanthema healed. After the third month of inpatient treatment, the patient's overall condition had returned to normal, and he was discharged. Cutaneous zygomycosis is a rare disease, and only 19 cases have been reported in Japan. Its characteristics, as reported in these cases, have been collected and collated.

1304

Primary cutaneous mucormycosis in a trauma patient. Song WK, Park HJ, Cinn YW, Rheem I, Pai H, Shin JH. J Dermatol. 1999 Dec;26(12):825-8.

We report a rare case of primary cutaneous mucormycosis caused by Rhizopus oryzae that occurred in an immunocompetent trauma patient. The patient had encrusted erythematous plaques with pustules on the left shin, which had been abraded in a traffic accident. Histologic examination revealed widespread granulomatous inflammation and characteristic broad, non-septate hyphae with right-angle branching in the dermis. The infection was cured with intravenous amphotericin B therapy.

1305

Primary cutaneous mucormycosis in a premature infant: case report and review of the literature. Linder N, Keller N, Huri C, Kuint J, Goldshmidt-Reuven A, Barzilai A. Am J Perinatol. 1998 Jan;15(1):35-8.

Mucormycosis is an uncommon infection caused by fungi of the order Mucorales, family Mucoraceae, and almost always occurs in individuals with predisposing factors such as diabetes mellitus, metabolic acidosis, or immunodeficiency states. Although mucormycosis is a rare infection in childhood, sporadic cases of skin infections have been described in young infants and older children; primary skin infection has been associated with multiple nosocomial outbreaks caused by contaminated elastic bandages. In all reported cases involving premature infants, the elimination of the infection involved surgical debridement. We report for the first time successful conservative treatment with intravenous amphotericin B in a premature infant with primary cutaneous infection caused by Rhizopus oryzae.

1306

Subcutaneous mucormycosis caused by Rhizopus oryzae probable nosocomial acquired infection.Telles Filho Fde Q, Coelho A, Porto E, Lameira RF, Freitas MM, Barboza J, Ramos JL. Rev Inst Med Trop Sao Paulo. 1985 Jul-Aug;27(4):201-6.

1307

Inguinal abscess caused by Rhizopus rhizopodiformis: successful treatment with surgery and amphotericin B. West BC, Kwon-Chung KJ, King JW, Grafton WD, Rohr MS. J Clin Microbiol. 1983 Dec;18(6):1384-7.

Rhizopus rhizopodiformis has seldom been isolated from human mucormycosis. We report the first subcutaneous abscess to be caused by this fungus. It occurred in a diabetic man and presented as an inguinal mass, suggestive of a hernia, superficial to his cadaveric renal transplant. The fungus was readily isolated from pus inoculated onto blood and chocolate agars after a short incubation. The patient was cured by surgical drainage and treatment with 2.0 g of intravenous amphotericin B. Complete identification of such isolates is recommended.

1308

Radiographic and radionuclide findings in Rhizopus osteomyelitis. Moore PH Jr, McKinney RG, Mettler FA Jr. Radiology. 1978 Jun;127(3):665-6.

A case of Rhizopus osteomyelitis is described. The radionuclide and radiographic findings differ from those of osteomyelitis secondary to common pathogens: low-level radionuclide activity is observed, while soft-tissue swelling, periosteal reaction, and loss of fascial margins are absent.

1309

Disseminated Rhizopus infection in a premature infant. Craig NM, Lueder FL, Pensler JM, Bean BS, Petrick ML, Thompson RB, Eramo LR. Pediatr Dermatol. 1994 Dec;11(4):346-50.

A 16-day-old premature male infant developed rapidly expanding necrotic facial plaques. Histology and cultures of tissue biopsy specimens revealed infection with Rhizopus arrhizius. The patient was treated aggressively with surgical debridement, amphotericin B, and rifampin, but had a progressive spread of the cutaneous infection and a fatal clinical course. He had gastrointestinal and pulmonary involvement on autopsy. Zygomycoses are rapidly progressive infections which generally affect immunocompromised hosts. Premature infants should be included as individuals at risk for disseminated zygomycotic disease.

1310

Disseminated mucormycosis in AIDS] Lagorce Pages C, Fabre A, Bruneel F, Zimmermann U, Henin D. Ann Pathol. 2000 Sep;20(4):343-5.

Mucormycosis is a rare often fatal opportunistic condition. It mainly occurs in immunocompromised subjects but rarely in AIDS patients. An eighteen-year-old HIV+ man from Zaire died rapidly from disseminated mucormycosis with pulmonary, cardiac, renal, hepatic, splenic and gastric involvement. Fungi were observed in all these organs with a particular vascular trophism. Rhizopus orizae was identified on cultures. Rapid microscopic diagnosis, in the localized stage, could improve the poor prognosis of this infection.

1311

Disseminated zygomycosis due to Rhizopus schipperae after heatstroke. Anstead GM, Sutton DA, Thompson EH, Weitzman I, Otto RA, Ahuja SK. J Clin Microbiol. 1999 Aug;37(8):2656-62.

A 21-year-old woman suffered heatstroke and developed diarrhea while trekking across south Texas. The heatstroke was complicated by seizures, rhabdomyolysis, pneumonia, renal failure, and disseminated intravascular coagulation. The patient's stool and blood cultures grew Campylobacter jejuni. The patient subsequently developed paranasal and gastrointestinal zygomycosis and required surgical debridement and a prolonged course of amphotericin B. The zygomycete cultured was Rhizopus schipperae. This is only the second isolate of R. schipperae that has been described. R. schipperae is characterized by the production of clusters of up to 10 sporangiophores arising from simple but well-developed rhizoids. These asexual reproductive propagules are produced on Czapek Dox agar but are absent on routine mycology media, where only chlamydospores are observed. Despite multiorgan failure, bacteremia, and disseminated zygomycosis, the patient survived and had a good neurological outcome. Heatstroke has not been previously described as a risk factor for the development of disseminated zygomycosis.

1312

Fatal fungal peritonitis in an adolescent on continuous ambulatory peritoneal dialysis: association with deferoxamine. Nakamura M, Weil WB Jr, Kaufman DB. Pediatr Nephrol. 1989 Jan;3(1):80-2.

An unusual case of Rhizopus microsporus (mucormycosis) fungal infection in a teenage boy on continuous ambulatory peritoneal dialysis is presented. Premortem cultures were negative and the patient developed a rapidly disseminated fatal infection. The patient was being treated with deferoxamine (DFO) for iron and aluminum overload. An argument is made for a probable association between DFO and this fatal fungal infection in patients with end-stage renal disease.

1314

Meningitis caused by Rhodotorula rubra in an HIV-infected patient. Gyaurgieva OH, Bogomolova TS, Gorshkova GI. J Med Vet Mycol. 1996 Sep-Oct;34(5):357-9.

Meningitis caused by Rhodotorula spp. in HIV-infected patients has not been reported previously. We present a brief review of the literature regarding medically important species of Rhodotorula and a case of meningitis caused by Rhodotorula rubra in an HIV-infected patient. The diagnosis was confirmed by the isolation of the fungus from the CSF. The course of Rhodotorula-induced meningitis was characterized by gradual development over several months, severe headache and high body temperature. No signs of damage to the meninx or inflammatory changes were observed. Therapy with 5-fluorocytosine for 15 days was successful in eliminating the yeast from the CSF. Eight months later the meningitis relapsed with R. rubra being recovered from the CSF. Suppressive therapy with itraconazole (400 mg daily during 3 months) followed by maintenance therapy (200 mg daily) eradicated the infection.

1315

Rhodotorula glutinis-related meningitis. Lanzafame M, De Checchi G, Parinello A, Trevenzoli M, Cattelan AM. J Clin Microbiol. 2001 Jan;39(1):410.

1316

Opportunistic infection with Rhodotorula in cancer patients treated by chemotherapy: two case reports. Alliot C, Desablens B, Garidi R, Tabuteau S. Clin Oncol (R Coll Radiol). 2000;12(2):115-7.

Rhodotorula species are commensal yeasts of variable pathogenicity. The authors report the case histories of two patients presenting with febrile neutropenia. The first was a 3-year-old girl who had been treated with combination chemotherapy for a tumour of the posterior fossa. The second was a 46-year-old man who had received chemotherapy for lymphoplasmocytic lymphoma, followed by consolidation treatment with autologous bone marrow transplantation. Investigation revealed infection caused by Rhodotorula. The outcome was favourable after removal of the catheter in both patients. Rhodotorula species have been isolated during a variety of infectious complications. Almost all published cases of fungaemia concern patients with central venous catheters that have been in place over long periods, who have also been treated with broad spectrum antibiotics. Neoplasia represents the most frequent underlying disease. The pathogenicity of Rhodotorula species appears to be moderate in most cases; fungal therapy or the removal of infected catheters is generally effective. Nevertheless, Rhodotorula has been reported to provoke fatal endocarditis or meningitis and can probably cause septic shock.

1317

Endocarditis caused by Rhodotorula successfully treated with 5-fluorocytosine. Naveh Y, Friedman A, Merzbach D, Hashman N. Br Heart J. 1975 Jan;37(1):101-4.

A 7-year-old boy suffering from aortic regurgitation and mitral stenosis and regurgitation was admitted with endocarditis caused by Rhodotorula pilimanae and was treated successfully with orally administered antifungal agent, namely 5-fluorocytosine (5-FC). A dose of 100 mg per kg body weight, divided into four equal parts, was prescribed. After a prolonged febrile period his temperature dropped to normal on the fourth day of 5-FC therapy. Review of the published reports disclosed few cases of endocarditis due to Rhodotorula spp. and this case seems to be the first treated with 5-FC. Follow-up in one year, after discharge from the hospital, revealed no evidence of relapse.

1318

Rhodotorula sp. infection in corneal interface following lamellar keratoplasty--a case report. Panda A, Pushker N, Nainiwal S, Satpathy G, Nayak N. Acta Ophthalmol Scand. 1999 Apr;77(2):227-8.

PURPOSE: To report an unusual organism causing infection following lamellar keratoplasty. METHOD: Case report. RESULT: Both gram stain smear and culture from the interlamellar bed revealed Rhodotorula sp., a red yeast as a causative agent. CONCLUSION: Rhodotorula sp. can cause corneal lamellar graft infection.

1319

Successful treatment of CAPD peritonitis caused by rhodotorula mucilaginosa. de Zoysa JR, Searle M, Lynn KL, Robson RA. Perit Dial Int. 2001 Nov-Dec;21(6):627-8.

1320

Rhodotorula rubra peritonitis in a child undergoing intermittent cycling peritoneal dialysis. Wong V, Ross L, Opas L, Lieberman E. J Infect Dis. 1988 Feb;157(2):393-4.

1321

Rhodotorula rubra peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. Eisenberg ES, Alpert BE, Weiss RA, Mittman N, Soeiro R. Am J Med. 1983 Aug;75(2):349-52.

Although still uncommon, fungal peritonitis is being reported with increasing frequency in patients with renal failure who are undergoing long-term peritoneal dialysis. Although most cases have involved Candida albicans, other opportunistic pathogens have been reported as well. Recently, three patients were seen with serious peritoneal infections due to Rhodotorula rubra, a "nonpathogenic" fungus. In two patients, peritoneal fibrosis made further peritoneal dialysis impossible. The third patient died from complications of peritonitis. Environmental cultures revealed a possible common-source outbreak. Literature review reveals that infection due to this organism is most unusual and occurs only in the hospital setting in patients with serious compromise of host defenses.

1322

Rhodotorula rubra ventriculitis. Donald FE, Sharp JF, Firth JL, Crowley JL, Ispahani P. J Infect. 1988 Mar;16(2):187-91.

We describe a case of post-operative ventriculitis in an immunocompetent patient caused by an unusual organism, namely Rhodotorula rubra. The patient was treated successfully with antifungal agents.

1323

Central venous catheter-related Rhodotorula rubra fungemia. Chung JW, Kim BN, Kim YS. J Infect Chemother. 2002 Mar;8(1):109-10.

With the increased use of indwelling central venous catheters, increasing numbers of cases of Rhodotorula fungemia have been observed in patients with neoplasia and neutropenia. In most patients with catheter-related Rhodotorula fungemia, the condition has been treated with broadspectrum antibiotics. We report two cases of central venous catheter-related Rhodotorula rubra fungemia that occurred in patients with acute myeloblastic leukemia. Both patients were in a state of neutropenia. One patient was treated with amphotericin B and his central venous catheter was removed, but he died of Klebsiella pneumoniae bacteremia. The other patient was treated with amphotericin B and discharged, with a central venous catheter, after recovery from neutropenia. Although the management of catheter-related Rhodotorula fungemia infections remains controversial, resolution of the underlying disease is more important than catheter removal for recovery from Rhodotorula rubra fungemia.

1324

. Transient fungemia due to Rhodotorula rubra in a cancer patient: case report and review of the literature. Samonis G, Anatoliotaki M, Apostolakou H, Maraki S, Mavroudis D, Georgoulias V. Infection. 2001 May-Jun;29(3):173-6.

