Recurrent cutaneous hyalohyphomycosis secondary to Purpureocillium lilacinum in an immunocompetent individual.

Purpureocillium lilacinum, previously classified as Paecilomyces lilacinus, is a ubiquitous hyaline hyphomycete considered to be an emerging opportunistic human pathogen that is resistant to traditional antifungal agents. This case report describes what is to our knowledge the only published case of P. lilacinum recrudescence in an immunocompetent host despite initial best-practice treatment with 10 weeks of voriconazole and surgical excision.

Novel Penicillium species causing disseminated disease in a Labrador Retriever dog.

This report describes the phenotypic characteristics of a novel Penicillium species, Penicillium labradorum, isolated from a 3-year-old male, castrated, Labrador retriever with disseminated fungal disease. The dog's presenting clinical signs included lethargy, lymphadenopathy, tachypnea, moderate pitting edema, and nonweight bearing lameness associated with the right hind limb. Fine-needle aspirate biopsies from the sublumbar and prescapular lymph nodes were initially examined. The cytologic findings were consistent with pyogranulomatous inflammation with abundant extracellular and phagocytized fungal fragments and hyphae. Based on the morphology of the organisms and lack of endogenous pigment, hyalohyphomycosis was considered most likely, with Fusarium, Penicillium, and Paecilomyces species being considerations. Fungal isolates were obtained via culture of samples from the lymph nodes, and molecular identification testing originally identified an undescribed Penicillium species belonging to the Penicillium section Exilicaulis. BLAST searches and phylogenetic analyses performed approximately 1 year and 9 months after the isolation date revealed an isolate within the Penicillium parvum clade in the Penicillium section Exilicaulis but phylogenetically distant from the other species in the section, thus representing a new species, Penicillium labradorum. Antifungal susceptibility testing was also performed on the isolate and low minimum inhibitory concentrations were observed with terbinafine, voriconazole, and posaconazole, while in vitro resistance was observed with fluconazole. The dog had been previously treated with fluconazole, itraconazole, amphotericin B lipid complex, voriconazole, and terbinafine. Approximately 587 days after the initial diagnosis, the dog was euthanized due to worsening of clinical signs and concerns for quality of life.

Afectación cutánea en las micosis profundas: una revisión de la literatura. Parte 1: micosis subcutáneas / Cutaneous involvement in the deep mycoses: a literature review. Part I-subcutaneous mycoses

Las micosis profundas son infecciones poco frecuentes en nuestro medio. Se presentan principalmente en pacientes inmunodeprimidos o en regiones de climas tropicales, que abarcan las micosis subcutáneas y las micosis sistémicas. Las micosis subcutáneas o por implantación siempre producen signos de afectación cutánea. En la primera parte de esta revisión se realizará una revisión de las principales micosis subcutáneas: esporotricosis, cromoblastomicosis, micetomas, feohifomicosis, hialohifomicosis y lacaziosis. Reconocer y tratar estas micosis subcutáneas de forma precoz es importante, ya que a menudo están asociadas a una alta morbilidad

The deep mycoses are uncommon in our setting. These fungal infections occur mainly in immunosuppressed patients or in tropical climates, and include subcutaneous infections and systemic infections. The skin is always involved in the former. In the first part of this review, we describe the main subcutaneous mycoses: sporotrichosis, chromoblastomycosis, mycetoma, phaeohyphomycosis, hyalohyphomycosis, and lacaziosis. Early recognition and treatment is important, as these infections are frequently associated with high morbidity

Disseminated penicilliosis due to Penicillium chrysogenum in a pediatric patient with Henoch-Schönlein syndrome.

A case of disseminated infection caused by Penicillium chrysogenum in a 10-year-old boy with a history of Henoch-Schönlein purpura and proliferative glomerulonephritis, treated with immunosuppressors, is reported herein. The patient had a clinical picture of 2 weeks of fever that did not respond to treatment with broad-spectrum antibiotics and amphotericin B. Computed tomography imaging showed diffuse cotton-like infiltrates in the lungs, hepatomegaly, mesenteric lymphadenopathy, and multiple well-defined round hypodense lesions in the spleen. His treatment was changed to caspofungin, followed by voriconazole. One month later, a splenic biopsy revealed hyaline septate hyphae of >1µm in diameter. Fungal growth was negative. However, molecular analysis showed 99% identity with P. chrysogenum. A therapeutic splenectomy was performed, and treatment was changed to amphotericin B lipid complex and caspofungin. The patient completed 2 months of treatment with resolution of the infection. P. chrysogenum is a rare causative agent of invasive fungal infections in immunocompromised patients, and its diagnosis is necessary to initiate the appropriate antifungal treatment.

