Pseudomicosis por oportunistas: desconocimiento y retos diagnósticos / Pseudomycosis due to opportunists: Lack of knowedge and diagnostic challenges

Resumen Se denominan pseudomicosis a las infecciones generadas por microorganismos que parecen hongos pero que no lo son. En esta revisión se abordan desde una perspectiva etiológica, epidemiológica y clínica algunas de las pseudomicosis por oportunistas más frecuentes: actinomicosis, botriomicosis, nocardiosis y prototecosis. Adicionalmente, se revisan las herramientas clínicas y paraclínicas para facilitar su diagnóstico y se actualizan las pautas de tratamiento.

Abstract Infections generated by microorganisms that look like fungi but are not fungal are called pseudomycosis. This review addresses pseudomycosis by more frequent opportunists: actinomicosis, botryomycosis, nocardiosis and prototechosis, from an etiological, epidemiological and clinical perspective. In addition, clinical and paraclinical tools are reviewed to facilitate diagnosis, and and treatment guides are updated.

Case for diagnosis. Ulcer and papular lesions in a patient with diabetes mellitus. protothecosis

Abstract Protothecosis is a rare disease caused by achlorophilic algae of the genus Prototheca spp. In general, three clinical forms are observed: cutaneous, articular and systemic. The cutaneous form is the most common one. This study describes a patient with isolated erythematous papules and erythematous papular plaques in the scapular regions, with a previous histopathological diagnosis of cryptococcosis. New tests were conclusive for the diagnosis of protothecosis, caused by Prototheca wickerhamii.

Biofilm formation by Prototheca zopfii isolated from clinical and subclinical bovine mastitis in distinct growth conditions under different dyes / Formação de biofilme por Prototheca zopfii isolados de mastite bovina clínica e subclínica em distintas condições de crescimento sob diferentes corantes

ABSTRACT: Prototheca spp. have been reported as an emergent environmental mastitis pathogen in several countries. Biofilm formation is a significant factor associated with different degrees of virulence developed by many microorganisms, including Prototheca spp. The present study aimed to compare two growth conditions and two staining dyes to determine which combination was more appropriate to evaluate qualitatively and quantitatively the production of biofilm by P. zopfii. Biofilm formation was evaluated in polystyrene microplates under static and dynamic growth conditions and staining with crystal violet or cotton blue dye. All P. zopfii isolates from cows with mastitis were classified as biofilm-producers in all growth conditions and staining. The cotton blue dye proved to be more appropriate method to classify the intensity of P. zopfii biofilm production.

RESUMO: Prototheca spp. tem sido relatado como um patógeno ambiental causador de mastite bovina em vários países. A formação de biofilme é um fator associado a diferentes graus de virulência desenvolvidos por muitos microrganismos, incluindo Prototheca zopfii. O presente estudo teve como objetivo comparar duas condições de crescimento e dois corantes para determinar a combinação mais adequada para avaliar qualitativa e quantitativamente a produção de biofilme por P. zopfii. A formação de biofilme foi avaliada em microplacas de poliestireno sob condições estáticas e dinâmicas de crescimento e coloração com cristal violeta ou azul de algodão. Todos os isolados de P. zopfii de vacas com mastite foram caracterizados como produtores de biofilme, independentemente das condições de crescimento e coloração. O corante azul de algodão demonstrou ser o método mais adequado para classificar a intensidade de produção de biofilme de P. zopfii.