A unique case of Rhodotorula rubra transient fungemia in a post-chemotherapy, febrile neutropenic patient with colon cancer, suffering from gastrointestinal mucositis, is described. The fungus was isolated repeatedly from his blood. However, all signs and symptoms of the infection disappeared, without antifungal treatment, as soon as neutropenia and mucositis, both of short duration, resolved. Restoration of the patient's defense mechanisms was adequate for disappearance of the fungus from the patient's blood and full recovery.

1325

Case report. Rhodotorula rubra fungaemia due to use of indwelling venous catheters. Kiraz N, Gülbas Z, Akgün Y. Mycoses. 2000;43(5):209-10.

Rhodotorula has been an infrequent cause of infection in humans but there have been some case reports about this systemic yeast infection. In this article, a Rhodotorula rubra fungaemia due to an indwelling catheter in a 23-year-old woman who had been diagnosed with non-Hodgkin's lymphoma grade IV B is described.

1326

Rhodotorula rubra fungaemia in an immunosuppressed patient. Papadogeorgakis H, Frangoulis E, Papaefstathiou C, Katsambas A. J Eur Acad Dermatol Venereol. 1999 Mar;12(2):169-70.

We report the case of a patient who, following surgical removal of an extensive tumour of the bowel, developed fungaemia. The yeast was isolated from repeated blood and urine cultures and identified as Rhodotorula rubra on the basis of macroscopic and microscopic features. Following treatment with amphotericin B, the patient's condition improved and the cultures became sterile.

1327

Rhodotorula septicemia: report of a case. Sheu MJ, Wang CC, Wang CC, Shi WJ, Chu ML. J Formos Med Assoc. 1994 Jul;93(7):645-7.

With the increased use of central venous catheters in cancer patients, there has been an increase in the recovery of environmental and skin organisms from blood cultures. A red yeast, Rhodotorula, an infrequent cause of infection in humans, was isolated from a patient with acute myeloblastic leukemia undergoing bone marrow transplant while he received parenteral nutritional fluids by an indwelling catheter. The patient was clinically ill, as manifested by fever and chills. The patient was treated with amphotericin B and the catheter was removed. He survived the fungemic episode with no recurrence of fungal infection.

1333

Seven cases of fungemia with Saccharomyces boulardii in critically ill patients. Lherm T, Monet C, Nougière B, Soulier M, Larbi D, Le Gall C, Caen D, Malbrunot C. Intensive Care Med. 2002 Jun;28(6):797-801.

Saccharomyces boulardii (Sb) is a particular strain of Saccharomyces cerevisiae (Sc). This viable yeast is used in intensive care adult patients, delivered in packets of 500 mg, for preventing diarrhea associated with antibiotics or enteral feeding at a regimen of 1-2 g/day. Between June 1996 and October 1998, seven cases of fungemia with Sb occurred in a 12-bed intensive care unit (ICU). All the patients concerned were severely ill patients, mechanically ventilated, treated by broad spectrum antibiotics with central venous catheter and were pretreated with Sb, except for one patient. In this study, Sb was identified by specific mycologic methods and confirmed the genomic identity between isolates of blood culture and yeasts from the treatment packets, contrary to a few other reports concerning Saccharomyces species published in international literature. The hypothesis discussed for explaining these cases of Sb fungemia are: (1) an intestinal translocation of Sb administered at a high dosage in severely ill patients, (2) a contamination of the central venous catheter, especially in the patient not pretreated with Sb and (3) a massive colonization of critically ill patients by the yeast as has been reported for Candida species. We note that cases of fungemia with Sc and Sb have become more and more frequent in the international literature during the last 10 years and we do not recommend administering Sb treatment in critically ill patients.

1334

Saccharomyces cerevisiae fungemia in a neutropenic patient treated with Saccharomyces boulardii. Cesaro S, Chinello P, Rossi L, Zanesco L. Support Care Cancer. 2000 Nov;8(6):504-5.

A case of Saccharomyces fungemia in an 8-month-old baby affected by acute myeloid leukemia while receiving intensive chemotherapy is reported. The patient was receiving prophylaxis treatment with Saccharomyces boulardii capsules (Codex) to prevent diarrhea, which is commonly associated with this type of chemotherapy. Fever spiked just the day after ending the chemotherapy course, and a strain of Saccharomyces cerevisiae was isolated from blood culture although the patient was also receiving antifungal prophylaxis with fluconazole. The patient recovered, though still neutropenic, with amphotericin-B and removal of the central venous catheter. The common biochemical characteristics make it difficult to differentiate between the strain of Saccharomyces cerevisiae and that of Saccharomyces boulardii with routine methods. In other cases, authors demonstrated an identity between the two strains with a more detailed analysis. These reports raise concern about the potential side effects of such biotherapeutic agents.

1335

Fungemia with Saccharomyces cerevisiae in two newborns, only one of whom had been treated with ultra-levura. Perapoch J, Planes AM, Querol A, López V, Martínez-Bendayán I, Tormo R, Fernández F, Peguero G, Salcedo S. Eur J Clin Microbiol Infect Dis. 2000 Jun;19(6):468-70.

Ultra-Levura (Upsamedica, Spain) is a yeast (Saccharomyces boulardii) widely used as a biotherapeutic agent. To date, few adverse effects have been reported, although fungemia with Saccharomyces cerevisiae can occur in weak and immunosuppressed patients. Reported here are two cases of fungemia with Saccharomyces cerevisiae. One patient had been treated with Ultra-Levura and the other contracted the infection from the first. This is the first report of infection with Saccharomyces boulardii (Saccharomyces cerevisiae) in a patient who was not being treated with the agent.

1336

Saccharomyces fungemia complicating Saccharomyces boulardii treatment in a non-immunocompromised host. Rijnders BJ, Van Wijngaerden E, Verwaest C, Peetermans WE. Intensive Care Med. 2000 Jun;26(6):825.

1337

Saccharomyces keratitis and endophthalmitis. Kirsch LS, Brownstein S, Deschênes J, Sorgini C, Jackson WB. Can J Ophthalmol. 1999 Jun;34(4):229-32.

1338

Primary cutaneous zygomycosis due to Saksenaea vasiformis and Apophysomyces elegans. Chakrabarti A, Kumar P, Padhye AA, Chatha L, Singh SK, Das A, Wig JD, Kataria RN. Clin Infect Dis. 1997 Apr;24(4):580-3.

We report three cases of primary cutaneous zygomycosis due to either Saksenaea vasiformis (two patients) or Apophysomyces elegans (one patient). Extensive surgical debridement helped two patients recover from their infections. The underlying disease in the one patient who died was diabetes mellitus. We reviewed the literature on primary cutaneous zygomycosis and found that S. vasiformis and A. elegans were the etiologic agents in 16 and 13 earlier cases, respectively.

1339

Cutaneous zygomycosis caused by Saksenaea vasiformis in a diabetic patient. Bearer EA, Nelson PR, Chowers MY, Davis CE. J Clin Microbiol. 1994 Jul;32(7):1823-4.

A 49-year-old woman with diabetes mellitus rapidly developed necrotizing cellulitis with fat necrosis and vasculitis after minor trauma to the right arm. Zygomycosis was diagnosed histologically. The lesion responded to aggressive debridement, amphotericin B, and normalization of blood glucose. Cultures yielded structures characteristic of Saksenaea vasiformis only after transfer to saline agar.

1340

Subcutaneous mucormycosis caused by Saksenaea vasiformis in a thalassaemic child: first case report in Thailand. Tanphaichitr VS, Chaiprasert A, Suvatte V, Thasnakorn P. Mycoses. 1990 Jun;33(6):303-9.

A first case of subcutaneous infection caused by Saksenaea vasiformis in an 11-year-old Thai thalassaemic boy was described. The specific diagnosis of infection was attained from microscopic demonstration of the causal agent as well as the isolation of the fungus. The patient was successfully treated by debridement of the lesion and parenteral amphotericin B. The predisposing factors, source of infection and regimen for treatment are discussed.

1341

First case of subcutaneous zygomycosis caused by Saksenaea vasiformis in India. Padhye AA, Koshi G, Anandi V, Ponniah J, Sitaram V, Jacob M, Mathai R, Ajello L, Chandler FW. Diagn Microbiol Infect Dis. 1988 Feb;9(2):69-77.

The first case of subcutaneous zygomycotic infection caused by Saksenaea vasiformis in a rice mill worker from India is described. The infection, confined to the man's left foot, showed multiple draining sinuses, inflammation, and intermittent low-grade fever following a crushing injury when a log fell on his foot. Histopathologic examination of two biopsy specimens, taken at 3-wk intervals, revealed the presence of broad, sparsely septate, branched, hyaline hyphae characteristic of a zygomycete. When they were grown on a nutritionally deficient medium, two cultures isolated from the biopsied tissues formed numerous, vase-shaped sporangia typical of S. vasiformis. Necrosis of the affected area led to amputation of the fore part of the foot. A split thickness graft was well accepted, and treatment with potassium iodide, following the graft, cured the infection.

1342

Rhinocerebral zygomycosis caused by Saksenaea vasiformis. Kaufman L, Padhye AA, Parker S. J Med Vet Mycol. 1988;26(4):237-41.

A fatal rhinocerebral zygomycotic infection caused by Saksenaea vasiformis in a 71-year-old man was diagnosed based on the presence of broad, infrequently septate, branched, hyaline hyphae in tissue obtained from the right and left base of the skull, soft tissue, both maxillary sinuses and the sphenoid sinus; isolation of S. vasiformis from the tissue; and demonstration of mucoraceous antibodies by enzyme-linked immunosorbent assay. Fluorescent antibody studies carried out with a Rhizopus arrhizus conjugate, stained hyphal fragments in tissue with a 2+ intensity.

1343

Saksenaea vasiformis breast abscess related to gardening injury. Wilson M, Robson J, Pyke CM, McCormack JG. Aust N Z J Med. 1998 Dec;28(6):845-6.

1344

Saksenaea vasiformis osteomyelitis. Pierce PF, Wood MB, Roberts GD, Fitzgerald RH Jr, Robertson C, Edson RS. J Clin Microbiol. 1987 May;25(5):933-5.

A 24-year-old man sustained a crush injury to the tibia, which subsequently became infected with Saksenaea vasiformis. He was treated with debridement and a free myocutaneous flap, but amputation was necessary because of mycotic osteomyelitis. S. vasiformis was recovered and identified on the basis of its characteristic morphology on cornmeal agar.

1345

Disseminated mucormycosis due to Saksenaea vasiformis in an immunocompetent adult. Solano T, Atkins B, Tambosis E, Mann S, Gottlieb T. Clin Infect Dis. 2000 Jun;30(6):942-3.

A case of disseminated infection due to Saksenaea vasiformis in a previously well adult male is presented. The clinical presentation was that of septic shock with a distinctive rash. At postmortem, endocarditis and widespread dissemination were evident.

1346

Disseminated zygomycosis (mucormycosis) caused by Saksenaea vasiformis. Hay RJ, Campbell CK, Marshall WM, Rees BI, Pincott J. J Infect. 1983 Sep;7(2):162-5.

A 14-year-old child from Iraq presented with an acute febrile illness accompanied by large necrotic skin lesions and bronchopneumonia from which he subsequently died. The infection was caused by an unusual zygomycete fungus Saksenaea vasiformis. Previous reports of infection with this organism are rare and tissue invasion has usually followed traumatic injury. In the child reported here no predisposing abnormalities were apparent.

1347

Disseminated Saksenaea vasiformis infection. Torell J, Cooper BH, Helgeson NG. Am J Clin Pathol. 1981 Jul;76(1):116-21.

Herein reported is a second case of human Saksenaea vasiformis infection. This unusual zygomycete was isolated postmortem from the tissues of an immunocompromised woman. The patient died of a disseminated infection that caused cutaneous, pulmonary, and renal infarcts. Clinical and pathologic features of the case and manifestations of zygomycete infection are discussed.

1348

Invasive infection with Sarcinosporon inkin in a patient with chronic granulomatous disease. Kenney RT, Kwon-Chung KJ, Witebsky FG, Melnick DA, Malech HL, Gallin JI. Am J Clin Pathol. 1990 Sep;94(3):344-50.

Sarcinosporon inkin, a rare skin fungus, was found to have caused progressive pneumonia in a young male with chronic granulomatous disease. Histologic sections of right upper lobe lung tissue showed clusters of globose to oblong hyalin-walled, septate, sporangia throughout the necrotic areas within the pyogranulomas. Pure cultures of S. inkin were recovered from the surgical specimen of the lung. Current status of the taxonomy of S. inkin is reviewed and clarified. Treatment of the patient with Amphotericin B and white blood cell transfusions led to clinical and radiographic response. This is the first documented case of systemic infection caused by S. inkin.

1350

Infection and colonization by Scedosporium prolificans] López L, Gaztelurrutia L, Cuenca-Estrella M, Monzón A, Barrón J, Hernández JL, Pérez R. Enferm Infecc Microbiol Clin. 2001 Aug-Sep;19(7):308-13.