An Unusual Association of Adult T-Cell Leukemia/Lymphoma With Hyalohyphomycosis.

Infection by human T-cell lymphotropic virus (HTLV-1) causes deregulation of the immune system, which makes the infected individuals more susceptible to infectious diseases. Immune deregulation is even more pronounced in HTLV-1 carriers with adult T-cell leukemia/lymphoma (ATLL), which results in frequent opportunistic infections. Hyalohyphomycosis is a rare subcutaneous mycosis which is more commonly associated with immunocompromised patients. We report a case of a HTLV-1-infected man with skin tumors, inguinal lymphadenomegaly, and lymphocytosis. Histopathological examination of skin biopsies revealed a T-cell lymphoma intermingled with a granulomatous process with abscesses and hyaline-septated hyphae. The lymph node showed only a T-cell lymphoma. The patient was diagnosed with acute ATLL and hyalohyphomycosis. He was treated with itraconazole for the subcutaneous mycosis and with chemotherapy for ATLL. A few months later, despite the treatment, he died because of progression of ATLL.

Aspectos actuales de las enfermedades invasivas por hongos filamentosos / State of the art in invasive diseases by filamentous fungi

Las micosis invasivas se han convertido en una causa importante de morbimortalidad en pacientes críticos, enfermos con neoplasias, inmunodeficiencias y otras enfermedades en las que se produce una alteración de las defensas. Candida albicans continúa siendo el agente patógeno más frecuente, pero los avances en el diagnóstico, la prevención y el tratamiento de las candidiasis invasivas están causando un cambio etiológico importante. Dentro de las micosis emergentes destacan aquellas producidas por hongos filamentosos como Aspergillus, Lomentospora/Scedosporium, Fusarium o los mucorales. Las aspergilosis invasivas son difíciles de diagnosticar, y aunque hay herramientas disponibles de diagnóstico, su uso no está generalizado y su eficacia varía según los grupos de pacientes. La sospecha clínica en pacientes de alto riesgo, el diagnóstico con técnicas de imagen y la detección de biomarcadores como 1,3-β-D-glucano y galactomanano son de gran ayuda. En otras micosis los recursos diagnósticos son más reducidos, pero la radiología, los estudios anatomopatológicos y el diagnóstico microbiológico pueden ser útiles. La alta mortalidad de estas micosis obliga a realizar en muchos casos un tratamiento empírico precoz. El voriconazol es el tratamiento de elección en la mayoría de las aspergilosis, escedosporiasis, fusariosis y otras hialohifomicosis. El tratamiento de las mucormicosis y de las micosis causadas por Lomentospora prolificans o por hongos dematiáceos es más complicado. La anfotericina B es activa contra muchos mucorales, pero la combinación de dos o más antifúngicos puede ser una alternativa en muchas micosis refractarias a la anfotericina B. Entre los retos clínicos actuales se encuentra mejorar tanto el diagnóstico como el tratamiento de estas micosis, junto con la adecuada prevención en los pacientes con alto riesgo de padecerlas (AU)

Invasive fungal infections have become a major cause of morbimortality in intensive care patients, persons suffering from cancer or immune deficiencies, and other diseases with impaired immunity. Candida albicans remains the most frequent fungal pathogen, but advances in the diagnosis, prevention and treatment of invasive candidiasis are leading to important etiological changes. Among the emerging invasive mycoses, are those caused by filamentous fungi, such as Aspergillus, Lomentospora/Scedosporium, Fusarium or the Mucorales. Invasive aspergillosis is difficult to diagnose, and although there are diagnostic tools available, their use is not widespread, and their effectiveness vary depending on the group of patients. Clinical suspicion in high-risk patients, radiological diagnosis and the use of biomarkers, such as 1,3-β-D-glucan and galactomannan, can be of great help. However, diagnostic resources are limited in other mycoses, but radiology, pathological studies and the microbiological diagnosis can be useful. The high mortality of these mycoses requires early empirical antifungal treatment in many cases. Voriconazole is the first choice for treatment of the majority of aspergillosis, scedosporiasis, fusariosis and other hyalohyphomycoses. The treatment of mucormycoses, Lomentospora prolificans infections or mycoses by dematiaceous fungi are more complicated. Amphotericin B is active against many mucoralean fungi, but the combination of two or more antifungal agents could be a therapeutic alternative in many amphotericin B-refractory mycoses. Current clinical challenges include improving the diagnosis and the treatment of these mycoses, along with improving the adequate prevention in patients at high risk of suffering from them (AU)