Identification and characterization of 4 Prototheca wickerhamii strains / 临床检验杂志

Objective@#To identify and characterize the 4 strains of Prototheca isolated from the clinical samples of skin or ascites samples in China. @*Methods@#The taxonomic position of 4 yeast-like organisms was revealed by polyphasic taxonomic approach, i.e., cultural and morphologic characteristics, commercial biochemical systems of Vitek 2 (YST kit) and Vitek matrix-assisted laser desorption/ionization time of flight (MALDI-TOF) mass spectrometry (MS) systems in combination with phylogenetic analysis based on the gene sequences of 16S and 28S rRNA. @*Results@#The 4 strains of Prototheca were characterized as cream-white, smooth, moist yeast-like colonies on Sabouraud gentamicin chloramph agar after incubation for 3 days. However, round, oval-shaped or elliptical sporangiums with mulberry-like or strawberry-like endospores were observed by optical microscope, which showed distinct differences from the general yeast species. The 4 isolates were identified as Prototheca wickerhamii with Vitek YST kits by Vitek 2 systems and Vitek MALDI-TOF MS systems. The genome for the 4 isolates was characterized with the existence of the prokaryotic 16S rRNA gene and eukaryotic 28S rRNA gene. The 16S rRNA gene sequence of the 4 strains showed more than 99.7% similarity to that of P. wickerhamii. Sequence analysis of 28S rRNA gene showed that the organisms included multiple copies of different sequences, which showed sequence similarities of 91.9% to 100% even in the same strain. The phylogenetic dendrogram based on 16S rRNA and 28S rRNA gene sequences showed that the 4 strains of Prototheca formed a cluster along with P. wickerhamii. @*Conclusion@#The 4 yeast-like organisms could be identified as P. wickerhamii, and 16S rRNA gene should be the suitable molecular target for the identification.

Unusual ulcerative keratitis caused by Prototheca wickerhamii in a diabetic patient

The purpose of the study was to report a case of ulcerative keratitis caused by an unusual algae Prototheca wickerhamii in a diabetic patient. This study design was a case report. A 46-year-old male, who was a known diabetic for 3 years, had an injury to the left cornea with the sparks of fire from wielding at work that developed into an ulcerative keratitis over a period of next 3 months as the patient was not on any medication. Corneal scraping culture report and Vitek 2 system investigation result confirmed it to be a P. wickerhamii infection. The patient was started on intensive topical 1% voriconazole and 5% natamycin for 1 month and with no improvement subsequently underwent penetrating keratoplasty. No recurrence of infection postoperatively was noted. This opportunistic algae rarely known to cause human eye infections is so far reported in either patients with severe systemic immunosuppression causing posterior segment eye involvement or as postcorneal surgery infections. We report an ulcerative keratitis by P. wickerhamii in a diabetic patient post corneal trauma with no prior ocular surgery.

Protothecosis in a patient with T cell lymphocytic leukemia / Prototecosis en un paciente con leucemia linfocítica de células T

Human protothecosis is a rare infection caused by algae of the genus Prototheca. Prototheca wickerhamii has been recognized as the main species that causes infection in immunocompromised hosts with deficits in innate or cellular immunity. We report a case of persisting subcutaneous protothecosis in a patient with T-cell large granular lymphocyte leukemia, who also presented a history of disseminated histoplasmosis.

La prototecosis humana es una infección rara causada por algas del género Prototheca. Prototheca wickerhamii ha sido reconocida como la principal especie causante de infección en huéspedes inmunocomprometidos, con déficit de inmunidad innata o celular. Presentamos un caso de prototecosis subcutánea persistente en un paciente con leucemia linfocítica granular de células T, con antecedentes de histoplasmosis diseminada.

Successful Treatment of Protothecal Tenosynovitis in an Immunocompetent Patient using Amphotericin B Deoxycholate

Protothecosis is an uncommon human infection caused by achlorophyllic algae of the genus Prototheca, especially P. wickerhamii. The skin is the most frequently involved organ and cases of protothecal tenosynovitis are very rare. A 71-year-old woman without prior medical history except hypertension presented with painful swelling of her right hand that did not improve despite receiving antibiotic treatment. She underwent tenosynovectomy and drainage. Histopathologic examination revealed necrotizing granulomatous inflammation and numerous spherical or morula-like organisms with a spoked wheel appearance. P. wickerhamii was identified from tissue culture. The lesion did not improve with empirical fluconazole therapy. Conventional amphotericin B was administered according to antifungal susceptibility tests and the lesion completely resolved. Protothecosis should be considered in the differential diagnosis for chronic tenosynovitis that does not respond to conventional antibacterial treatment; tissue biopsy with culture is required for diagnosis.

A Case of Protothecosis on Scalp and Face in the Immunocompetent Patient / 대한의진균학회지

Protothecosis is an unusual human infection, caused by the genus prototheca, especially Prototheca wickerhamii. A 80-year-old immunocompetent man presented with a 1-month history of multiple reddish brown lobulated plaques on the scalp and face. He denied any history of trauma and had no evidence of underlying diseases such as diabetes mellitus or malignancy. On histopathological examination, characteristic morula-like sporangia in the dermis was revealed. After treatment with oral itraconazole for 8 weeks, the patient's skin lesions are almost healed.