BACKGROUND: Scedosporium prolificans is a dematiaceous fungus that is known to cause a wide spectrum of infections in humans, bearing a severity and a prognosis that is relationed with the patients immune status. METHODS: A retrospective review was made of the clinical charts of all patients who developed positive S. prolificans cultures in our centre from 1990 to 2000. Isolates were identified by colonial morphology and microscopic features. The in vitro susceptibility was evaluated using the microdilution method according to NCCLS. RESULTS: S. prolificans was isolated in 15 patients. Eight were affected with cystic fibrosis and the isolation of S. prolificans in their airways did not worsen their clinical status. Among the remaining 7 cases there were five leukemic patients with neutropenia and two immunocompetent hosts with cutaneous infection and endocarditis. Four of five neutropenic patients died of sudden sepsis and S. prolificans was isolated from blood cultures made a few days before their death, and the fifth neutropenic case suffered a bilateral pneumonia with improving course probably due to recovery from neutropenia. As to the immunocompetent group the clinical course was good in the cutaneous infection case, but the endocarditis case died four days after the antifungical therapy was started. All the isolates tested were found to be resistant to amphotericin, 5 flucytosine, fluconazole, itraconazole, voriconazole, miconazole and terbinafine. CONCLUSIONS: Scedosporium prolificans is a fungal pathogen that colonizes the airways of patients affected with cystic fibrosis. It can also cause a wide variety of infections, whose severity and prognosis depends on the patients immune status. Due to the resistance of this fungus to antifungal drugs, the therapeutic options are limited. Only with the correction of neutropenia and surgery in local infections in immunocompetent hosts it has been possible to cure these infections.

1351

Cutaneous Scedosporium apiospermum infection in an immunocompromised patient. Bower CP, Oxley JD, Campbell CK, Archer CB. J Clin Pathol. 1999 Nov;52(11):846-8.

Scedosporium apiospermum infection occurred in the left forearm of a patient who was taking oral prednisolone for pulmonary fibrosis. The infection appeared to follow a scratch from a blackcurrant bush. This is the first reported case in the United Kingdom of a cutaneous infection from Scedosporium apiospermum in an immunocompromised patient.

1352

Cutaneous infection by Scedosporium apiospermum and its successful treatment with itraconazole. Liu YF, Zhao XD, Ma CL, Li CX, Zhang TS, Liao WJ. Clin Exp Dermatol. 1997 Jul;22(4):198-200.

We report the case of a 42-year-old man with a 13-year history of bilateral faciocervical infiltrative erythema, which had been misdiagnosed as tuberculoderma and which had failed to respond to treatment with adrenal corticosteroids and antituberculotics. On admission to the department, Scedosporium apiospermum was identified on lesion biopsies and fungus cultures as the causative agent and a diagnosis of cutaneous infection by S. apiospermum was made. This is the first report of chronic skin granuloma caused by S. apiospermum in China. Treatment with oral itraconazole (100-400 mg/day) led to clinical cure within 4 months.

1353

Chronic, recurrent osteomyelitis caused by Scedosporium inflatum. Malekzadeh M, Overturf GD, Auerbach SB, Wong L, Hirsch M. Pediatr Infect Dis J. 1990 May;9(5):357-9.

1354

Pathology of hyalohyphomycosis caused by Scedosporium apiospermum (Pseudallescheria boydii): an emerging mycosis. Tadros TS, Workowski KA, Siegel RJ, Hunter S, Schwartz DA. Hum Pathol. 1998 Nov;29(11):1266-72.

The genus Scedosporium contains two medically significant species of emerging mycotic agents, S. apiospermum and S. prolificans, which have received scant attention. Scedosporium apiospermum is the anamorph, or asexual state, of the cosmopolitan fungus Pseudallescheria boydii, with both sharing the same risk factors for infection, clinical spectrum, and histopathologic features. Scedosporium prolificans is a recently recognized agent of bone, soft tissue, and joint infections that occurs with highest frequency in children and young adults. S. prolificans may also cause potentially fatal disseminated infections in immunocompromised persons. The drug sensitivities of both Scedosporium species are significantly different from those of most other fungi, and thus identification of these organisms is important. Unfortunately, the pathological features of Scedosporium infections may be easily confused with other mycotic agents, resulting in delayed or inappropriate medical therapy. Because many pathologists and clinicians are unfamiliar with the significance of Scedosporium spp. infection, this communication describes three persons with differing clinical and pathological presentations of S. apiospermum infection. In one patient with sickle cell disease and chronic mycotic sinusitis, fungal colonies of S. apiospermum removed from the sinuses showed a pattern of alternating zones of mycelial hypercellularity and hypocellularity associated with conidiation, similar to a previous report of P. boydii infection. The clinicopathologic features of an immunocompetent person with S. apiospermum osteomyelitis, and a patient with S. apiospermum infection of the brain after bone marrow transplantation, are also described.

1355

Successful treatment of Scedosporium apiospermum suppurative arthritis with itraconazole. Piper JP, Golden J, Brown D, Broestler J. Pediatr Infect Dis J. 1990 Sep;9(9):674-5.

1356

Endocarditis and hip arthritis associated with Scedosporium inflatum. Toy EC, Rinaldi MG, Savitch CB, Leibovitch ER. South Med J. 1990 Aug;83(8):957-60.

A 30-year-old man had endocarditis and hip arthritis associated with the recently recognized fungus, Scedosporium inflatum. Inhibition, and possibly cure, of endocarditis occurred with medical therapy alone. Data from in vitro susceptibility testing did not predict clinical response. This case also illustrates the need to standardize fungal susceptibility testing and to remain vigilant for emerging pathogens.

1357

Scedosporium apiospermum (Pseudallescheria boydii) endocarditis. O'Bryan TA, Browne FA, Schonder JF. J Infect. 2002 Apr;44(3):189-92.

Scedosporium apiospermum, the asexual state of Pseudallescheria boydii, is increasingly recognized as an opportunistic pathogen. We report a case of native valve endocarditis due to this organism that developed in an elderly patient following a prolonged hospitalization. Literature on endocarditis caused by S. apiospermum and P. boydii is reviewed.

1358

Endocarditis caused by Scedosporium prolificans after autologous peripheral blood stem cell transplantation. Carreter de Granda ME, Richard C, Conde E, Iriondo A, Marco de Lucas F, Salesa R, Zubizarreta A. Eur J Clin Microbiol Infect Dis. 2001 Mar;20(3):215-7.

1359

Deep infections caused by Scedosporium prolificans. A report on 16 cases in Spain and a review of the literature. Scedosporium Prolificans Spanish Study Group. Berenguer J, Rodríguez-Tudela JL, Richard C, Alvarez M, Sanz MA, Gaztelurrutia L, Ayats J, Martinez-Suarez JV. Medicine (Baltimore). 1997 Jul;76(4):256-65.

Scedosporium prolificans, a mold morphologically similar to Scedosporium apiospermum, may cause asymptomatic colonization or localized or disseminated infection following trauma, surgery, and immunosuppression. S. prolificans is normally resistant to available antifungal agents, and prognosis depends largely on the host's immune status, extent of infection, and feasibility of surgical debridement. We report on 16 patients with deep S. prolificans infections, focusing on predisposing factors, clinical characteristics, outcome, postmortem findings, and antifungal susceptibility testing to 6 antifungal agents. Between 1989 and 1994, 16 cases of deep infections by S. prolificans were documented in 6 clinical centers in Spain (15 adults and 1 child: male/female = 0.77). Fifteen patients had underlying hematologic malignancy (14 with neutropenia) and 1 had a prosthetic cardiac valve. Syndromes included disseminated infection in 14 patients (1 with prosthetic valve endocarditis) and fungal pneumonia and meningoencephalitis in 1 patient each. S. prolificans was isolated from 2 specimens in 14 patients and from 1 specimen in 2 patients (blood, n = 12; respiratory tract, n = 4; CNS, n = 4; and skin biopsy, n = 3). Antifungal susceptibility testing by a micromethod with RPMI-2% glucose medium was performed in 8 isolates, all of which were resistant to amphotericin B, flucytosine, ketoconazole, fluconazole, itraconazole, and miconazole. All patients received antifungal therapy (amphotericin B, n = 9; amphotericin B+ flucytosine, n = 1; amphotericin B+ itraconazole, n = 2; liposomal amphotericin B+ itraconazole, n = 1; amphotericin B+ fluconazole, n = 1 and 2 underwent surgical procedures. Two patients survived coinciding with hematologic recovery and 14 (87.5%) patients died in a median time of 4 days after the first positive culture (range, 0-60 d). Necropsy was performed in 10 patients, and disseminated infection was found in 9. In conclusion, S. prolificans is an emerging multiresistant fungal pathogen that may cause asymptomatic colonization, localized infection related to trauma or surgery, and rapidly fatal disseminated infection in immunocompromised hosts, particularly those with neutropenia. This mycosis underscores the urgent need for new antifungal agents.

1360

Maxillary sinusitis: isolation of Scedosporium (Monosporium) apiospermum, anamorph of Petriellidium (Allescheria) boydii. Bloom SM, Warner RR, Weitzman I. Mt Sinai J Med. 1982 Nov-Dec;49(6):492-4.

1361

Pulmonary infection with Scedosporium prolificans in an immunocompetent individual. Greig JR, Khan MA, Hopkinson NS, Marshall BG, Wilson PO, Rahman SU. J Infect. 2001 Jul;43(1):15-7.

We report a case of histologically confirmed Scedosporium prolificans pulmonary infection secondary to long-standing bronchiectasis that necessitated excision lung surgery. This case emphasizes the difficulties with the medical management of deep-seated fungal infections.

1362

Invasive Scedosporium apiospermum infection in a heart transplant recipient presenting with multiple skin nodules and a pulmonary consolidation. Kusne S, Ariyanayagam-Baksh S, Strollo DC, Abernethy J. Transpl Infect Dis. 2000 Dec;2(4):194-6.

1363

Pneumonia due to Scedosporium apiospermum in a patient with HIV infection. Rollot F, Blanche P, Richaud-Thiriez B, Le Pimpec-Barthes F, Riquet M, Dusser D, Salmon D, Sicard D. Scand J Infect Dis. 2000;32(4):439.

A 29-y-old woman from Congo Democratic Republic was admitted to hospital with dyspnoea of 5-months duration. Chest X-ray showed left white lung and infiltrates of the right superior lobe. The patient underwent left pneumonectomy. Histopathological examination showed pulmonary cavitary lesions and bronchectasis full of branching septated fungi. Cultures yielded Scedosperium apiospermum.

1364

Invasive pulmonary infection due to Scedosporium apiospermum in two children with chronic granulomatous disease. Jabado N, Casanova JL, Haddad E, Dulieu F, Fournet JC, Dupont B, Fischer A, Hennequin C, Blanche S. Clin Infect Dis. 1998 Dec;27(6):1437-41.

Scedosporium apiospermum is an opportunistic fungus in humans. The incidence of S. apiospermum infection in patients with acquired neutropenia (e.g., patients receiving chemotherapy and bone marrow transplant recipients) is steadily increasing. S. apiospermum has poor in vitro susceptibility to "conventional" antifungal agents, rendering the management of infections complex. Patients with chronic granulomatous disease (CGD) are highly susceptible to fungal infections, which are mostly due to Aspergillus species. We describe two children with CGD and invasive pulmonary infection due to S. apiospermum. Both patients were treated with antifungal therapy including azole derivatives (itraconazole or voriconazole) and surgical resection of infected tissues. These cases highlight that scedosporium infection can closely mimic aspergillus infection and should be considered in any case in which there is a failure to respond to appropriate "conventional" antifungal therapy. We also suggest that the emergence of this pathogen may have been favored by long-term use of amphotericin B in both patients.

1365

Fatal meningoencephalitis caused by Scedosporium inflatum (Scedosporium prolificans) in a child with lymphoblastic leukemia. Madrigal V, Alonso J, Bureo E, Figols FJ, Salesa R. Eur J Clin Microbiol Infect Dis. 1995 Jul;14(7):601-3.

A fatal case of meningoencephalitis caused by Scedosporium inflatum (Scedosporium prolificans) in a 5-year-old boy with acute myeloblastic leukemia who was given intrathecal treatment is reported. Itraconazole treatment was ineffective. The fungus was identified on brain sections at autopsy and was not observed in any other organ. As no other portal of entry was detected, meningoencephalitis may have originated via direct introduction of the fungus at therapeutic lumbar puncture.

1366

Scedosporium endophthalmitis: two fatal disseminated cases of Scedosporium infection presenting with endophthalmitis. McKelvie PA, Wong EY, Chow LP, Hall AJ. Clin Experiment Ophthalmol. 2001 Oct;29(5):330-4.

The incidence of disseminated infection with Scedosporium species is increasing in patients with haematological malignancy. Two fatal cases are reported of patients with acute myeloid leukaemia and neutropenia who presented with Scedosporium endophthalmitis. Diagnosis of fungal infection was delayed as blood and vitreous cultures were positive only after 3 days in patient 1 and blood culture was positive at 7 days in patient 2. Despite antifungal therapy with amphotericin B and additional fluconazole in patient 2, both patients died of overwhelming fungal septicaemia. Post-mortem examination of the right globe in patient 1 showed haemorrhagic necrotizing chorioretinitis with numerous fungal hyphae in choroidal vessels, choroid, retina and vitreous. Scedosporium species are often resistant to conventional antifungal therapy including amphotericin B. Diagnosis is difficult and mortality in disseminated infection is high.

1367

Scedosporium apiospermum fungemia in a lung transplant recipient. Raj R, Frost AE. Chest. 2002 May;121(5):1714-6.

