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.

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.

Mastite bovina por Prototheca zopfii na região oeste do Paraná: Relato de casos / Bovine mastitis by Prototheca zopfii in western Paraná: Case reports / Mastitis bovina por Prototheca zopfii en la región oeste de Paraná: Relato de casos

Relatam-se três casos de mastite clínica em vacas da raça Jersey de uma propriedade localizada na região Oeste do estado do Paraná, refratários ao tratamento com antimicrobianos. Após realização de cultura das amostras de leite, foi identificada Prototheca zopfii, uma alga aclorofilada, unicelular, presente em matéria orgânica e resistente a antimicrobianos. Foi indicado o descarte dos animais positivos e, como medida de profilaxia, a higienização de caixas de abastecimento de água e bebedouros, uma vez que o manejo da ordenha e higienização da ordenhadeira era realizada de maneira adequada na propriedade. De acordo com a literatura consultada, este é o primeiro relato de mastite por Prototheca zopfii na região Oeste do Paraná, salientando a importância da realização da cultura de amostras de leite de vacas portadoras de mastite, especialmente em casos refratários ao tratamento.(AU)

Three cases of clinical mastitis were reported in Jersey cows at a farm located in western Parana, with a history of refractory treatment with antimicrobials. Milk sample cultures presented Prototheca zopfii, an aclorophylated, unicellular algae, present in organic matter and resistant to antimicrobial treatment. The disposal of positive animals was indicated, and the prophylactic measure of cleaning the water storage and drinking containers were encouraged, since the milking and cleaning of the milking machine were properly performed at the farm. According to the literature, this is the first report of mastitis by Prototheca zopfii in western Parana, thus emphasizing the importance of performing cultures to the milk samples of cows presenting mastitis, especially in cases that are refractory to treatment.(AU)

Tres casos de mastitis clínica se ha relatado en vacas de la raza Jersey, de una propiedad ubicada en la región Oeste del Estado de Paraná, resistentes al tratamiento con antimicrobianos. Después de la realización de cultura de las muestras de leche, se identificó Prototheca zopfii, un alga aclorofilada, unicelular, presente en materia orgánica y resistente a antimicrobianos. Se aconsejó el descarte de los animales positivos y, como medida de profilaxis, la higienización de las cajas de abastecimiento de agua y bebederos, una vez que el manejo de ordeña e higienización de la ordeñadera era realizada de forma adecuada en la propiedad. De acuerdo con la literatura consultada, este es el primer relato de mastitis por Prototheca zopfii en la región Oeste de Paraná, resaltando la importancia de realización de cultura de las muestras de leche de vacas portadoras de mastitis, especialmente en casos resistentes al tratamiento.(AU)

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.

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.

Cutaneous protothecosis - case report / Prototecose cutanea - relato de caso

Cutaneous protothecosis is a rare infection caused by achlorophyllic algae of the genus Prototheca. The lesions usually occur on exposed areas, related with trauma, in immunocompromised patients. The most common clinical presentation is a vesicobullous and ulcerative lesion with pustules and scabs, simulating bacterial, fungal or herpetic infections or eczema. The diagnosis is determined by agent identification through histopathology, culture and the carbohydrates assimilation test. The finding of morula-like spherules is characteristic of Prototheca sp. Its rarity and non-specific clinical aspect may difficult the disease diagnosis. We report a case of a diabetic patient, in chronic use of systemic corticosteroids, that developed a skin lesion after trauma to the right leg.

A prototecose cutânea é uma infecção rara causada por algas aclorofílicas do gênero Prototheca. Geralmente as lesões ocorrem em áreas expostas, relacionadas à trauma, em indivíduos imunocomprometidos. A apresentação clínica mais comum é uma lesão vesico-bolhosa e ulcerativa com pústulas e crostas, simulando piodermites, infecções fúngicas, infecções herpéticas ou eczemas. O diagnóstico é realizado pela identificação do agente através do exame histopatológico, da cultura e do teste de assimilação dos carboidratos. O achado de esférulas com aspecto de mórula são características da Prototheca sp. A raridade da doença e o aspecto clínico inespecífico dificultam o diagnóstico da doença. Relatamos um caso em paciente diabética, em uso crônico de corticoide sistêmico, que desenvolveu lesão cutânea após trauma na perna direita.

Intoxicação por metronidazol em um cão / Intoxication metronidazole in a dog

Relata-se o caso de intoxicação de uma cadela da raça dálmata tratada cronicamente com o metronidazol, onde o diagnóstico foi baseado no histórico de administração, que pode ser de doses normais a aumentadas, e na resolução dos sinais clínicos após a suspensão da droga e instituição do tratamento de suporte, conforme cita a literatura (KIM et al, 2011; HECKLER et al, 2012). Nesses casos o prognóstico geralmente é favorável, mas alguns cães podem morrer ou desenvolver lesões hepáticas (HECKLER et al, 2012).

