Combinatory effect of ALA-PDT and itraconazole in the treatment of cutaneous protothecosis.

BACKGROUND: As a rare subcutaneous infection, protothecosis is easily misdiagnosed. Similar to other subcutaneous infection, there is no unified standard for treatment, for cases not suitable for surgery, clinicians often use antifungal drugs based on their experience, and the course of treatment varies from several months to several years. Based on the fact that there are few relevant materials and researches on photodynamic therapy (PDT), we conducted a study based on a clinical case that used oral itraconazole combined with 5-aminolevylinic acid photodynamic therapy (ALA-PDT) to treat a patient with cutaneous protothecosis caused by Prototheca wicherhamii. METHODS: Different concentrations of ALA and different light doses were used to investigate the effects of ALA-PDT on the growth inhibition of P. wickerhamii in vitro with Colony-counting Methods. And we used transmission electron microscopy (TEM) to visualize the structural changes and the effects of ALA-PDT treating on cellular structures of the P. wickerhamii. Futher, we performed the susceptibility test of P. wickerhamii to itraconazole before and after ALA-PDT in vitro. RESULTS: We have successfully treated a patient with cutaneous protothecosis caused by P. wickerhamii by using combination therapy in a total of 9-week course of treatment. In vitro, ALA-PDT can inhibit the growth of P. wickerhamii when the ALA concentration was 5 mg/mL (P < 0.01), and this effect became stronger as the concentration of ALA or light dose is increased. Using TEM, we confirmed that ALA-PDT can disrupt the cell wall structure and partition structure of P. wickerhamii, which may contribute to its inhibitory effect. Further studies showed that the MIC of itraconazole for P. wickerhamii was decreased after ALA-PDT. CONCLUSIONS: ALA-PDT combined with oral itraconazole can be used to treat cutaneous protothecosis. Accordingly, ALA-PDT can destroy the cell wall and partition structure of P. wickerhamii leading to an inhibitory effect on it in vitro, and the effect is enhanced with the increase of ALA concentration and light dose. Also, the sensitivity of P. wickerhamii to itraconazole is observed increased after ALA-PDT. So our study provides a theoretical basis for the promising treatment against cutaneus protothecosis.

The oldest patient infected with cutaneous protothecosis.

Human protothecosis is a rare achlorophyllic algal infection found in immunocompromised hosts; commonly those patients on glucocorticoids. Irradiation of the infection is uncommon, but has been previously attempted with antifungal therapy. We present a case of hard-to-heal wounds on an 89-year-old female patient taking glucocorticoids. A wound biopsy noted the wounds to be infected with Prototheca. The patient underwent operative debridement of her wounds, which began to improve and show signs of granulation. This report details the oldest known case of human protothecosis invasion, to our knowledge, and the successful treatment of a Prototheca infection by operative debridement.

Cutaneous Protothecosis with Meningitis Due to Prototheca wickerhamii in an Immunocompetent Teenager: Case Report and Literature Review.

Human protothecosis is a rare infection caused by Prototheca spp., which are environmental achloric algae ubiquitously existing in nature. Members of the genus of Prototheca usually cause localized infection that affects the skin or wounds. Systemic infection is extremely rare and tends to occur in immunocompromised patients. Here, we report a case of cutaneous protothecosis and meningitis due to Prototheca wickerhamii in an immunocompetent teenager who obtained full-body tattoos at the time of infection. To the best of our knowledge, this is the first description of P. wickerhamii isolated from both skin tissue and cerebrospinal fluid. The data contained in this report will increase our understanding of this pathogen and elucidate the most optimal treatment.

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.

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.

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.

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.

A Case of Cutaneous Protothecosis / 대한피부과학회지

Protothecosis is an unusual cutaneous soft tissue infection caused by the Prototheca, which is a genus of the unicelluar, achloric algae. We report a case of cutaneous protothecosis in a 66-year-old female, who showed erythematous, purulent patches and plaques with ulcerations on the right forearm for 2 months. Biopsy specimen revealed the characteristic thick-walled morulalike sporangia in the dermis. Prototheca wickerhamii was isolated in the culture and the biochemical study. Electron microscopic examination showed the thick-walled spores containing dark dense bodies and amyloplasts. After two months of oral itraconazole 200mg/day, skin lesions were improved.

A Case of Cutaneous Protothecosis

Protothecosis is a rare cutaneous soft tissue infection caused by the genus prototheca, most commonly Prototheca wickerhatmii. An 80-year-old woman has had a painful or tender, non-healing, eczematous plaque on the extensor surface of the left forearm for 4 years. A biopsy specimen revealed the characteristic thick-walled morulalike sporangia in the dermis. P. wickerha mili was isolated in the culture and the biochemical studies. Electron microscopic examination showed the thick-walled spores containing dark dense bodies and amyloplasts. Oral itraconazole therapy for 4 weeks resulted-in a marked improvement of the skin lesion.