Primary Cutaneous Coccidioidomycosis in an Italian Nun Working in South America and Review of Published Literature.

Coccidioidomycosis is a systemic disease caused by the dimorphic fungus Coccidioides, endemic in parts of the Southwestern USA and Central and South America. Two species, Coccidioides immitis and Coccidioides posadasii, were differentiated. Primary cutaneous coccidioidomycosis (PCC) has been reported rarely. An unusual case of PCC characterized by a persistent solitary lesion diagnosed in Italy in an immunocompetent Italian nun living in Argentina is described. The isolate was identified by sequence analysis as C. posadasii. Antibody screening was negative. A total of 39 cases of PCC have been reported in the literature. Infections occurred as a consequence of traumatic implantation in a natural setting in endemic areas or of accidental inoculation in laboratory workers. Importance of accurate investigation of travel history and of occupational hazards to laboratory workers is outlined.

Primary cutaneous cryptococcosis in an eight-year-old immunocompetent child: how to treat?

Here we report on a case of primary cryptococcal skin infection in an immunocompetent 8-year-old boy. The infection first manifested itself as a subcutaneous abscess around the proximal joint of his right thumb after a minor injury from contact with a thorny shrub. After surgical incision and drainage was performed, Cryptococcus neoformans var. neoformans was the only pathogen cultured from the lesion. An agglutination test for the capsular antigen in serum displayed negative results and the immunological work-up revealed no underlying immunodeficiency. A "watch and wait" strategy - one without systemic antifungal treatment - was adopted and this resulted in uneventful healing. In summary, primary cryptococcal skin infections in immunocompetent hosts may be managed successfully by surgical treatment in combination with careful clinical follow-up. This approach may help avoid unnecessary antimicrobial treatments.

Prevalence of Scedosporium species and Lomentospora prolificans in patients with cystic fibrosis in a multicenter trial by use of a selective medium.

OBJECTIVE: Detection of hyphomycetes of the Scedosporium apiospermum complex and Lomentospora prolificans (Sac-Lp) is not yet standardized. Prevalence rates in patients with cystic fibrosis (CF) and the resistance pattern of these pathogens in Germany are unknown. METHODS: In a one-year prospective study 11 laboratories used a selective medium for isolation of Sac-Lp, examining >11,600 respiratory samples from 2346 patients with CF. Isolates were identified by molecular methods and tested for susceptibility to antifungal drugs. RESULTS: The prevalence of Sac-Lp in patients with CF in Germany varied from 0.0 to 10.5% (mean: 3.1%) among the clinical centres. The benefit of the selective medium SceSel(+) compared to standard media for fungi was documented for >5000 samples. High antifungal resistance was detected in the S. apiospermum complex, and the multiresistance of L. prolificans was confirmed. CONCLUSION: Microbiology laboratories should be aware of these resistant species in patients with CF and consider using a selective medium.

[A 55-year-old woman with cough, fever, swelling of joints, and exanthema after a trip to Ecuador]. / 55-jährige Patientin mit Husten, Fieber, Gelenkschwellungen und Exanthem nach einem Urlaub in Ecuador.

A 55-year-old woman presented 18 months after a trip to Ecuador with night sweat, malaise, and an unclear lesion of the lung. Computed tomography of the lung showed a nodular lesion of 14 mm. Antibodies against Histoplasma capsulatum were detected in the complement fixation text (CFT) and IgG western blot. Re-examination of a formalin fixed paraffin embedded (FFPE) lung-biopsy revealed yeasts after silver staining, compatible with H. capsulatum , which was verified by extraction and amplification of DNA from FFPE. After therapy with itraconazole 400 mg/day, the patient showed an uneventful clinical recovery without regression of the lung lesion. The serological follow-up examination after 17 months showed CFT without pathological findings.