Onychoprotothecosis: An uncommon presentation of protothecosis.

Onychomycosis is a fairly common condition seen in a dermatology clinic. Dermatophytes Trichophyton and Epidermophyton are the known filamentous fungi implicated. The yeast‑like fungi such as Candida less commonly cause Onychomycosis. The genus Prototheca may on preliminary observation resemble yeast‑like fungi but a detailed microscopy will reveal the absence of budding and presence of endospores. Onychoprotothecosis is an uncommon presentation of human protothecosis. Of the two Prototheca species (Prototheca zopfii and Prototheca wickerhamii) known to cause the disease, P. wickerhamii has been reported more commonly. We report a culture proven case of this condition caused by P. zopfii. The patient, a 55‑year‑old housewife presented with discolouration and breaking off of the right thumb and forefinger nails since a period of six months. Samples of nail scrapping sent to the Microbiology Laboratory were culture‑positive for Prototheca. Speciation by the automated Vitek‑2 system (bioMerieux) identified the isolate as P. zopfii, which was further confirmed at PGI, Chandigarh.

A Case of Cutaneous Protothecosis / 대한의진균학회지

Protothecosis is a rare skin infection caused by pathogenic algae of the genus Prototheca, especially Prototheca wickerhamii. It is widely distributed throughout the natural world in tree, river, lake, sewage, soil, marsh, household waste, etc. A 79-year-old woman presented with ill-defined edematous and erythematous patches with various sized and shaped deep ulcers on both dorsal hands and left distal forearm for 1 month. The left forearm was initially injured by scratching due to pruritus and insidiously aggravated. Biopsy specimen revealed the characteristic morula-like sporangias containing multiple endospores in the dermis. The GMS and D-PAS stains highlighted the characteristic spores showing multiple internal septations and some unicellular endospore. P. wickerhamii was isolated in culture and identified by biochemical studies. Oral itraconazole 200 mg/day administration for 7 weeks resulted in marked improvement of the skin lesion.

Prototecosis cutánea: presentación de un caso con énfasis en la histopatología / Cutaneous protothecosis: report of a case with emphasis on histopathology

La prototecosis es una infección infrecuente causada por algas del género Prototheca. Su diagnóstico se hace mediante estudios microbiológicos o por la identificación del alga en biopsias por su morfología característica. Se presenta el hallazgo histopatológico de prototecosis en una mujer de 72 años con diagnóstico presuntivo de dermatitis actínica crónica; en el estudio anatomatopatológico de una biopsia de piel se observaron estructuras con septos internos típicos de Prototheca. Se hace una revisión de todos los registros de esta enfermedad en Colombia.

Protothecosis is a rare infection caused by algae of the Prototheca genus. Its diagnosis is based on microbiological studies and on the identification in biopsies of the characteristic structures of the algae. We present the histopathological findings of protothecosis in a 72 year-old woman with the presumptive diagnosis of chronic actinic dermatitis. The pathological study of a skin biopsy revealed structures with internal septa typical of Prototheca. A review of all reports of this disease in Colombia is also presented.

Detection of Prototheca zopfii infection in mouse skin tissue sections by using fluorescence in situ hybridization / 中华皮肤科杂志

Objective To evaluate the feasibility to detect Prototheca in a mouse model of Prototheca zopfii cutaneous infection by using fluorescence in situ hybridization (FISH).Methods The model of Prototheca zopfii cutaneous infection was established by abdominal subcutaneous inoculation of Prototheca zopfii suspensions into 20 male BALB/c mice.Seven days after the inoculation,the mice were sacrificed,and tissue specimens were obtained from abdominal skin and subjected to microscopic examination,fungal culture and paraffin embedding.A PZ-probe was artificially synthesized and used to detect Prototheca in paraffin-embedded sections by using FISH.Moreover,both periodic acid-Schiff (PAS) and hematoxylin-eosin (HE) staining were performed to examine the paraffin-embedded sections.Skin specimens obtained from normal mice and Candida albicans-or Cryptococcus neoformans-infected mice served as the negative control.Results Clinical presentations,pathological examination and fungal culture results all confirmed the successful establishment of Prototheca zopfii skin infection model in mice.Prototheca was identified by FISH with the PZ-probe in the paraffin-embedded skin tissue sections from the murine model of Prototheca zopfii cutaneous infection,but not detected in the negative control tissue specimens,which was consistent with the results of PAS and HE staining.Conclusion FISH can be used to detect Prototheca in paraffin-embedded skin sections from the mouse model of Prototheca zopfii cutaneous infection.