Scedosporium apiospermum, the asexual anamorph of the cosmopolitan fungus Pseudallescheria boydii, is emerging as an important cause of disseminated infection in immunocompromised patients. We present our experience with the first reported case of S apiospermum fungemia in a lung transplant patient. Disseminated infection resulted in sepsis, multiorgan failure, and death. Review of the literature highlights the diagnostic difficulties related to the similarities between S. apiospermum and Aspergillus sp. This superficial resemblance has a significant impact on clinical outcomes considering the inherent resistance of Scedosporium to amphotericin B, the traditional antifungal of choice for disseminated hyalohyphomycoses.

1368

Disseminated infection and colonization by Scedosporium prolificans: a review of 18 cases, 1990-1999. Idigoras P, Pérez-Trallero E, Piñeiro L, Larruskain J, López-Lopategui MC, Rodríguez N, González JM. Clin Infect Dis. 2001 Jun 1;32(11):E158-65.

Scedosporium prolificans infection was analyzed in 18 patients from whom the fungus was isolated during the period 1990-1999. Of these 18 patients, 12 had some predisposing factor and either unconfirmed infection or colonization, and 6 patients had confirmed disseminated infection: 4 patients with leukemia died, 1 patient with breast cancer who underwent autologous bone marrow transplantation survived, and 1 patient with advanced acquired immunodeficiency syndrome died, although the fungal infection did not seem to affect his clinical symptoms.

1369

Fatal disseminated infection by Scedosporium prolificans during induction therapy for acute leukemia: a case report and literature review. Westerman DA, Speed BR, Prince HM. Pathology. 1999 Nov;31(4):393-4.

We report a case of fatal disseminated fungal infection by Scedosporium prolificans which occurred in a patient with acute leukemia during induction chemotherapy. Rapid clinical deterioration despite high-dose empirical amphotericin B highlights both the pathogenicity of this fungus in immunocompromised hosts and its resistance to standard antifungal therapy.

1370

Fatal Scedosporium prolificans infection in a leukemic patient. Feltkamp MC, Kersten MJ, van der Lelie J, Burggraaf JD, de Hoog GS, Kuijper EJ. Eur J Clin Microbiol Infect Dis. 1997 Jun;16(6):460-4.

The case is described of a 42-year-old patient with acute myeloid leukemia who received two courses of chemotherapy complicated by prolonged bone marrow depression. He was admitted to hospital with fever, hepatosplenomegaly and bilateral nodular pulmonary infiltrates. After admission diffuse cutaneous skin nodules, and hypodense lesions in the hemispheres and cerebellum developed. Cultures of cerebrospinal fluid, bronchoalveolar lavage fluid, skin biopsy specimens and blood revealed Scedosporium prolificans, indicative of disseminated mycosis. Treatment with amphotericin B and fluconazole was unsuccessful and the patient died within five days after admission. Features that may enhance early recognition of Scedosporium prolificans infection by both clinicians and microbiologists, as well as options in the treatment of infection with this fungal agent are discussed.

1371

Disseminated Scedosporium prolificans (S. inflatum) infection after single-lung transplantation. Rabodonirina M, Paulus S, Thevenet F, Loire R, Gueho E, Bastien O, Mornex JF, Celard M, Piens MA. Clin Infect Dis. 1994 Jul;19(1):138-42

This report concerns the first case of disseminated infection with Scedosporium prolificans (S. inflatum) that occurred in a patient who had received an organ transplant and was verified at autopsy. The patient underwent single (right)-lung transplantation and subsequently died on the 33rd postoperative day in a context of septic shock. S. prolificans was isolated from various specimens, including two cultured blood samples. The organism was associated with Candida albicans in some of these specimens. Autopsy revealed the presence of numerous nodular abscesses in the lungs, myocardium, kidneys, spleen, and gall bladder. These abscesses contained mycelial filaments and numerous oval conidia suggestive of Scedosporium species but no yeasts. MIC studies demonstrated the resistance of the S. prolificans isolate to amphotericin B, fluctyosine, miconazole, ketoconazole, and itraconazole, whereas the isolate of C. albicans was susceptible to amphotericin B, flucytosine, miconazole, and ketoconazole. From the data from our case and six published reports of cases of disseminated S. prolificans infection, it can be concluded that this filamentous fungus is a new agent responsible for the most serious mycoses in both neutropenic patients and patients who have undergone organ transplantation.

1375

Brain abscess caused by Schizophyllum commune: an emerging basidiomycete pathogen. Rihs JD, Padhye AA, Good CB. J Clin Microbiol. 1996 Jul;34(7):1628-32.

Despite the worldwide distribution and prevalence of Schizophyllum commune, an emerging basidiomycetous pathogen, human infections occur only rarely. We describe the first well-documented pulmonary infection caused by S. commune which disseminated to the brain of a 58-year-old patient undergoing empiric corticosteroid therapy. Magnetic resonance imaging scans revealed ring-enhancing masses. Histologic examination of biopsy tissue from lungs and brain showed hyaline, septate, branched hyphae with clamp connections. Cultures of the lung tissue grew S. commune, which produced numerous, characteristic flabelliform and medusoid fruiting bodies on Czapek's agar. The isolate was susceptible to amphotericin B (MIC, < 0.03 microgram/ml) and fluconazole (MIC, 8 micrograms/ml). Despite treatment with antifungal and antibacterial agents, the patient developed progressive pulmonary failure and bacterial sepsis and died.

1376

Maxillary sinus infection caused by the homobasidiomycetous fungus Schizophyllum commune. Kern ME, Uecker FA. J Clin Microbiol. 1986 Jun;23(6):1001-5.

We investigated a case of maxillary sinus infection caused by the medusoid mutant of the basidiomycetous fungus Schizophyllum commune. Morphologies of both typical and medusoid forms of S. commune were determined. Prior reports of pathogenic homobasidiomycetes are discussed.

1377

Chronic maxillary sinusitis associated with the mushroom Schizophyllum commune in a patient with AIDS. Rosenthal J, Katz R, DuBois DB, M.orrissey A, Machicao A. Clin Infect Dis. 1992 Jan;14(1):46-8.

Invasive infection with fungi of the Basidiomycota (rusts, smuts, toadstools, mushrooms, and puffballs) is extremely rare. We report such an infection in a patient with human immunodeficiency virus disease who presented with chronic maxillary sinusitis associated with the mushroom Schizophyllum commune. The organism was isolated from the surgical drainage material, and septate hyphae were seen invading the maxillary submucosa. The limited literature on this subject is reviewed.

1378

Chronic sinusitis caused by Schizophyllum commune in AIDS] Marlier S, De Jaureguiberry JP, Aguilon P, Carloz E, Duval JL, Jaubert D. Presse Med. 1993 Jun 26;22(23):1107.

1379

Maxillary sinusitis caused by Schizophyllum commune and experience with treatment. Sigler L, Estrada S, Montealegre NA, Jaramillo E, Arango M, De Bedout C, Restrepo A. J Med Vet Mycol. 1997 Sep-Oct;35(5):365-70.

A case of sinusitis caused by the basidiomycete Schizophyllum commune is reported in a 36-year-old female with a history of allergic rhinitis and dermatitis. The patient presented with sudden nasal obstruction, purulent nasal discharge, headache and general discomfort. Computer tomography revealed extensive opacity of the left maxillary sinus as well as erosion of the nasal wall and maxillary bone. Mycological examinations of nasal discharges and material aspirated during anthrostomy showed hyaline, septate hyphae with rare spicules. Primary isolation yielded a white, woolly mould which demonstrated clamp connections and basidiocarp primordia but these characteristics were lost in subculture. Identification was confirmed by vegetative compatibility studies. The patient was treated with itraconazole to avoid possible postsurgical dissemination. Three months after cessation of therapy, no recurrence of infection had occurred.

1380

Diagnostic difficulties caused by a nonclamped Schizophyllum commune isolate in a case of fungus ball of the lung. Sigler L, de la Maza LM, Tan G, Egger KN, Sherburne RK. J Clin Microbiol. 1995 Aug;33(8):1979-83.

The presence of clamp connections on hyphae and the development of fruiting bodies in culture are primary characters which allow identification of the basidiomycete Schizophyllum commune in cases of human infection. The diagnostic problems presented by a nonclamped, nonfruiting isolate from a dense mass in the right upper lobe of the lung in a female with a past history of pulmonary tuberculosis and diabetes are described. Several features of the isolated fungus, including rapid growth rate and white, dense, cottony colonies, tolerance to the fungicide benomyl at a concentration of 10 micrograms/ml, and susceptibility to cycloheximide at 400 micrograms/ml, suggested that it might be a basidiomycete. Transmission electron microscopy showed the presence of a dolipore septum with perforate pore cap characteristic of fungi in the class Holobasidiomycetes. However, species identification remained elusive until compatibility tests with known single-basidiospore isolates confirmed the identification of the sterile lung isolate as S. commune. Sequence analysis of the 5' internal transcribed spacer region of ribosomal DNA further supported conspecificity.

1381

Phototoxic dermatitis caused by celery infected by Sclerotinia sclerotiorum. Austad J, Kavli G. Contact Dermatitis. 1983 Nov;9(6):448-51.

11 men developed a severe phototoxic dermatitis of the hands and forearms after harvesting celery infected with Sclerotinia sclerotiorum. By thin-layer chromatography and fluorescence spectrophotometry, xanthotoxin, bergapten and sphondin were isolated. The Canadida albicans test demonstrated xanthotoxin and bergapten as the phototoxic compounds.

1383

Invasive hyalohyphomycosis caused by Scopulariopsis brevicaulis in a patient undergoing allogeneic bone marrow transplant. Phillips P, Wood WS, Phillips G, Rinaldi MG. Diagn Microbiol Infect Dis. 1989 Sep-Oct;12(5):429-32.

Scopulariopsis brevicaulis is a common soil saprobic mould. Occasionally, S. brevicaulis has been reported as an etiologic agent of human disease. The spectrum of human mycoses includes toenail infection, hypersensitivity pneumonitis, fungus ball formation in a preformed pulmonary cavity, and, most recently, documented deep tissue infections in immunocompromised hosts. A case of invasive hyalohyphomycosis of the great toe caused by S. brevicaulis is reported in an allogeneic bone-marrow transplant recipient.

1384

Scopulariopsis: an invasive nasal infection. Jabor MA, Greer DL, Amedee RG. Am J Rhinol. 1998 Sep-Oct;12(5):367-71.

Scopulariopsis, a soil saprophyte, rarely produces disease and has not been reported to cause invasive nasal destruction in a nonimmunocompromised host. We report the first case of Scopulariopsis in the otolaryngology literature. Prompt surgical debridement is required and usually adequate. Disagreement exists on the use of antifungals as an effective treatment. A case of invasive Scopulariopsis involving the nasal septum of a 72-year-old man is detailed, and successful treatment consisted of local debridement without antifungal drugs. His diagnosis, clinical course, and outcome illustrates the expanding differential diagnosis faced by the otolaryngologist in patients with nasal disease.

1385

Report of the first case of invasive fungal sinusitis caused by Scopulariopsis acremonium: review of scopulariopsis infections. Ellison MD, Hung RT, Harris K, Campbell BH. Arch Otolaryngol Head Neck Surg. 1998 Sep;124(9):1014-6.

Scopulariopsis acremonium is a species of saprophytic fungus not previously reported to cause invasive disease in humans, although invasive infections from other species of Scopulariopsis have been reported and are reviewed. Deep infection with this fungus is associated with a high mortality rate. Invasive fungal sinusitis, in general, is a potentially fatal disease that typically affects immunocompromised patients, such as those receiving intensive chemotherapy or undergoing bone marrow transplantation. We report a case of invasive fungal sinusitis caused by Scopulariopsis acremonium in a patient with leukemia, who was successfully treated with amphotericin B, itraconazole, endoscopic sinus surgery, and granulocyte colony-stimulating factor.

1386

Invasive sinonasal disease due to Scopulariopsis candida: case report and review of scopulariopsosis. Kriesel JD, Adderson EE, Gooch WM 3rd, Pavia AT. Clin Infect Dis. 1994 Aug;19(2):317-9.

Sinonasal infection with fungi of the order Mucorales--termed mucormycosis or zygomycosis--is sometimes seen in immunosuppressed patients, including those with diabetic ketoacidosis and malignancy. We describe a case of invasive sinonasal infection with Scopulariopsis candida (not among the Mucorales organisms) in a 12-year-old girl who was being treated for non-Hodgkin's lymphoma. Only a few cases of invasive infection with Scopulariopsis species have been reported previously; five of six of these cases were associated with persistent or fatal disease. Our patient survived without undergoing radical surgical debridement and was treated with granulocyte colony-stimulating factor, amphotericin B, and itraconazole; chemotherapy was stopped. In vitro susceptibility testing of our patient's Scopulariopsis isolate showed that it was resistant to amphotericin B and that it was relatively susceptible to itraconazole and miconazole. The case described herein demonstrates the expanding spectrum of fungal organisms that may cause invasive sinonasal infection in immunocompromised hosts and the need for reliable antifungal susceptibility testing.

1387

Invasive Scopulariopsis in the immunocompromised host. Neglia JP, Hurd DD, Ferrieri P, Snover DC. Am J Med. 1987 Dec;83(6):1163-6.