Etiology, antimicrobial susceptibility profile of Staphylococcus spp. and risk factors associated with bovine mastitis in the states of Bahia and Pernambuco / Etiologia, perfil de sensibilidade dos Staphylococcus spp. aos antimicrobianos e fatores de risco associados à mastite bovina nos estados da Bahia e Pernambuco

The purpose of this paper was to study the etiology of mastitis, determine the antimicrobial susceptibility profile of Staphylococcus spp. and to identify the risk factors associated with infection in dairy cows in the states of Bahia and Pernambuco, Brazil. From the 2,064 milk samples analyzed, 2.6% were associated with cases of clinical mastitis and 28.2% with subclinical mastitis. In the microbiological culture, Staphylococcus spp. (49.1%) and Corynebacterium spp. (35.3%) were the main agents found, followed by Prototheca spp. (4.6%) and Gram negative bacilli (3.6%). In the antimicrobial susceptibility testing, all 218 Staphylococcus spp. were susceptible to rifampicin and the least effective drug was amoxicillin (32.6%). Multidrug resistance to three or more drugs was observed in 65.6% of Staphylococcus spp. The risk factors identified for mastitis were the extensive production system, not providing feed supplements, teat drying process, not disinfecting the teats before and after milking, and inadequate hygiene habits of the milking workers. The presence of multiresistant isolates in bovine milk demonstrates the importance of the choice and appropriate use of antimicrobial agents. Prophylactic and control measures, including teat antisepsis and best practices for achieving hygienic milking should be established in order to prevent new cases of the disease in herds.

Objetivou-se estudar a etiologia da mastite, determinar o perfil de sensibilidade dos Staphylococcus spp. aos antimicrobianos e identificar os fatores de risco associados à infecção em vacas leiteiras nos estados da Bahia e Pernambuco. Das 2.064 amostras de leite analisadas, 2,6% estavam associadas a casos de mastite clínica e 28,2% à mastite subclínica. No exame microbiológico, Staphylococcus spp. (49,1%) e Corynebacterium spp. (35,3%) foram os principais agentes isolados, seguidos de Prototheca spp. (4,6%) e bacilos Gram negativos (3,6%). No teste de sensibilidade aos antimicrobianos, todos os 218 Staphylococcus spp. apresentaram-se sensíveis à rifampicina e a droga menos eficaz foi a amoxicilina (32,6%). A resistência simultânea a três ou mais drogas foi observada em 65,6% dos Staphylococcus spp. Os fatores de risco identificados para a mastite foram o sistema de criação extensivo, não realização de suplementação alimentar, processo de secagem dos tetos, não realização de desinfecção dos tetos antes e após a ordenha e hábitos higiênicos inadequados dos ordenhadores. A presença de isolados multirresistentes no leite bovino demonstra a importância da escolha e da utilização adequada de antimicrobianos. Medidas de controle e profilaxia, incluindo a antissepsia dos tetos e boas práticas para a obtenção de ordenha higiênica devem ser estabelecidas, com o intuito de prevenir novos casos da doença nos rebanhos.

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.

Disseminated protothecosis.

Here is presented, a rare case of disseminated protothecosis in a 10-year-old boy with combined immunodeficiency, hitherto unreported from India. Even though it is difficult to diagnose clinically,observation of the sporangiospores within the sporangium in culture gives the accurate laboratory identification of Prototheca spp. In this patient, failure to eradicate the infection with amphotericin B and recurrence with olecranon bursitis along with skin lesions and splenomegaly was observed. Disseminated protothecosis in a child with combined immunodeficiency and failure to eradicate the infection with amphotericin B is reported.

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.

Prototecose cutânea: relato de caso / Cutaneous protothecosis: case report

Descreve-se um caso de prototecose cutânea em paciente de 78 anos, submetido a tratamento para pênfigo foliáceo e feohifomicose. Ele apresentava lesões eritematosas infiltradas na perna direita e o diagnóstico foi feito através de estudo histológico e através de cultura da pele lesada. A cura foi obtida com o uso oral de itraconazol.

A case of cutaneous protothecosis was reported in a 78-year-old man that was in treatment for pemphigus foliaceus and phaeohyphomycosis. He presented erythematous lesions which were infiltrated into his right leg. The diagnosis was made histopathologically and confirmed by culture, and the patient was successfully treated with itraconazole.

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

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 Protothecosis / 대한피부과학회지

Protothecosis is an unusual human infection caused by the achlorophyllic algae Prototheca, and most commonly by Prototheca wickerhamii. A 65-year-old man presented with a 2-month history of a painful, erythematous, non-healing, ulcerative plaque on the extensor surface of his left forearm. He was previously diagnosed with diabetes and iatrogenic Cushing syndrome. A skin biopsy specimen revealed characteristic morula-like sporangia in the dermis by PAS positive staining. Prototheca wickerhamii was identified by culture and biochemical studies. Initially, itraconazole was administered for 8 weeks, followed by fluconazole, and the patient's condition was greatly improved.