ESCMID and ECMM joint guidelines on diagnosis and management of hyalohyphomycosis: Fusarium spp., Scedosporium spp. and others.

Mycoses summarized in the hyalohyphomycosis group are heterogeneous, defined by the presence of hyaline (non-dematiaceous) hyphae. The number of organisms implicated in hyalohyphomycosis is increasing and the most clinically important species belong to the genera Fusarium, Scedosporium, Acremonium, Scopulariopsis, Purpureocillium and Paecilomyces. Severely immunocompromised patients are particularly vulnerable to infection, and clinical manifestations range from colonization to chronic localized lesions to acute invasive and/or disseminated diseases. Diagnosis usually requires isolation and identification of the infecting pathogen. A poor prognosis is associated with fusariosis and early therapy of localized disease is important to prevent progression to a more aggressive or disseminated infection. Therapy should include voriconazole and surgical debridement where possible or posaconazole as salvage treatment. Voriconazole represents the first-line treatment of infections due to members of the genus Scedosporium. For Acremonium spp., Scopulariopsis spp., Purpureocillium spp. and Paecilomyces spp. the optimal antifungal treatment has not been established. Management usually consists of surgery and antifungal treatment, depending on the clinical presentation.

Neglected and emerging fungal infections: review of hyalohyphomycosis by Paecilomyces lilacinus focusing in disease burden, in vitro antifungal susceptibility and management.

Paecilomyces lilacinus is an emerging pathogenic fungus that can cause different clinical manifestations ranging from cutaneous and sub-cutaneous infections to severe oculomycosis. This review discusses infections caused by P. lilacinus, as well as their symptoms and correlates of immune responses, morphological characteristics of the fungus, therapies, in vitro susceptibility tests, laboratory diagnosis and the experimental models available.

Pneumonia and lung infections due to emerging and unusual fungal pathogens.

Invasive mold infections affecting the lungs are increasing in incidence and diversity. Severely immunocompromised patients are particularly vulnerable to infection from unusual, normally nonpathogenic fungi that are found naturally in the environment. Certain fungi such as Scedosporium and the dematiaceous fungi also cause lung disease in hosts without overt immune compromise. The impacts of these emerging pathogens range from airway colonization to locally invasive lung, and disseminated, disease. Diagnosis requires isolation and identification of the etiologic agent by either or both phenotypic and molecular biology methods. Evidence of tissue invasion on histopathology is often required to distinguish infection from colonization. Diagnostic imaging techniques are nonspecific, and there are no reliable serological biomarkers of infection. Many rare molds and yeasts demonstrate reduced in vitro susceptibility to antifungal agents. Although amphotericin B formulations remain clinically useful for many of these infections, voriconazole and posaconazole are more effective for some of these difficult-to-treat pathogens. Surgical resection of diseased tissue and support of the host immune system are often required to optimize outcomes.

Cutaneous hyalohyphomycosis in a girdled lizard (Cordylus giganteus) caused by the Chrysosporium anamorph of Nannizziopsis vriesii and successful treatment with voriconazole.

The Chrysosporium anamorph of Nannizziopsis vriesii was associated with dermatomycosis and high mortality in a group of captive giant girdled lizards (Cordylus giganteus). Treatment of one of the infected girdled lizards with voriconazole, which was selected on the basis of in vitro sensitivity testing of the isolate, resulted in resolution of lesions and negative fungal cultures from the skin. Three hours after oral administration of 10 mg/kg, the plasma level of voriconazole exceeded the 0.25-µg/mL minimal inhibitory concentration tenfold. In conclusion, administration of voriconazole at 10 mg/kg of body weight once daily for 10 weeks resulted in clinical cure and was well tolerated. A longer follow-up time and larger studies will be necessary to determine the long-term efficacy and safety of this treatment in giant girdled lizards.