Opportunistic infections with fungal organisms have been well described in patients undergoing intensive chemotherapy and bone marrow transplantation. In two patients, invasive infections with the saprophyte Scopulariopsis developed either following intensive chemotherapy or bone marrow transplant. Fungal disease persisted in both patients despite resection of the primary focus and prolonged treatment with the usual antifungal agents, and contributed to the death of one patient.

1388

Subcutaneous mycosis due to Scopulariopsis brevicaulis in an immunocompromised patient] Martel J, Faisant M, Lebeau B, Pinel C, Feray C, Feuilhade M. Ann Dermatol Venereol. 2001 Feb;128(2):130-3.

BACKGROUND: Scopulariopsis brevicaulis is a causal agent of onchomycosis. We report the unusual clinical manifestations caused by this opportunist fungus.CASE REPORT: A 61-year-old man consulted in February 1997 for a budding lesion located on the right medial malleolus. This patient had had a liver transplantation for primary biliary cirrhosis in 1990 and had been taking prednisone and cyclosporine since this time. Cyclosporine had been recently replaced by tacrolimus. The histology examination of a lesion specimen taken from the ankle evidenced a dermal mycosis due to opportunist filamentous fungus. Total excision was performed. The patient then developed nodular lesions of the left elbow during the summer of 1997. Mycology culture of a skin biopsy grew numerous colonies of Scopulariopsis brevicaulis. Excision of the elbow lesion was delayed due to hospitalization for suspected graft rejection and development of insulin-dependent diabetes. The elbow lesion was then resected followed by a skin graft. The mycology examination identified the same causal agent.DISCUSSION: This liver transplant recipient developed two unusual extra-ungual localizations (ankle and elbow) of a Scopulariopsis brevicaulis infection. Chronic immunosuppression favored development of the infection with a pseudo-epithéliomatous presentation. The histology and mycology examinations were necessary for positive diagnosis.

1389

Granulomatous skin infection caused by Scopulariopsis brevicaulis. Bruynzeel I, Starink TM. J Am Acad Dermatol. 1998 Aug;39(2 Pt 2):365-7.

A 14-year-old girl with a granulomatous infection of the cheek caused by Scopulariopsis brevicaulis is described. Treatment successively consisted of itraconazole and/or terbinafine for 19 months, after which clinical and mycologic cure seemed to be obtained. However, a relapse occurred 10 months later.

1390

Ulcerous granulomatous cheilitis with lymphatic invasion caused by Scopulariopsis brevicaulis infection. Creus L, Umbert P, Torres-Rodríguez JM, López-Gil F. J Am Acad Dermatol. 1994 Nov;31(5 Pt 2):881-3.

A 43-year-old man with ulcerous granulomatous cheilitis and submaxillary lymph node invasion caused by Scopulariopsis brevicaulis infection is described. Administration of itraconazole produced a dramatic and definitive cure. Reported cases of deep mycosis caused by S. brevicaulis infection are also reviewed.

1391

. Cutaneous 'ringworm' lesions of Scopulariopsis brevicaulis. Cox NH, Irving B. Br J Dermatol. 1993 Dec;129(6):726-8.

Scopulariopsis brevicaulis is a saprophytic fungus which is occasionally isolated as an apparent cause of toenail fungal infection, and which rarely has been reported as a cause of deep fungal granuloma. We report a case of skin infection with this organism, which was proved by culture of a pure isolate. The skin lesions had an annular ringworm appearance with pustules, they occurred initially at a site of minor injury, and they responded to treatment with terbinafine and itraconazole.

1392

Fungal keratitis due to Scopulariopsis brevicaulis in an eye previously suffering from herpetic keratitis. Del Prete A, Sepe G, Ferrante M, Loffredo C, Masciello M, Sebastiani A. Ophthalmologica. 1994;208(6):333-5.

In the case reported, herpes virus I after having caused relapsing keratitis in an eye promoted the formation of a severe corneal ulcer caused by Scopulariopsis brevicaulis, a saprophytic mycete found in soil, which only once has been described as the cause of keratitis in man. Scopulariopsis was identified microscopically after culturing the conjunctival secretion on Sabouraud dextrose agar medium, while DNA probe tests confirmed the absence of herpes virus I. Topical and oral administration of miconazole and scraping of the corneal infiltrate dispersed the infection. Subsequently local steroids were given to reduce the neovascularization, and a therapeutic contact lens was applied because of intercurrent corneal thinning. Three months after beginning antifungal therapy, the visual acuity had increased from 1/120 to 1/10. The case described confirms that S. brevicaulis can cause opportunist infections in a cornea previously damaged by a different agent.

1393

A case of fungal keratitis caused by Scopulariopsis brevicaulis: treatment with antifungal agents and penetrating keratoplasty. Ragge NK, Hart JC, Easty DL, Tyers AG. Br J Ophthalmol. 1990 Sep;74(9):561-2.

A case of fungal keratitis caused by Scopulariopsis brevicaulis following a penetrating eye injury is described. Treatment with antifungal agents and keratoplasty resulted in a favourable outcome.

1394

Posttraumatic fungal endophthalmitis resulting from Scopulariopsis brevicaulis. Gariano RF, Kalina RE. Retina. 1997;17(3):256-8.

1395

A case of mycetoma caused by Scopulariopsis maduromycosis. Wang DL, Xu C, Wang GC. Chin Med J (Engl). 1986 May;99(5):376-8.

1396

Cerebral phaeohyphomycosis caused by a dematiaceous scopulariopsis species. Hart AP, Sutton DA, McFeeley PJ, Kornfeld M. Clin Neuropathol. 2001 Sep-Oct;20(5):224-8.

This report describes a rapidly fatal case of cerebral phaeohyphomycosis in a 33-year-old immunocompetent male. The infection presented as a single large lesion in the deep white matter of one temporal lobe, which was then removed surgically. Histologic features observed in the lobectomy specimen were characterized by perivascular sleeves of mononuclear cells accompanied by hemorrhages. These were reminiscent of acute hemorrhagic leukoencephalitis except for the presence of rare fungal organisms and sparse multinucleated giant cells similar to those occurring in AIDS. During the four days following surgery, a large focus of cerebritis with massive invasion of fungi developed in each centrum semiovale around the ventriculostomy sites. Fungal culture of the brain obtained at autopsy grew an organism consistent with a Scopulariopsis species.

1399

Subcutaneous hyphomycosis caused by Scytalidium hyalinum. Zaatari GS, Reed R, Morewessel R. Am J Clin Pathol. 1984 Aug;82(2):252-6.

Scytalidium hyalinum is a hyaline species of the genus Scytalidium. It first was described as a cause of skin and nail infection in humans. In this report, the authors describe the first case of subcutaneous hyphomycosis with multiple cyst formation caused by this fungus. The patient is a 54-year old man who has Reiter's syndrome, liver cirrhosis, and coronary artery disease. He was receiving azathioprine and prednisone for arthritis. The pathology, mycology, and clinical course are discussed.

1400

Subcutaneous phaeohypomycosis caused by Scytalidium dimidiatum in the foot of an immunosuppressed host. Rockett MS, Gentile SC, Zygmunt KH, Gudas CJ. J Foot Ankle Surg. 1996 Jul-Aug;35(4):350-4.

The authors present a case report of a subcutaneous phaeohypomycosis of the foot in an immuno-suppressed patient. The lesion was caused by Scytalidium dimidiatum, a dematiaceous fungus, which has only been reported to cause three previous similar lesions. To our knowledge, this is the first reported case of this fungus causing a deep-seated mycoses in the United States. A review of the literature concerning this organism is also presented.

1401

Two cases of tinea pedis caused by Scytalidium hyalinum. Romano C, Valenti L, Difonzo EM. J Eur Acad Dermatol Venereol. 1999 Jan;12(1):38-42.

Two cases of tinea pedis due to Scytalidium hyalinum, the first to be described in Italy, are reported. The patients were a 41-year-old woman and a 35-year-old man who had spent periods in the Caribbean. The clinical manifestations were indistinguishable from those caused by dermatophytes. In the women they were striking with 'moccasin foot' type lesions, whereas in the man they were less evident, with minor plantar desquamation and interdigital maceration. Diagnosis was based on direct mycological microscopic examination and culture. Clinical and mycological remission were obtained with systemic itraconazole therapy. These cases are reported because infections caused by Scytalidium hyalinum are rare in Europe and their clinical and mycological diagnosis, as well as therapy, may be problematic.

1402

A case of subcutaneous infection in a patient with discoid lupus erythematosus caused by a Scytalidium synanamorph of Nattrassia mangiferae, and its treatment. Dhindsa MK, Naidu J, Singh SM. Med Mycol. 1998 Dec;36(6):425-7.

A case of subcutaneous infection caused by Scytalidium synanamorph of Nattrassia mangiferae is reported in a 24-year-old female suffering from subacute discoid lupus erythematosus. Lesions were seen on the palm of the left hand and dorsal aspect of the right hand. Histopathology of the biopsied specimen revealed light brown hyphae and single celled structures along with many inflammatory cells. The patient showed marked improvement with oral chloroquin and itraconazole orally and ketoconazole cream topically.

1403

Scytalidium dimidiatum pseudodermatophyte, agent of superficial mycoses and phaehyphomycosis] Soler CP, Gerome P, Leguyadec T, Hance P, Nizou JY, Le Vagueresse R. Med Trop (Mars). 1999;59(4):375-7.

Scytalidium dimidiatum is a fungus found mainly in tropical and subtropical zones. Infection can cause a benign disease closely resembling dermatophytosis. In immunocompromised hosts, Scytalidium dimidiatum can also lead to phaehyphomycosis. Although awareness of these hyphae remains limited in developed countries, their incidence is growing due to increasing immigration and tourism. The rising incidence is well illustrated by three patients who presented onyxis and squamous-like manifestations on the arch of the foot upon returning from trips overseas and in whom various treatments were unsuccessful. In all three cases, culture in non-selective Sabouraud medium identified Scytalidium dimidiatum. These findings underline the need for laboratory testing before undertaking local or systemic treatment of onyxis especially since this pathogen can cause systemic disease. Study of ribosome genes showed that Scytalidium hyalinum is an homologous unpigmented mutant form of Scytalidium dimidatum. No antifungal agent has been effective for management of superficial manifestations and prevention depends mainly on the use of appropriate footwear in endemic areas.

1404

Scytalidium dimidiatum melanonychia and scaly plantar skin in four patients from the Maghreb: imported disease or outbreak in a Belgian mosque? Arrese JE, Piérard-Franchimont C, Piérard GE. Dermatology. 2001;202(2):183-5.

Scytalidium dimidiatum is a geophilic dematiaceous, non-dermatophyte mould that can become a pathogen for plants and humans particularly in tropical and subtropical regions. We report 4 cases of S. dimidiatum onychomycosis presenting clinically as thickened and dark toenails. The skin of the soles was scaly. The time and location of the contaminations were uncertain. Indeed, the patients were ancient immigrants from the Maghreb to Belgium. They were also regularly travelling to their countries of origin. They were also often barefoot in the same Belgian mosque. The disease was unresponsive to current oral antifungal treatments.

1408

Sphaeropsis subglobosa keratomycosis--first reported case. Kirkness CM, Seal DV, Clayton YM, Punithalingam E. Cornea. 1991 Jan;10(1):85-9.

Recurrent keratomycosis is reported due to the coelomycete Sphaeropsis subglobosa, which has not been recognised previously as a human pathogen. Infection followed corneal injury by a frayed bamboo cane with implantation of its splinters. Initial successful therapy with 2% clotrimazole topically, to which it was sensitive, was followed by recurrent infection after 39 months, initially a keratitis but progressing to an endophthalmitis. Penetrating keratoplasty was necessary to eradicate the infection. Further isolation of the fungus showed that it had not developed resistance to clotrimazole but had survived dormant, deep in the corneal stroma. S. subglobosa should be considered in bamboo-associated and horticultural injuries.

1413

Dermatitis due to Sporobolomyces infection. Bergman AG, Kauffman CA. Arch Dermatol. 1984 Aug;120(8):1059-60.

A 30-year-old woman had a pruritic skin lesion from which a yeastlike organism, Sporobolomyces holsaticus, was isolated. Members of this group of yeasts are found in the soil throughout the world and have been implicated only twice before in human infection. We report a third case of infection due to a Sporobolomyces organism.

1414

Prosthetic cranioplasty infection due to Sporobolomyces. Morrow JD. J Tenn Med Assoc. 1994 Nov;87(11):466-7.

I have presented an unusual case of an infected prosthetic cranioplasty due to Sporobolomyces species found to be sensitive to amphotericin B in vitro. The infection was successfully treated with a combination of surgery and antifungal therapy.

1415

Sporobolomyces salmonicolor lymphadenitis in an AIDS patient. Pathogen or passenger? Plazas J, Portilla J, Boix V, Pérez-Mateo M. AIDS. 1994 Mar;8(3):387-8.

1419

Case report. Successfully treated subcutaneous infection with Sporothrix schenckii in Turkey. Koç AN, Ukşal U, Oymak O. Mycoses. 2001;44(7-8):330-3.