[Cutaneous infection due to Fusarium oxysporum in a female diabetic: molecular biological detection of the mold from formalin-fixed paraffin embedded tissue using sequencing of the ITS region of the rDNA]. / Kutane Infektion durch Fusarium oxysporum bei einer Diabetikerin: Molekularbiologischer Schimmelpilznachweis aus Formalin-fixiertem, Paraffin-eingebettetem Gewebe mittels Sequenzierung der ITS-Region der rDNA.

BACKGROUND: Skin lesions due to Fusarium spp. occur either secondarily following hematological spread in systemic infection or represent primary cutaneous infections following traumatic inoculation. CASE REPORT: A 34-year-old woman with insulin-dependent diabetes mellitus presented with a most likely posttraumatic leg ulcer present for 4 weeks. The ulcer showed superficial necrosis with cellular debris, neutrophils, and leukocytoclasia. Septate hyphae were detected both in the necrotic area and between the collagen fibers on initial H & E stained sections. Using PAS and Grocott-Gomori silver staining, the dichotomous branching hyphae were clearly visible. Unfortunately, cultural detection of the fungi was impossible. After extraction and purification of the fungal DNA from formalin-fixed and paraffin embedded (FFPE) tissue sections, the amplification of the ITS region of rDNA was done. Using sequencing and comparison with reference sequences of a gene bank, Fusarium oxysporum was identified. THERAPY: Therapy was performed by surgical excision of the entire ulcer followed by topical antiseptic treatment and wound conditioning. No systemic antifungal treatment was given. The lesion healed without any problems. DISCUSSION: Cutaneous fusarium infections are rare but emerging opportunistic infections. Histological examination represents the quickest diagnostic method for detection of the fungal infection. An alternative approach represents the species identification based on molecular techniques.

[Differential diagnosis for detection of hyphae in tissue]. / Differenzialdiagnosen beim Nachweis von Hyphen im Gewebe.

Usually the detection of hyphae in tissue is unmistakable evidence of a deep mycosis requiring antimycotic treatment. Micromorphology alone rarely allows a specific diagnosis, thus confusion is possible between Candida, Aspergillus, Alternaria and Fusarium species or several other fungal agents. If broad, nearly non-septated hyphae are detected histologically mucormycosis can be suspected. Detection of hyphae in tissue is always a cause for concern because therapeutic consequences must follow. Because therapeutic strategies may differ depending on the specific fungal agent, a suspected diagnosis should be supplemented by other methods, e.g. culture of unfixed specimens, by immunohistology or molecular biological methods.

[Differential diagnoses for detection of yeasts and yeast-like organisms]. / Differenzialdiagnosen beim Nachweis von Hefen und hefeähnlichen Organismen.

The differential diagnosis of yeasts or yeast-like organisms includes a series of imported and domestic fungal pathogens. The spectrum of fungal pathogens involves dimorphic fungi which may cause deep mycoses in healthy people as well as opportunistic fungi, which require predisposing factors for infection, e.g. immunosuppression or a trauma. The histology is sometimes unambiguous; however, frequently there is a great similarity between diverse fungal infections in tissues and the diagnostically decisive criteria are only obvious in a few pathogens. In addition to a classical culture technique in doubtful cases molecular biological or serological methods are necessary to confirm any suspected pathogen diagnosis.

[Fungal infections of the central nervous system in the immunocompetent host]. / Pilzinfektionen des Zentralnervensystems bei immunkompetentem Wirt.

The majority of mycoses which lead to mycotic tumors in patients without any predisposing underlying disease are either caused by Cryptococcus gattii and C. neoformans or by dematiaceous fungi which include Cladophialophora bantiana, Ramichloridium mackenziei, Exophiala and Fonsecaea species. The detection of hyphae in granuloma in the brain should lead to screening for pigmented fungi, which are recognized best in hematoxylin eosin (HE) or sometimes also in periodic acid-Schiff (PAS) stained sections. In patients who survive a near drowning accident and those who develop brain abscesses, scedosporiosis should always be considered as a possible infection.

[Coccidioidomycosis with manifestation on the tongue]. / Kokzidioidomykose mit Befall der Zunge.