Human Cutaneous Protothecosis: Report of a Case and Literature Review

The Prototheca species is achlorophyllic algae and rarely causes human infection. Human protothecosis presents clinically as a cutaneous infection, olecranon bursitis, and disseminated systemic disease. We report a case of human cutaneous protothecosis involving the left wrist. A 68-year-old man presented with an ill-defined erythematous lesion with crust at the dorsal aspect of his left wrist. A punch biopsy was performed to reveal the histologic features of granulomatous inflammation with necrosis at the upper dermis, containing Prototheca organisms, of which, the characteristic features were highlighted by special staining. Through a molecular study, the Prototheca zopfii species was identified.

Prototecose: uma doença emergente / Protothecosis: an emergent disease

Prototecose, causada por Prototheca zopfii ou P. wickerhamii, é uma doença emergente em animais e humanos. Em bovinos, P. zopfii é uma importante causa de mastite ambiental. Em cães e gatos, a prototecose é causada principalmente por P. zopfii. Em cães, causa infecção cutânea ou uma forma sistêmica envolvendo diversos órgãos. Em gatos, predominam as lesões tegumentares na região da face e plano nasal. No homem, a prototecose, causada principalmente por P. wickerhamii, manifesta-se sob três formas: cutânea, articular com bursite do olécrano e sistêmica. Pode ocorrer em indivíduos imunocompetentes, os quais podem apresentar bursite e/ou infecções cutâneas localizadas, ou em indivíduos imunossuprimidos, nos quais a enfermidade pode ser disseminada e/ou com envolvimento visceral. A prototecose causada por P. wickerhamii foi descrita recentemente em caprinos como causa de rinite afetando o vestíbulo nasal, união mucocutânea, pele da face e orelha. Nesta revisão são abordadas as características microbiologias e susceptibilidade a antimicrobianos do agente, e a epidemiologia, sinais clínicos, patologia, diagnóstico, tratamento e controle da prototecose em animais domésticos e no homem.

Protothecosis, caused by Prototheca zopfii or P. wickerhamii, is an emergent disease of human and animals. In cattle, P. zopfii is an important cause of environmental mastitis. In dogs and cats protothecosis is caused mainly by P. zopfii, causing cutaneous infections or a systemic form affecting many organs in dogs, and cutaneous infection affecting mainly the skin of the face and nose in cats. In humans, protothecosis, caused mainly by P. wickerhamii, occurs in three forms: cutaneous; olecran bursitis; and disseminated. The lesion is usually localized in the site of inoculation in immunocompetent individuals; however, in immunocompromised patients, it can become widespread. Protothecosis caused by P. wickerhamii was recently reported in goats causing rhinitis and dermatitis of the face and pinna. This paper reviews microbiologic characteristics and susceptibility to antimicrobials of Prototheca spp., and the epidemiology, clinical signs, pathology, diagnosis, treatment and control of protothecosis.

Prototecose em animais de companhia e aspectos da doença no homem / Protothecosis in companion animals and aspects of the disease in human

Foram revisados dados de etiologia, epidemiologia, patogenia, sinais clínicos, procedimentos diagnósticos, conduta terapêutica e ações de controle e profilaxia da prototecose em cães e gatos, além de aspectos da doença no homem e em bovinos.

Etiology, epidemiology, pathogeny, clinical signs, diagnosis, therapeutic, control and preventive measures in protothecosis in dogs and cats were reviewed, besides aspects of disease in human and bovines.