Sporotrichosis is rare in Turkey. We report a 48-year-old man who had subcutaneous sporotrichosis caused by Sporothrix schenckii that was successfully treated with short-term itraconazole and potassium iodide. The isolate was susceptible to itraconazole also in vitro. Short-term itraconazole and potassium iodide should be agents of choice for treatment of subcutaneous sporotrichosis. However, treatment is controversial both in choice of agent used and in duration of therapy.

1420

Prevalence, epidemiology and geographical distribution of Sporothrix schenckii infections in Gauteng, South Africa. Vismer HF, Hull PR. Mycopathologia. 1997;137(3):137-43.

Sporotrichosis is a subcutaneous fungal infection caused by the traumatic implantation of the dimorphic, pathogenic fungus, Sporothrix schenkii. It constitutes the most common subcutaneous fungal infection in the general population in South Africa. Sporotrichosis in South Africa dates back to 1914, when the disease was first diagnosed in the gold mines. Occupational and recreational circumstances of infection are well established, and the environmental requirements for contracting the disease are better understood. Sporotrichosis cases were recorded from 42 suburbs in the greater Pretoria area as well as from 23 towns outside the Pretoria municipal boundary. It occurred in 154 patients with ages ranging from less than 1 year to 90 years old, with males predominating. Females in the area seemed to be at lesser risk, mainly becoming infected through gardening injuries, insect bites or other minor injuries due to outdoor activities. Exposure to possible sources of the fungus, either from recreational or occupational activities in males, was the main determining factor in acquiring the disease. The lymphocutaneous and localized forms of the disease were most often recorded. Our study indicates that, while there is no pronounced seasonal variation, the onset of the disease seemed to be mainly in the cooler and dryer months of the year.

1421

Sporotrichosis. Davis BA. Dermatol Clin. 1996 Jan;14(1):69-76.

Sporothrix schenckii is a fungus that can be found worldwide in decaying vegetative matter. It is the causative agent of sporotrichosis, a chronic infection of humans and animals. The infection is characterized by nodular lesions of the cutaneous and subcutaneous tissues with lymphatic involvement. Systemic spread may occur with bone, muscle, central nervous system, and pulmonary involvement. Diagnosis may be made based on clinical presentation and on laboratory identification of the etiologic agent.

1422

Epidemic cutaneous sporotrichosis. Campos P, Arenas R, Coronado H. Int J Dermatol. 1994 Jan;33(1):38-41.

BACKGROUND. Sporotrichosis is a subcutaneous fungal infection. Lymphocutaneous and fixed sporotrichosis are the most common forms; cases of disseminated sporotrichosis are rare. There have been isolated reports and some epidemic familial outbreaks of the infection. METHODS. We studied four members of two families who contracted sporotrichosis after sleeping in an old and rust-stained camping tent. RESULTS. All cases presented with polymorphic lesions, three of them with multiple sites of inoculation. The camping tent was shown to be the source of infection. CONCLUSIONS. We report an epidemic of sporotrichosis in a family. In three cases disseminated cutaneous sporotrichosis occurred in nonimmunodeficient patients. The isolate of Sporothrix schenckii from a camping tent is extremely rare.

1423

Cutaneous sporotrichosis in Thailand: first reported case. Kwangsukstith C, Vanittanakom N, Khanjanasthiti P, Uthammachai C. Mycoses. 1990 Nov-Dec;33(11-12):513-7.

A case of cutaneous sporotrichosis is reported for the first time in Thailand. The infection occurred in a 33-year-old Thai female who has been in good health and had no history of previous trauma or contact with any animals. Histopathology revealed pseudoepitheliomatous hyperplasia of the epidermis and a combination of granulomatous and pyogenic reactions in the dermis and subcutaneous tissue. Typical asteroid bodies (Splendore-Hoeppli phenomenon) with central yeast cells were seen. Sporothrix schenckii was recovered from skin biopsy specimens. The patient responded well to the treatment with saturated solutions of potassium iodide within three months. No recurrence was seen after more than six months follow-up.

1424

Ocular and concomitant cutaneous sporotrichosis. Vieira-Dias D, Sena CM, Oréfice F, Tanure MA, Hamdan JS. Mycoses. 1997 Oct;40(5-6):197-201.

We report here the case of a 12-year-old girl with concomitant cutaneous and ocular sporotrichosis. Sporothrix schenckii was isolated from skin lesions and aqueous humour. The difficulty in the diagnosis and treatment of this form of mycosis is discussed and the data are compared with those published in the few reports available in the literature.

1425

Endophthalmitis due to Sporothrix schenckii after penetrating ocular injury. Witherspoon CD, Kuhn F, Owens SD, White MF, Kimble JA. Ann Ophthalmol. 1990 Oct;22(10):385-8.

A 13-year-old boy developed endophthalmitis from traumatic inoculation of vegetable material penetrating his right eye. Sporothrix schenckii was morphologically identified from the intraocular fluids. However, repeated attempts to culture the organism proved negative. Seventeen sporotrical endophthalmitis cases have so far been reported, and before this report, only one of them was secondary to trauma. This is the sole eye to our knowledge not only to have escaped enucleation after sporotrical endophthalmitis but to have achieved useful (20/50) vision.

1426

Chronic cavitary pulmonary sporotrichosis: efficacy of oral itraconazole. Ramirez J, Byrd RP Jr, Roy TM. J Ky Med Assoc. 1998 Mar;96(3):103-5.

The small number of patients suffering from pulmonary involvement with Sporothrix schenckii has prevented prospective controlled studies that could determine the optimal therapy for this chronic infection. The clinician's ability to determine the best medical treatment for chronic cavitary pulmonary sporotrichosis is also tempered by the limited use of newer azole antifungal agents in this disorder as well as the relative lack of efficacy reported with older therapies. We present a 50-year-old male with primary pulmonary sporotrichosis whose chronic cavitary disease responded to oral itraconazole.

1427

Pulmonary sporotrichosis with hyphae in a human immunodeficiency virus-infected patient. A case report. Gori S, Lupetti A, Moscato G, Parenti M, Lofaro A. Acta Cytol. 1997 Mar-Apr;41(2):519-21.

BACKGROUND: Pulmonary sporotrichosis is a rare event. Sporothrix schenckii is a dimorphic fungus and develops at 37 degrees C in yeast form. Usually hyphae are not observed in tissues, although their presence has been occasionally demonstrated in biopsies. CASE: A 37-year-old man, human immunodeficiency virus-1 positive, with a CD4 cell count of 345/mm3, developed a productive cough. A sputum smear revealed the presence of a large amount of long, thin, septated micelia. The hyphae bore oval, sessile conidia. Cultures of sputum yielded numerous colonies of S schenckii. CONCLUSION: This is the first report of hyphae of S schenckii in sputum. This case emphasizes the possibilities of cytology for the diagnosis of mycotic infections. Fungi have typical morphologies, and it is possible, on the basis of microscopic evidence, to suspect the nature of the infection early and thus to direct culture procedures.

1428

Fatal pulmonary sporotrichosis caused by Sporothrix schenckii var. luriei in India. Padhye AA, Kaufman L, Durry E, Banerjee CK, Jindal SK, Talwar P, Chakrabarti A. J Clin Microbiol. 1992 Sep;30(9):2492-4.

The first case of fatal pulmonary sporotrichosis caused by Sporothrix schenckii var. luriei in a patient from the northwestern region of India is described. In the absence of cultures, the diagnosis was suspected by notation, in lung tissue, of large, thick-walled, hyaline fungal cells that divided internally by septation or a budding process. The thick-walled, internally septated cells often became muriform. The presence of an "eyeglass" configuration of incompletely separated cells characteristic of S. schenckii var. luriei in large numbers aided the diagnosis. The identity of the etiologic agent was confirmed by application of a fluorescent-antibody reagent specific for S. schenckii.

1429

A case of primary pulmonary sporotrichosis] Nakano H, Suzuki A, Tojima H, Imahashi M, Kashiyama T, Honda A, Watanabe A, Mizuguchi K, Kamei K. Nihon Kyobu Shikkan Gakkai Zasshi. 1989 Feb;27(2):220-4.

We report the first case of primary pulmonary sporotrichosis in Japan. A 53-year-old man was admitted to our hospital for further examination of the abnormal shadows on chest X-ray film. Six months before admission, he was admitted to another hospital because of alcoholic liver disease and diabetes mellitus. Since the initial chest film showed cavities with infiltration in the left upper lung field, he was treated with antituberculous drugs despite negative sputum cultures for mycobacterium. In spite of the medication, his chest X-ray film revealed another cavitary lesion, so he was referred to our hospital. He had been asymptomatic during this period. Chest X-ray on admission disclosed multiple cavities in the left upper lobe and a cavity in the right lower lobe. Repeated sputum specimens, bronchial washings and brushings for cytology and cultures were all negative. In an attempt to clarify the pathogen, percutaneous lung aspiration (PLA) was performed. The PLA sample yielded a positive culture of Sporothrix shenckii. After the diagnosis, S. schenckii was also cultured from sputa. A sporothrix skin test and yeast agglutination test for S. schenckii were positive. In the absence of a history for skin lesion, the patient was diagnosed as a primary pulmonary sporotrichosis. As iodide therapy was ineffective, he was started on a regimen of intravenous amphotericin B. However his renal function progressively deteriorated, so amphotericin B was discontinued. Now he receives miconazole intravenously and is still under careful observation. As far as we know, this is the first report of primary pulmonary sporotrichosis in Japan. The possibility of sporotrichosis should be considered in any cases of undiagnosed cavitary lung diseases.

1430

Sporothrix infection of the lung without cutaneous disease. Primary pulmonary sporotrichosis. England DM, Hochholzer L. Arch Pathol Lab Med. 1987 Mar;111(3):298-300.

The clinical spectrum of sporotrichosis is expanding and now includes pulmonary infection in absence of skin lesions. Lung involvement, albeit unusual, is a granulomatous pneumonitis which may progress to bilateral, apical, fibrotic, and contracted infiltrates or cavities, thereby mimicking tuberculosis or histoplasmosis. The patients are most often middle-aged men with alcoholism and chronic obstructive pulmonary disease. Our case report is yet another variant of primary pulmonary sporotrichosis that presented as diffuse, bilateral granulomatous pneumonitis without cavitation or predilection for upper lobes.

1431

Primary pulmonary sporotrichosis. Report of eight cases with clinicopathologic review. England DM, Hochholzer L. Am J Surg Pathol. 1985 Mar;9(3):193-204.

Pulmonary sporotrichosis in the absence of lymphocutaneous disease is unusual; however, its incidence may be greater than previously recognized. This report describes the AFIP experience in eight cases of primary pulmonary sporotrichosis and reviews an additional 23 cases. The disease is often a bilateral, apical, chronic and cavitary, progressive, destructive, and debilitating infection, most often seen in middle-aged men with a history of alcoholism and chronic obstructive pulmonary disease. In this clinical setting, pulmonary sporotrichosis closely mimics tuberculosis or histoplasmosis. However, this clinical charade can be unmasked by serologic tests, cultures, and identification of the causative agent, Sporothrix schenckii, in sections of paraffin-embedded lung containing necrotizing granulomas and stained with periodic acid-Schiff and Gomori methenamine-silver nitrate. Previously not recognized is the presentation of primary pulmonary sporotrichosis as a solitary, peripheral, necrotizing pulmonary nodule, observed in two patients. Chronic cavitary pulmonary sporotrichosis is usually refractory to drug therapy; however, when combined with surgical resection, cure can be attained.

1432

Sporothrix meningitis. Wescott BL, Nasser A, Jarolim DR. Nurse Pract. 1999 Feb;24(2):90, 93-4, 97-8 passim.

Sporothrix schenckii is a fungus commonly found in soil and on plants, wood splinters, rosebush thorns, and decaying vegetation. It is also carried by some wild and domestic animals and rodents. When this organism penetrates the skin of individuals handling contaminated substances, the cutaneous manifestation may be lymphangitic or fixed. The treatment of choice for the cutaneous form of the disease (sporotrichosis) is potassium iodide. If iodides are contraindicated or not tolerated, itraconazole may be used. Sporotrichosis can persist for years if unrecognized and can progress to systemic forms, including osteoarticular, pulmonary (may occur when the organism is inhaled), and meningeal involvement. Systemic forms can be life-threatening and very difficult to treat. Primary care providers must be familiar with this disorder and its presentation because it is easily mistaken for a bacterial infection and inappropriately treated.

1433

Disseminated cutaneous and meningeal sporotrichosis in an AIDS patient. Donabedian H, O'Donnell E, Olszewski C, MacArthur RD, Budd N. Diagn Microbiol Infect Dis. 1994 Feb;18(2):111-5.

We report the first proven case of Sporothrix meningoencephalitis in an AIDS patient. The patient had dramatic, wide-spread ulcerative and infiltrative disease with progressive meningoencephalitis in spite of amphotericin and itraconazole therapy. Sporothrix was cultured from premortem cerebrospinal fluid and seen in the meninges and in brain vessels at autopsy.

1434

Sporothrix schenckii meningitis in a farmer with Hodgkin's disease. Ewing GE, Bosl GJ, Peterson PK. Am J Med. 1980 Mar;68(3):455-7.