Systemic mycoses are rare but important differential diagnoses in patients with imported infections. We report the case of a 51-year-old German traveller who acquired coccidioidomycosis during a holiday in Arizona, USA. The disease became apparent several months later primarily as a swelling of the tongue. Subsequent diagnostic investigations revealed infiltration of both lungs. The causal agent Coccidioides posadasii could be cultivated from transbronchial biopsy samples.

[Molecular biological identification of fungal pathogens in FFPE tissue from cases of cephalic mycosis]. / Molekularbiologischer Erregernachweis aus FFPE-Proben bei zephaler Mykose.

BACKGROUND: Due to the lack of histopathological differentiation the unequivocal identification of fungal pathogens is rarely possible. In order to understand the pathogen spectrum causing cephalic mycosis the use of alternative methods is essential. MATERIAL AND METHODS: In a retrospective study 24 formalin-fixed, paraffin-embedded (FFPE) samples from patients with histologically confirmed cerebral or cephalic mycosis were analyzed with molecular biological methods. RESULTS: In two samples obtained during the patients' lifetime human as well as fungal DNA was detected, making an unambiguous diagnosis possible. For tissue that had been fixed over a longer period, detection of human and fungal DNA was possible merely in 60% and 47 % of the samples, respectively. Most frequently diagnosed were aspergillosis (n = 9), followed by mucormycosis (n = 2) and imported blastomycosis (n = 1). CONCLUSIONS: Using biopsy material a DNA analysis seems promising although only with limited success using brain samples taken at autopsy which have been fixed over a longer period. For unambiguous retrospective diagnostics of pathogens when cephalic mycosis is suspected, the sample extraction for postmortem diagnostics should be performed prior to a long period of formalin fixation.

[Cryptococcosis: case reports, epidemiology and treatment options]. / Kryptokokkose: kasuistiken, epidemiologie und therapiestrategien.

Cryptococcosis is a fungal infection that is usually caused by Cryptococcus neoformans. Given the decreasing number of cases in HIV-infected patients in developed countries, infections in other patient populations, such as solid organ transplant recipients, patients with chronic organ diseases or even patients without immunodeficiency gain more attention. Due to a possible involvement of many organs, the clinical presentation varies from localized infections of the respiratory tract and the skin, to the characteristic meningoencephalitis or other organs after hematogenous dissemination. Sensitive laboratory tests allow a rapid diagnosis in patients with disseminated infection. Crucial therapeutic decisions depend on the underlying patient condition and the particular organ involvement. The induction therapy of disseminated infections or severe localised infections is based on amphotericin B in combination with 5-flucytosine. In non-severe localised infections and after induction therapy, antifungal treatment with fluconazole is indicated. Echinocandins are not effective in cryptococcosis.

Multilocus sequence typing of Scedosporium apiospermum and Pseudallescheria boydii isolates from cystic fibrosis patients.

BACKGROUND: Scedosporium and Pseudallescheria species are the second most common lung-colonising fungi in cystic fibrosis (CF) patients. For epidemiological reasons it is important to trace sources of infection, routes of transmission and to determine whether these fungi are transient or permanent colonisers of the respiratory tract. Molecular typing methods like multilocus sequence typing (MLST) help provide this data. METHODS: Clinical isolates of the P. boydii complex (including S. apiospermum and P. boydii) from CF patients in different regions of Germany were studied using MLST. Five gene loci, ACT, CAL, RPB2, BT2 and SOD2, were analysed. RESULTS: The S. apiospermum isolates from 34 patients were assigned to 32 sequence types (STs), and the P. boydii isolates from 14 patients to 8 STs. The results revealed that patients can be colonised by individual strains for years. CONCLUSIONS: The MLST scheme developed for S. apiospermum and P. boydii is a highly effective tool for epidemiologic studies worldwide. The MLST data are accessible at http://mlst.mycologylab.org/.

Phylogeny of chrysosporia infecting reptiles: proposal of the new family Nannizziopsiaceae and five new species.