Fatores de risco associados à mastite bovina causada por Prototheca zopfii / Risk factors associated with bovine mastitis caused by Prototheca zopfii

Este trabalho teve como objetivo o estudo de fatores de risco associados à mastite bovina causada por Prototheca zopfii. Foram analisadas 13 propriedades leiteiras dos Estados do Paraná e de São Paulo, segundo os seguintes critérios de seleção: confirmação prévia de casos de mastite por Prototheca spp., triagem pela pesquisa de Prototheca spp. em tanques de expansão e latões e rebanhos com contagem de células somáticas acima de 5x105cel mL-1. As amostras coletadas consistiram de: leite, água, solo, fezes e swab de teteiras. Prototheca spp. foi isolada de amostras de leite dos quartos mamários com mastite clínica ou subclínica em uma propriedade e de amostras de leite e do ambiente em quatro propriedades, nas quais foi isolada em amostras de: água de bebedouro, abastecimento, esgoto, empoçada no piso de estábulo e sala de ordenha, solo de piquete e pasto, teteiras, fezes de bezerros e suínos. Do total de 383 vacas examinadas, Prototheca spp. foi isolada em 20 (5,2 por cento) vacas, sendo caracterizada como P. zopfii em 18. Os fatores de risco associados à mastite causada por P. zopfii foram: criação das vacas a pasto, alimentação dos animais com pasto e silagem, realização de ordenha mecânica em estábulo, permanência das vacas após ordenha em piquete sem alimento, criação de suínos próxima às instalações dos bovinos, existência de cães, gatos e roedores, falta de higienização dos tetos com água, pré-imersão dos tetos em aplicador com retorno e sem a troca do anti-séptico, alimentação dos bezerros com leite de vacas com mastite clínica e serem as vacas da raça holandesa.

This research had as objective the study of risk factors associated with bovine mastitis caused by Prototheca zopfii. Thirteen dairy herds in Paraná and São Paulo states were analyzed and selected according to the following criteria: previous confirmation of Prototheca spp. mastitis cases, screening of Prototheca spp. in bulk tanks and milk cans, and herds with somatic cells count over 5x105cel mL-1. The samples collected consisted of: milk, water, soil, manure and swabs of teat cup rubbers. Prototheca spp. was isolated from mammary quarters with clinical and subclinical mastitis of milk samples in one herd and from the environment and cows in four herds. Out of 383 cows examined, Prototheca spp. was isolated in 20 (5.2 percent) cows with mastitis, and 18 of them were characterized as P. zopfii. In four herds when Prototheca spp. was identified from mammary quarters and environment the agent was isolated from the following samples: water in the waterers, puddled water in the stalls and the milking parlour, supply, sewage, cow pen and pasture soil, teat cup rubbers and manure from calves and swines. The risk factors associated with P. zopfii mastitis consisted of: pasture system, pasture and silage feeding, use of milking machine in stalls, cow pen without fresh feed after milking, raising of swines near bovine housing, existence of dogs, cats and rodents, absence of teats hygienization with water, use of pre-immersion devices with return and without change of antiseptic, calves fed with milk of clinical mastitis cases and the Holstein breed.

Isolamento de Prototheca spp. de vacas com mastite, de leite de tanques de expansão e do ambiente dos animais / Isolation of Prototheca spp. from cows with mastitis, bulk tanks milk and in the environment of the animals

As infecções da glândula mamária de vacas leiteiras acarretam sérios prejuízos ao produtor pela diminuiçãoda produção leiteira, tratamento e descarte de animais com infecções crônicas. Elevada incidência de mastite no rebanho também altera a composição e qualidade do leite. Agentes de mastite podem causar infecções ou intoxicações no homem. Nos últimos anos tem-se dado ênfase às infecções intramamárias por algas do gênero Prototheca, agentes de infecções persistentes e refratárias à terapêutica tradicional além do caráter zoonótico. Este trabalho teve como objetivo o isolamento e identificação de Prototheca spp. de amostras de leite coletadas em tanques de expansão e latões, de vacas com mastite e do ambiente dos animais. Foram coletadas 81 amostras de leite de tanques e latões de 81 propriedades. Prototheca zopfii foi identificada em amostras de tanques de 10 propriedades. Dessas propriedades foram estudadas oito quanto à ocorrência de Prototheca spp. no ambiente do rebanho e em casos de mastite, além da identificação dos principais agentes bacterianos causadores de mastite. Foram isoladas bactérias, algas e leveduras em 324 amostras de leite provenientes de 197 vacas. Em três propriedades foi isolada P. zopfii de onze amostras de leite obtidas de cinco vacas com mastite clínica e subclínica. Nestas propriedades o agente foi isolado do meio ambiente das vacas, fezes de bezerros e teteiras. Os resultados deste trabalho mostram a importância do isolamento no tanque como indicativo da presença de Prototheca spp. em propriedades leiteiras.