A fatal case of chronic meningeal sporotrichosis occurring as an opportunistic infection in a patient with Hodgkin's disease is presented. A pulmonary source of infection was identified at autopsy. The diagnostic importance of the isolation of Sporothrix schenckii from cerebrospinal fluid, even if only from a single specimen, is stressed.

1435

Musculoskeletal sporotrichosis. Chang AC, Destouet JM, Murphy WA. Skeletal Radiol. 1984;12(1):23-8.

Sporotrichosis is a chronic, indolent, fungal infection that rarely involves the musculoskeletal system. The etiologic agent, Sporothrix schenckii, is ubiquitous in nature and has been isolated from soil, timber, decaying vegetation, and a variety of foliage. The organism gains entrance to the body through trauma to the skin or, in rare instances, by inhalation. The vast majority of infections in humans is characterized by nodular or ulcerated lesions of the cutaneous tissues and adjacent lymphatics. Osteoarticular involvement may occur either by contiguous spread from a cutaneous focus, through direct inoculation of tissue by the organism, or by hematogenous dissemination. The rarity of musculosketetal sporotrichosis often causes a delay in diagnosis which leads to inappropriate therapy and permanent deformity in some patients. Three cases which show a spectrum of bone and joint involvement are presented.

1436

Disseminated sporotrichosis with extensive cutaneous involvement in a patient with AIDS. Ware AJ, Cockerell CJ, Skiest DJ, Kussman HM. J Am Acad Dermatol. 1999 Feb;40(2 Pt 2):350-5.

Sporotrichosis most commonly presents as a localized, lymphocutaneous infection that follows trauma, such as an injury from a rose thorn. In patients infected with HIV, it may be widespread and disseminated. We describe a patient with AIDS who developed disseminated sporotrichosis, a rare opportunistic fungal infection that may affect these patients. The condition remained undiagnosed because of failure to recognize characteristic histopathologic findings and failure of clinicians to interface closely with the microbiology laboratory. The condition was difficult to treat, requiring systemic administration of amphotericin. While localized sporotrichosis is an innocuous disorder that responds well to therapy, in immunocompromised hosts, it is potentially life-threatening and may require prolonged therapy with potentially toxic medications such as amphotericin B. It is important that clinicians be aware of the presentation of this unusual opportunistic infection and that they maintain close communication with pathology and clinical microbiology laboratories to ensure that proper stains and cultures are performed to avoid potential misdiagnosis.

1437

Disseminated sporotrichosis and Sporothrix schenckii fungemia as the initial presentation of human immunodeficiency virus infection. al-Tawfiq JA, Wools KK. Clin Infect Dis. 1998 Jun;26(6):1403-6.

Infection with Sporothrix schenckii causes a localized lymphocutaneous disease in the immunocompetent host, while it frequently results in disseminated disease in the immunocompromised patient. There are a growing number of reports of S. schenckii infection in the human immunodeficiency virus (HIV)-infected population, where the disease usually starts as a localized cutaneous lesion and subsequently disseminates. The optimal treatment of systemic sporotrichosis in HIV-positive patients is as yet unknown. This article presents a case report of disseminated sporotrichosis in an HIV-infected patient, a review of the literature, and discussion of treatment options for HIV-infected patients.

1438

Sporothrix schenckii fungemia without disseminated sporotrichosis. Kosinski RM, Axelrod P, Rex JH, Burday M, Sivaprasad R, Wreiole A. J Clin Microbiol. 1992 Feb;30(2):501-3.

Fungemia is a rare complication of Sporothrix schenckii infection and has always been associated with disseminated sporotrichosis. We describe an immunocompetent patient with localized lymphocutaneous sporotrichosis from whose blood the fungus was isolated. A lysis-centrifugation blood culture system may have improved our ability to detect low-level S. schenckii fungemia.

1439

Disseminated sporotrichosis in patients with AIDS: case report and review of the literature. Heller HM, Fuhrer J. AIDS. 1991 Oct;5(10):1243-6.

Sporotrichosis is the disease caused by the dimorphic fungus Sporothrix schenkii. Disseminated sporotrichosis is an uncommon infection which usually occurs in alcoholics or patients receiving immunosuppressive medication. We report a case of a patient with AIDS who had disseminated sporotrichosis which was progressive and fatal despite antifungal therapy. Four previously reported cases of disseminated sporotrichosis in patients with AIDS are reviewed. Disseminated sporotrichosis occurs in patients with HIV-1 infection and severe CD4 lymphocyte depletion. It usually presents with diffuse cutaneous lesions and is associated with polyarticular arthritis. Response to treatment is variable and chronic suppressive therapy is probably needed to prevent relapse.

1459

Acute pulmonary hemorrhage in a Delaware infant after exposure to Stachybotrys atra. Weiss A, Chidekel AS. Del Med J. 2002 Sep;74(9):363-8.

1460

Isolation of Stachybotrys from the lung of a child with pulmonary hemosiderosis. Elidemir O, Colasurdo GN, Rossmann SN, Fan LL. Pediatrics. 1999 Oct;104(4 Pt 1):964-6.

Recently, Stachybotrys atra, a toxigenic fungus, has been implicated as a potential cause of pulmonary hemorrhage/hemosiderosis in infants living in water-damaged homes. Although epidemiologic evidence supports this association, neither the organism nor its toxic products has ever been recovered from humans. We report the first case in which Stachybotrys was isolated from the bronchoalveolar lavage fluid of a child with pulmonary hemorrhage. Stachybotrys was also recovered from his water-damaged home. The patient recovered completely after his immediate removal from the environment and subsequent cleaning of his home. This case provides further evidence that this fungus is capable of causing pulmonary hemorrhage in children.

1461

Clinical experience and results of a Sentinel Health Investigation related to indoor fungal exposure. Johanning E, Landsbergis P, Gareis M, Yang CS, Olmsted E. Environ Health Perspect. 1999 Jun;107 Suppl 3:489-94.

This is a review of exposure conditions, clinical presentation, and morbidity of children and adults with indoor fungal exposure such as toxic Stachybotrys chartarum. Indoor exposure was characterized using different methods including microscopic, culture, cytotoxicity screening tests, and chemical analyses. Clinical case histories and physical and laboratory findings are presented of children (age < 18 years, n = 22; mean age 9 years; 60% females) and adults (age >18 years, n = 125; mean age 39 years, 67% females) who consulted an environmental health specialty clinic. In the pediatric patients' exposure history, widespread fungal contamination of water-damaged building materials with known toxic or allergic fungi was identified. Primarily disorders of the respiratory system, skin, mucous membranes, and central nervous system were reported. Some enumeration and functional laboratory abnormalities, mainly of the lymphatic blood cells, were observed, although no statistically significant differences were found. IgE or IgG fungi-specific antibodies, used as exposure markers, were positive in less than 25% of all tested cases. In an evaluation of a symptomatic girl 11 years of age (sentinel case investigation) living in an apartment with verified toxigenic fungi (i.e., S. chartarum), several health indicators showed improvement after exposure cessation.

1466

Cutaneous infection by Syncephalastrum. Kamalam A, Thambiah AS. Sabouraudia. 1980 Mar;18(1):19-20.

Cutaneous infection of the thumb by a Syncephalastrum sp. is described in an adult male suffering from diabetic ketosis. The fungus was isolated from the skin and was found to produce arteritis in the dermal vessels. The patient died of diabetes mellitus without any associated systemic mycosis. Syncephalastrum in this case had occurred as an opportunistic infection.

1467

An intracavitary fungus ball composed of syncephalastrum. Kirkpatrick MB, Pollock HM, Wimberley NE, Bass JB, Davidson JR, Boyd BW. Am Rev Respir Dis. 1979 Oct;120(4):943-7.

A case of a pulmonary intracavitary fungus ball composed of Syncephalastrum sp., a member of the class Zygomycetes not previously reported in association with human disease, is presented. The fungus was cultured preoperatively from bronchial secretions as well as from the fungal mass from the resected lung. This fungus appeared to behave in a saprophytic manner similar to that of the more common Aspergillus fungus ball.

1468

Taeniolella boppi, a new species, causative agent of chromomycosis] Borelli D. Med Cutan Ibero Lat Am. 1983;11(4):227-32.

The holotype is described of a new species of chromomycetes, that was isolated by Prof. Clovis Bopp (Porto Alegre, Rio Grande do Sul, Brasil) from lesions of chromomycosis in the inferior limb of a woman. The binomium Taeniolella boppii is proposed for the new taxon. The whole mycelium is dark. The culture surface is velvetyyowdery, folded into a few forrows, at first olive green later on olive black in color. The macro-culture's diameter grows 1,5 mm. a day. The minimum growing temperature lies at 10, the optimum one at 23-28 and the maximum one at 36 degrees C. The gelatin and the milk proteins are very slowly digested. The vegetative mycellum is made up of smooth, cylindrical hyphae, whose diameter measure, 2,25-3,75 m. From these toruloid hyphae are formed, simple or ramified whose cells measure 3-4 x 3-5 in size, and are smooth, continuous or 1-septate. Sometimes, bigger intercalary or terminal cells are seen that are ellypsoid and dictyoseptated and can measure until 14 m in diameter. No part of the mycellium secredes. By injecting Taeniolella boppii's cultures into peritoneum of white mice, into the derma of a voluntary, into the testes of a guinea-pig and into the plantar bursa of white mice, no progressive injection could be elicted; only an ephemeral germination of some toruloid cells but not the transformation to the chromomicetic parasitic form could be observed. The holotype is preserved in the mycologic collection of the medical faculty of Caracas at the position FMC 292.

1469

[Chromoblastomycosis caused by a new species: Taeniolella boppii] Bopp C, Vetoratto, Borelli D. Med Cutan Ibero Lat Am. 1983;11(4):221-6.

The authors report a case of a 51-year-old woman, living in the extreme west of the Santa Catarina State (South of Brazil, near the Argentine border), who presented a vegetating plaque in the foot, associated with inflammatory nodules in the leg, according to the sporotrichoid form of chromoblastomycosis, with a histologic pattern distinct from the commonly observed. In culture the fungus produced exclusively and repeatidly colonies of a Cladosporium type. More detailed studies of the fungus made by Dante Borelli of Venezuela, proved it to be the type of a new species of Dematiaceous mould.

1473

Tetraploa keratomycosis. Newmark E, Polack FM. Am J Ophthalmol. 1970 Dec;70(6):1013-5.

1474

Phaeohyphomycotic cyst caused by Tetraploa aristata. Markham WD, Key RD, Padhye AA, Ajello L. J Med Vet Mycol. 1990;28(2):147-50.

A case of phaeohyphomycotic cyst on the left knee of a 54-year-old man caused by Tetraploa aristata is described. Identification was based on the coloration and morphology of the fungus in tissue and the macro- and micro-morphologic characteristics of the mould isolated from the cyst fluid. T. aristata is a dematiaceous hyphomycete found on the leaves and stems of a variety of plants. Previously, it has been known as an etiologic agent of two human cases of keratomycosis. Here we describe the first known subcutaneous phaeohyphomycotic infection caused by T. aristata.

1475

Peritonitis due to Thermoascus taitungiacus (Anamorph Paecilomyces taitungiacus). Korzets A, Weinberger M, Chagnac A, Goldschmied-Reouven A, Rinaldi MG, Sutton DA. J Clin Microbiol. 2001 Feb;39(2):720-4.

The first case of human disease due to the thermophilic ascomycete Thermoascus taitungiacus (the teleomorph of Paecilomyces taitungiacus) is presented. T. taitungiacus was recovered from four dialysate fluid specimens of a 57-year-old patient undergoing chronic peritoneal dialysis. Identification was based upon cylindrical conidia, reddish orange nonostiolate ascomata, lack of growth at 20 degrees C, thermotolerance, and ascospores that appeared pale yellow, elliptical, thick walled, and predominately echinulate by light microscopy but irregularly verrucose by scanning electron microscopy.

1476

Prosthetic valve endocarditis due to Thermomyces lanuginosus Tsiklinsky--first case report. Lecso-Bornet M, Gueho E, Barbier-Boehm G, Berthelot G, Gaildrat M, Taravella D, Bergogne-Berezin E. J Med Vet Mycol. 1991;29(3):205-9.

The first case of Thermomyces lanuginosus endocarditis occurring on a porcine heterograft prosthesis, secondary to a Staphylococcus aureus infection of the aortic valve, is reported. The diagnosis was made post-mortem by direct examination of the prosthesis and culture of surgical samples on Sabouraud's agar. Identification was based on the presence of warty, dark brown aleurioconidia. The route of contamination could not be established but the most likely cause was the air of the operating room or the insertion of a contaminated graft.

1480

Tilletiopsis minor: a new etiologic agent of human subcutaneous mycosis in an immunocompromised host. Ramani R, Kahn BT, Chaturvedi V.

J Clin Microbiol. 1997 Nov;35(11):2992-5.

We describe herein the isolation of Tilletiopsis minor from a subcutaneous cyst of a 70-year-old immunocompromised male. The diagnosis was based on repeated isolation of the fungus, observation of hyphal elements in tissue sections, the ability of the mold to grow at or near body temperature, and the achievement of a complete cure following surgery and antifungal therapy.