We have performed a phenotypic and phylogenetic study of a set of fungi, mostly of veterinary origin, morphologically similar to the Chrysosporium asexual morph of Nannizziopsis vriesii (Onygenales, Eurotiomycetidae, Eurotiomycetes, Ascomycota). The analysis of sequences of the D1-D2 domains of the 28S rDNA, including representatives of the different families of the Onygenales, revealed that N. vriesii and relatives form a distinct lineage within that order, which is proposed as the new family Nannizziopsiaceae. The members of this family show the particular characteristic of causing skin infections in reptiles and producing hyaline, thin- and smooth-walled, small, mostly sessile 1-celled conidia and colonies with a pungent skunk-like odour. The phenotypic and multigene study results, based on ribosomal ITS region, actin and ß-tubulin sequences, demonstrated that some of the fungi included in this study were different from the known species of Nannizziopsis and Chrysosporium and are described here as new. They are N. chlamydospora, N. draconii, N. arthrosporioides, N. pluriseptata and Chrysosporium longisporum. Nannizziopsis chlamydospora is distinguished by producing chlamydospores and by its ability to grow at 5 °C. Nannizziopsis draconii is able to grow on bromocresol purple-milk solids-glucose (BCP-MS-G) agar alkalinizing the medium, is resistant to 0.2 % cycloheximide but does not grow on Sabouraud dextrose agar (SDA) with 3 % NaCl. Nannizziopsis arthrosporioides is characterised by the production of very long arthroconidia. Nannizziopsis pluriseptata produces 1- to 5-celled sessile conidia, alkalinizes the BCP-MS-G agar and grows on SDA supplemented with 5 % NaCl. Chrysosporium longisporum shows long sessile conidia (up to 13 µm) and does not produce lipase.

Benefit of polyhexamethylene biguanide in Fusarium keratitis.

PURPOSE: To report a series of 3 patients with soft contact lens-related Fusarium keratitis. Two of them were treated with the antiamoebic polyhexamethylene biguanide 0.02% (PHMB) in combination with antifungal drugs, and 1 patient was treated with PHMB as sole antifungal regimen. METHODS: Chart review of 3 patients treated with PHMB in Fusarium keratitis. Two of them were refractory to the commonly used therapy. The antifungal power of PHMB and propamidine isethionate was tested against the patients' isolates as well as against the clinical isolates from another 9 patients with ocular mould infections. RESULTS: An excellent outcome could be achieved in 2 patients with Fusarium solani keratitis refractory to common antifungal treatment by the additional use of PHMB 0.02%. In another patient PHMB alone was sufficient to resolve Fusarium proliferatum infection. The drug was well tolerated. In all patients repeated abrasion was done for better penetration of the drugs. PHMB revealed a marked in vitro antifungal activity for the three Fusarium isolates as well as for another 9 isolates of ocular infections from other patients including also the genera Scedosporium, Aspergillus and Rhizopus giving minimal inhibitory concentrations ranging from 1.56 to 3.12 µg/ml. CONCLUSIONS: Fusarium keratitis is a severe ocular infection. We report on the use of PHMB in 3 patients given additionally or as sole antifungal drug. We emphasize the benefit of PHMB 0.02% in Fusarium keratitis which might be considered as a therapeutic option especially in cases refractory to common antifungal therapy and possibly in keratitis due to other fungi.

Breakthrough zygomycosis on posaconazole prophylaxis after allogeneic stem cell transplantation.

Antifungal prophylaxis with posaconazole (POS) has been shown to decrease the mortality associated with invasive fungal infections in high-risk patients. We report on a patient, with severe graft-versus-host disease after allogeneic stem cell transplantation, who developed proven pneumonia due to Rhizopus microsporus after 40 days of POS prophylaxis (fasting serum levels: 691-904 ng/mL). Despite combination treatment with liposomal amphotericin B and POS for 39 days, the patient died from pulmonary hemorrhage. This case highlights the need for continued awareness of breakthrough zygomycosis in patients receiving POS.