The dairy cattle mammary gland infections cause serious economic losses to dairy farmers due to the decrease in milk production, therapeutic procedures and culling of chronic infected animals. Highincidence of mastitis in herds also alters both the composition and the quality of the milk. Mastitispathogens can also cause infections and poisoning in humans. In the last years, emphasis has beengiven to intramammary infections caused by the genus Prototheca which, besides their zoonotic characteristics, are considered mastitis pathogens of persistent infection and are refractory to traditional therapeutic procedures. The objective of this work was the isolation and identification of Prototheca spp.from milk samples collected from bulk tanks and milk cans, cows presenting mastitis and the dairy herdenvironment. Milk samples were collected from 81 bulk tanks and milk cans of 81 dairy herds. Protothecazopfii was identified in milk samples in 10 dairy herds. From these, eight dairy herds were studiedregarding Prototheca spp. mastitis and environmental occurrence as well as the main mastitis bacterialagents. Bacteria, algae and yeasts were isolated from 324 milk samples from 197 cows. P. zopfii wasisolated in three dairy herds from eleven milk samples from five cows with clinical and subclinical mastitis. In these dairy herds with positive isolation of P. zopfii the agent was isolated from the herd environment, excrements of the calves and teat cup rubbers. The results of this work demonstrate the importance of isolation in bulk tanks as an indicative of Prototheca spp. presence in dairy herds

Identification of a strain Prototheca zopfii var. hydrocarbonea by analyzing the sequence of ribosome RNA gene / 中国人兽共患病学报

A strain of Prototheca species isolated from a case of meningitis was identified by routine morphologic and biochemical methods as well as amplification of the related genes, in which the 28S large-subunit (LSU) region of ribosomal RNA (rRNA) gene and intergenic space (ITS) were amplified with universal fungal primers. The small-subunit (SSU) rRNA gene was amplified with eukaryote-specific primers and Prototheca genus-specific primers. Then, compared the sequences with the ones posted on BLAST (www. ncbi. nlm. nih. gov/BLAST). The organism choice giving the closest match, up to 99%, was considered the most likely correct identification. It was found that this strain of fungus grew well at 25 ℃ or 37 ℃. Smooth,moist colonies with white color were observed on Sabouraud Dextrose Agar (SDA) and Potato Dextrose Agar (PDA). Microscopically, globular or ovoid cells, a number of round, ovoid shaped endospores could be observed. No hypha, ascus or blastic conidia was found upon cultivation on SDA. Based on the morphological characteristics, this isolate could be identified as Prototheca species. The identity with Prototheca wickerhamii was 2.9 % as demonstrated by the API 20C AUX system. Sequence analysis showed that the ITS gene was proved to be a complex structural region which was not suitable for the identification of Prototheca species, but the LSU and SSU rDNA regions showed 94% and 99.9% sequence identities with Prototheca zopfii var. hydrocarbonea (P. zopfii var. hydrocarbonea) respectively, indicating that the SSU rRNA gene sequence might be more reliable on than the LSU rRNA gene sequence for identification of Prototheca species.

A Case of Cutaneous Protothecosis / 대한의진균학회지

Cutaneous protothecosis is a rare skin infection, caused by the genus prototheca, especially Prototheca wickerhamii. A 73-year-old woman had a painful, ulcerative patch and oozing plaque on left wrist and dorsum of hand for 2 months. Biopsy specimen revealed thick walled morula-like sporangia in the dermis. P. wickerhamii was isolated in the culture. Oral itraconazole therapy for 8 weeks is not satisfactory. New skin lesion is formed. After oral fluconazole therapy, patient's skin lesion is improved.

A Case of Cutaneous Prototheocsis / 대한의진균학회지

Protothecosis is an infection caused by achloric algae of the genus Prototheca. It is found ubiquitously in nature, particularly in the slime flux of trees and sewage. Only two species including Prototheca wickerhamii and Prototheca zopfii have been known to be pathogenic in humans. A 64-year-old man presented intermittent pruritic erythematous confluent grouped papules and nodules on the left upper arm. Histopathologic study revealed some sporangia of morula-like appearance and chronic granulomatous inflammation. The PAS stain demonstrated the characteristic spores showing multiple internal septations and some unicellular endospore. P. wickerhamii was isolated from culture and identified by the biochemical studies. Oral itraconazole 200 mg/day administration resulted in marked regression of the skin lesion after 8 weeks.