1501

Invasive infections due to Trichoderma species: report of 2 cases, findings of in vitro susceptibility testing, and review of the literature. Chouaki T, Lavarde V, Lachaud L, Raccurt CP, Hennequin C. Clin Infect Dis. 2002 Dec 1;35(11):1360-7.

Trichoderma species are filamentous fungi that were previously considered to be culture contaminants. We report 2 well-documented cases of invasive Trichoderma infections, and we comprehensively review the literature on this topic. Trichoderma species are mainly responsible for continuous ambulatory peritoneal dialysis-associated peritonitis (7 cases) and invasive infections in immunocompromised patients (9 cases) with a hematologic malignancy or solid-organ transplant. Definitive diagnosis is difficult to achieve because of the lack of specific diagnosis tools. Species identification can benefit from a molecular approach. Trichoderma longibrachiatum is the most common species involved in these infections. Regardless of the type of infection, the prognosis was poor, with 8 deaths among 18 cases. This may be partially because of the resistance of these organisms to the majority of available antifungal agents, including amphotericin B. Trichoderma species now should be added to the growing list of emerging filamentous fungal pathogens.

1502

Acute invasive sinusitis due to Trichoderma longibrachiatum in a liver and small bowel transplant recipient. K, Skedros D, Todo S, Rinaldi MG. Clin Infect Dis. 1998 Feb;26(2):487-9.

We describe a case of acute invasive sinusitis due to an unusual moniliaceous fungus, Trichoderma longibrachiatum Rifai 1969 (a member of the class Hyphomycetes), in a small bowel and liver transplant recipient treated with tacrolimus (FK-506) and prednisone. The patient was successfully treated with surgical debridements and amphotericin B followed by oral itraconazole.

1503

Fatal case of Trichoderma harzianum infection in a renal transplant recipient. Guarro J, Antolin-Ayala MI, Gene J, Gutierrez-Calzada J, Nieves-Diez C, Ortoneda M. J Clin Microbiol. 1999 Nov;37(11):3751-5.

We describe the second known case of human infection by Trichoderma harzianum. A disseminated fungal infection was detected in the postmortem examination of a renal transplant recipient and confirmed in culture. The only other reported infection by this fungus caused peritonitis in a diabetic patient. The in vitro antifungal susceptibilities of the clinical strain and three other strains of Trichoderma species to six antifungal drugs are provided. This case illustrates the widening spectrum of opportunistic Trichoderma spp. in immunocompromised patients and emphasizes the problems in diagnosing invasive fungal diseases.

1504

Fatal disseminated Trichoderma longibrachiatum infection in an adult bone marrow transplant patient: species identification and review of the literature. Richter S, Cormican MG, Pfaller MA, Lee CK, Gingrich R, Rinaldi MG, Sutton DA. J Clin Microbiol. 1999 Apr;37(4):1154-60.

Trichoderma longibrachiatum was recovered from stool surveillance cultures and a perirectal ulcer biopsy specimen from a 29-year-old male who had received an allogeneic bone marrow transplant for acute lymphoblastic leukemia. The amphotericin B (2.0 microgram/ml) and itraconazole (1.0 microgram/ml) MICs for the organism were elevated. Therapy with these agents was unsuccessful, and the patient died on day 58 posttransplantation. At autopsy, histologic sections from the lungs, liver, brain, and intestinal wall showed infiltration by branching septate hyphae. Cultures were positive for Trichoderma longibrachiatum. While Trichoderma species have been recognized to be pathogenic in profoundly immunosuppressed hosts with increasing frequency, this is the first report of probable acquisition through the gastrointestinal tract. Salient features regarding the identification of molds in the Trichoderma longibrachiatum species aggregate are presented.

1505

Trichoderma longibrachiatum infection in a pediatric patient with aplastic anemia. Munoz FM, Demmler GJ, Travis WR, Ogden AK, Rossmann SN, Rinaldi MG. J Clin Microbiol. 1997 Feb;35(2):499-503.

Trichoderma longibrachiatum infection of the skin in an 11-year-old child with severe aplastic anemia and prolonged neutropenia is reported. The patient received systemic antifungal therapy and underwent bone marrow transplantation. To our knowledge, this is the first description of T. longibrachiatum infection in a pediatric patient. It also is the first case successfully treated with medical therapy. A review of the literature suggests that Trichoderma spp. are recognized as human pathogens with increasing frequency, particularly for immunocompromised patients, and should be considered in the differential diagnosis of fungal infections in the pediatric population.

1510

Cutaneous hyalohyphomycosis and onychomycosis caused by Onychocola canadensis: report of the first case from Turkey. Erbagci Z, Balci I, Erkiliç S, Zer Y, Inci R. J Dermatol. 2002 Aug;29(8):522-8.

We present the first Turkish case of skin and nail infection due to Onychocola canadensis in an otherwise healthy farmer who frequently worked barefoot on soil. Cutaneous involvement consisted of scaly and hyperkeratotic lesions resembling tinea pedis, erythematous plaques, and dermal papulonodules of various sizes simulating Majocchi's granuloma. Repeated cultures from nail plates, skin scrapings and needle aspiration materials from papules or nodules all yielded the same mold on Sabouroud dextrose media with and without cycloheximide, trichophyton agar, and potato dextrose agar at 26 degrees C. The causal isolate was identified as Onychocola canadensis Sigler gen. et sp. nov., a slow-growing arthroconidial hyphomycete, on the basis of its colonial and microscopic morphology. While skin lesions were responsive to daily itraconazole in a dose of 200 mg for three months, the onychomycosis was resistant to therapy. To our knowledge, this is the first presentation of O. canadensis as the cause of cutaneous hyalohyphomycosis to date.

1511

Trichophyton rubrum showing deep dermal invasion directly from the epidermis in immunosuppressed patients. Smith KJ, Welsh M, Skelton H. Br J Dermatol. 2001 Aug;145(2):344-8.

Trichophyton rubrum is the most widely encountered dermatophyte infection, and is usually regarded as exclusively keratinophilic often leading to chronic cutaneous and nail infections, even in healthy individuals. We present three patients with acute leukaemias, with ill-defined pre-existent cutaneous eruptions that were treated with a potent topical corticosteroid. All three patients received aggressive marrow toxic chemotherapy. These patients had progression of their cutaneous disease, which showed deep dermal invasion of T. rubrum, invading directly from the epidermis with no evidence of systemic spread. We conclude that systemic pancytopenia, in association with prolonged local immunosuppression, may increase the risk of direct dermal invasion of dermatophyte infections. However, even in these patients, the risk of systemic spread still appears very low. Amphotericin B did not appear effective in treating these dermatophyte infections.

1512

Microbiological and molecular diagnosis of deep localized cutaneous infection with Trichophyton mentagrophytes. Sommer S, Barton RC, Wilkinson SM, Merchant WJ, Evans EG, Moore MK. Br J Dermatol. 1999 Aug;141(2):323-5.

We describe a healthy young woman with a localized deep dermal infection on the right side of the chest wall. It was caused by the dermatophyte Trichophyton mentagrophytes, and resolved after two pulses of oral itraconazole 200 mg twice daily for 1 week. As cultural and microscopic features did not enable a precise identification of the fungus, molecular investigation was undertaken. Patterns of HaeIII restriction digests of genomic DNA from the culture matched those from Arthroderma incurvata and A. benhamiae, which is the teleomorph of T. mentagrophytes var. mentagrophytes.

1522

[Case of Trichocephalus trichurus present in the uvea and treated surgically] Rusinowa E, Rusin A. Klin Oczna. 1973 Feb;43(2):199-201.

1523

Exogenous corneal ulcer caused by Tritirachium roseum. Rodrigues MM, Laibson P. Am J Ophthalmol. 1975 Nov;80(5):804-6.

A 29-year-old white man developed a corneal ulcer following trauma to his left cornea by a piece of wire. Tritirachium roseum, a saprophytic fungus, was cultured from corneal scrapings and demonstrated in the corneal button by histopathologic examination.

1525

Cutaneous mold fungus granuloma from Ulocladium chartarum. Altmeyer P, Schon K. Hautarzt. 1981 Jan;32(1):36-8.

Cutaneous granulomas due to the mold fungus Ulocladium chartarum (Preuss) are described in a 58 year old woman. This fungus is usually harmless for mammalian. It is thought that a consisting immunosuppression (Brill-Symmer's disease, therapy with corticosteroids) was a priming condition for the infection. The route of infection in this patient described is unknown.

1527

Central venous catheter infection due to Ustilago species. Patel R, Roberts GD, Kelly DG, Walker RC. Clin Infect Dis. 1995 Oct;21(4):1043-4.

1528

Cutaneous phaeohyphomycosis caused by Veronaea bothryosa in a liver transplant recipient successfully treated with itraconazole. Foulet F, Duvoux C, de Bievre C, Hezode C, Bretagne S. Clin Infect Dis. 1999 Sep;29(3):689-90.

1529

Occupational asthma in tomato growers following an outbreak of the fungus Verticillium albo-atrum in the crop. Davies PD, Jacobs R, Mullins J, Davies BH. J Soc Occup Med. 1988 Spring-Summer;38(1-2):13-7.

1536

Fungal peritonitis in peritoneal dialysis: critical review of six cases. Amici G, Grandesso S, Mottola A, Virga G, Calconi G, Bocci C. Adv Perit Dial. 1994;10:169-73.

Fungal peritonitis (FP) is uncommon in patients on peritoneal dialysis (PD); it is difficult to treat and has a high mortality rate. We report 6 cases of fungal peritonitis observed between 1980 and 1992 in our center. The etiologic agents were: Candida spp., C. guilliermondi, C. parapsilosis, C. albicans, and Verticillium spp. All 6 patients had suffered at least one episode of bacterial peritonitis in the two months before the fungal infection appeared and were all treated by intraperitoneal administration of antibiotics. The catheter was removed early in 3 patients followed by antimycotic therapy, while the remaining 3 patients received antimycotic therapy, with removal of the catheter in a later stage. The result in the first group was that they all switched permanently to hemodialysis, while in the second group there were 2 deaths and 1 transfer to hemodialysis. In the light of these 6 cases, we analyzed 22 published reports to assess risk factors, therapy, and outcome of this pathology. The major predisposing factors were intraperitoneal antibiotics and bacterial peritonitis, and the best results were obtained by continuing PD plus intraperitoneal and systemic antifungal agents.

1537

Verticillium peritonitis in a patient on peritoneal dialysis. Amici G, Grandesso S, Mottola A, Virga G, Teodori T, Maresca MC, Bocci C. Am J Nephrol. 1994;14(3):216-9.

We describe a case of peritonitis due to Verticillium spp. in a 33-year-old farmer on continuous ambulatory peritoneal dialysis (CAPD) for 3 months for end-stage renal failure due to chronic pyelonephritis. The etiologic agent was a hyaline hyphomycete which we report as a new human opportunistic pathogen. The fungus was isolated from the peritoneal fluid culture and from the tip of the catheter; identification was made on the basis of macroscopic and microscopic features. The patient had previously been admitted to our hospital for peritonitis caused by mixed enteric flora and treated for 8 days with intraperitoneal broad-spectrum antibiotic therapy. Five days after discharge he was readmitted for severe abdominal pain and cloudy drainage fluid. Two days of intraperitoneal broad-spectrum antimicrobial therapy produced no clinical improvement. Intravenous fluconazole and oral flucytosine were administered upon identifying the fungus. After another 2 days without improvement, peritoneal dialysis was discontinued and the catheter removed. Antimycotic therapy was continued for 4 days with complete resolution of the peritonitis. The patient chose to start hemodialysis and was discharged in good clinical condition.

1538

Keratitis caused by Verticillium species. Shin JY, Kim HM, Hong JW. Cornea. 2002 Mar;21(2):240-2.

PURPOSE: To report a case of fungal keratitis caused by Verticillium species. METHODS: A 50-year-old man developed pain, redness, and an infiltrate in his left eye and had no history of trauma. The cornea showed superficial, white, stromal infiltrates and epithelial ulceration with a dendritic margin. The clinical features suggested herpetic keratitis, and the patient was treated with topical antiviral medication. Two weeks later, his condition deteriorated. Examination of the left eye showed stromal infiltrates with a feathery margin and epithelial ulceration with its covering white exudates. Corneal scrapings were taken for direct microscopic examination and culture. RESULTS: Corneal scraping showed the presence of fungal filaments. The fungus was identified as Verticillium species. Topical amphotericin B and systemic fluconazole were started after discontinuing the antiviral treatment. Clinically, the inflammation subsided during the 3 weeks after treatment. CONCLUSION: This is a rare case of infectious keratitis caused by Verticillium species. Rare species of fungal infection should be considered in the differential diagnosis of stromal keratitis refractive to conventional medical treatment.

1543

Recurrent self-limited fungemia caused by Yarrowia lipolytica in a patient with acute myelogenous leukemia. Chang CL, Park TH, Lee EY, Lim YT, Son HC. J Clin Microbiol. 2001 Mar;39(3):1200-1.

Yarrowia lipolytica is a weakly pathogenic yeast that is rarely isolated from the blood. We observed transient recurrent catheter-related fungemia attributable to this organism in a leukemic patient. The fungemia and accompanying fever subsided spontaneously. The data suggest that it might be possible to withhold specific treatment for Y. lipolytica fungemia even in an immunocompromised patient.