Cryptococcus gattii meningoencephalitis in an immunocompetent person 13 months after exposure.

A 53-year old immunocompetent Swiss female is described who developed severe meningoencephalitis due to infection with Cryptococcus gattii 13 months following exposure on Vancouver Island, Canada. Diagnosis was based on cerebrospinal fluid (CSF) examination, i.e., positive India-ink staining, positive latex particle agglutination, and positive culture. Species identification was performed by growth on L-canavanine-glycine-bromthymol blue medium and by sequencing of the intergenic and internal transcribed spacer regions of the rRNA genes. After initial therapy with fluconazole by which the patient did not improve, therapy was changed to amphotericin B and flucytosine and later to high-dose fluconazole and amphotericin B. Despite long-term treatment and external drainage of the CSF, the patient's condition improved only slowly. The patient was discharged after 132 days of hospitalization.

A review of German Scedosporium prolificans cases from 1993 to 2007.

Scedosporium prolificans is one of the most life-threatening fungal opportunistic pathogens due to its high resistance to common systemic antifungal agents. While a close relative of Pseudallescheria boydii, S. prolificans has a more limited geographic range being primarily found in Australia, USA and Spain. Infections have also been reported from several other European countries and from Chile. Twenty patients with Scedosporium prolificans infection or colonization from August 1993 to May 2007 were retrospectively reviewed in Germany. They had all been identified at or reported to the Reference Laboratory for Pseudallescheria/Scedosporium spp. in Berlin. Twelve of 13 patients with haematological disorders and/or on immunosuppressive therapy developed a fatal invasive scedosporiosis. Colonization of the respiratory tract was reported for one patient after heart-lung-transplantation, all six patients with cystic fibrosis and one with chronic sinusitis. Molecular studies of the S. prolificans isolates confirmed that parts of the 18S, the Internal Transcribed Spacer (ITS) regions and the D1/D2 domain of the 28S region of rDNA are monomorphic. However, sequencing of parts of the translation elongation factor EF1-alpha (EF-1alpha) and the chitin synthase (CHS-1) genes revealed the presence of three and two distinct genotypes, respectively. Two informative mutations were found in EF-1alpha and a single nucleotide exchange in the CHS-1 gene.

Nail infection by Aspergillus ochraceopetaliformis.

Aspergillus ochraceopetaliformis is a rare fungal species that has not yet been identified as a proven human pathogen. Here we report a case of a toenail infection in a healthy woman caused by this fungus. Species identification was performed by scrutinizing the phenotypic and genetic characteristics of distinct isolates obtained at different times during the course of the infection. Treatment with terbinafine plus ciclopiroxolamine was effective.

Histoplasmosis in Europe: report on an epidemiological survey from the European Confederation of Medical Mycology Working Group.

The purpose of this survey was to systematically collect data on individuals with histoplasmosis in Europe over a 5-year period (from January 1995 to December 1999). This included information on where and how the infection was acquired, the patient's risk factors, the causative organism, how the infection was diagnosed and what therapy the patients received. Data were sent on a standardized survey form via a national convenor to the coordinator. During the survey, 118 cases were reported, with 62 patients having disseminated disease, 31 acute pulmonary infection, chronic pulmonary infection in 6 and localized disease in 2 patients. For 17 patients, the diagnosis of histoplasmosis was incidental, usually secondary to investigations for lung cancer. Most patients had travelled to known endemic areas, but 8 patients (from Italy, Germany and Turkey) indicated that they had not been outside their countries of origin and hence these cases appear to be autochthonous. Notable observations during the survey were the reactivation of the disease up to 50 years after the initial infection in some patients and transmission of the infection by a transplanted liver. Itraconazole was the most commonly used therapy in both pulmonary and disseminated disease. The observation of autochthonous cases of disease suggests that the endemic area of histoplasmosis is wider than classically reported and supports continued surveillance of the disease throughout Europe.