Unusual location of cutaneous alternariosis in an immunocompetent patient

Alternaria fungal dacryocystitis with cutaneous fistula: a case report

Alternaria is a fungal genus that can cause opportunistic human infection in immunocompromised hosts. While the majority of clinical manifestations are cutaneous or subcutaneous infections, there are reports of oculomycosis, which is most commonly present as keratomycosis or endophthalmitis.Here, we present a rare case of Alternaria dacryocystitis with cutaneous fistula in a diabetic patient. The patient was referred with a non-healing medial canthal wound and an initial biopsy report showing "ruptured hair follicle;" re-examination of the biopsy specimen with fungal stains led to the diagnosis of alternariosis. The patient underwent surgical debridement and systemic antifungal treatment, with complete resolution of the infection. In order to initiate prompt treatment and prevent invasive disease, fungal infection should be considered in an immunocompromised patient with chronic dacryocystitis and cutaneous fistula or a nonhealing medial canthus wound.

Phaeohyphomycosis of the Eyelid: A Case Report

Phaeohyphomycosis is a fungal infection caused by dematiaceous fungi that presents as a superficial, cutaneous, subcutaneous, or systemic infection. Subcutaneous phaeohyphomycosis is the most common manifestation and presents as a subcutaneous nodule or cystic lesions and abscesses. It usually results from traumatic implantation of the saprophytic fungus from soil and vegetative matter; therefore, the commonest sites of infection are the extremities. Rarely, involvement of the eyelid is seen with extensive facial infection or as a part of multiple nodular lesions in the face, scalp, or other regions in cases of cutaneous/subcutaneous phaeohyphomycosis. Here, we report a case of subcutaneous phaeohyphomycosis presenting as a solitary nodular lesion of the eyelid with extension into the anterior orbit in a 35-year-old immunocompetent male. The patient was successfully treated with combined surgical and medical therapy.

Greenhouses represent an important evolutionary niche for Alternaria alternata

Alternaria alternata is a ubiquitous soil-borne fungus capable of causing diseases in a variety of plants and occasionally in humans. While populations of A. alternata from infected plants have received significant attention, relatively little is known about its soil populations, including its population genetic structure and antifungal susceptibilities. In addition, over the last two decades, greenhouses have become increasingly important for food and ornamental plant production throughout the world, but how greenhouses might impact microbial pathogens such as A. alternata populations remains largely unknown. Different from open crop fields, greenhouses are often more intensively cultivated, with each greenhouse being a relatively small and isolated space where temperature and humidity are higher than surrounding environments. Previous studies have shown that greenhouse populations of two common molds, Aspergillus fumigatus and A. alternata, within a small community in southwestern China were variably differentiated. However, the relative contribution of physical separation among local greenhouses to the large-scale population structure remains unknown. Here, we isolated strains of A. alternata from seven greenhouses in Shijiazhuang, northeast China. Their genetic diversity and triazole susceptibilities were analyzed and compared with each other and with 242 isolates from nine greenhouses in Kunming, southwest China. Results showed that the isolation of greenhouses located <1 km from each other locally contributed similarly to the overall genetic variation as that between the two distant geographic regions. In addition, our results indicate that greenhouses could be significant sources of triazole resistance, with greenhouses often differing in their frequencies of resistant strains to different triazoles.

IMPORTANCE

Greenhouses have become increasingly important for food production and food security. However, our understanding of how greenhouses may contribute to genetic variations in soil microbial populations is very limited. In this study, we obtained and analyzed soil populations of the cosmopolitan fungal pathogen Alternaria alternata in seven greenhouses in Shijiazhuang, northeast China. Our analyses revealed high proportions of isolates being resistant to agricultural triazole fungicides and medical triazole drugs, including cross-resistance to both groups of triazoles. In addition, we found that greenhouse populations of A. alternata located within a few kilometers showed similar levels of genetic differentiation as those separated by over 2,000 km between northeast and southwest China. Our study suggests that greenhouse populations of this and potentially other fungal pathogens represent an important ecological niche and an emerging threat to food security and human health.

Cutaneous Alternariosis in Immunosuppressed Patients Treated with Photodynamic Therapy and Oral Antifungals, a Synergistic Strategy

Cutaneous alternariosis is a rare condition, more frequently presented in immunocompromised patients, which usually requires long courses of systemic antifungals that may interact with other medications. The presented series shows three cases of cutaneous alternariosis in immunocompromised patients and organ transplant recipients that were successfully treated with photodynamic therapy and oral antifungals, allowing a reduction in the systemic treatment duration and therefore decreasing the risk of side effects and drug interactions.

First Reported Case of a Clinically Nonresponsive-to-Itraconazole Alternaria alternata Isolated from a Skin Infection of a Nonimmunocompromised Patient from Romania

BACKGROUND

Alternaria alternata is a melanic fungus capable of causing a wide variety of infections, some of which have lethal potential. It is a ubiquitous fungus and a well-known plant pathogen. Cutaneous infections with Alternaria alternata most often occur in the extremities of patients who perform conventional agriculture, thus being exposed to occupational hazards leading to the disruption of the skin barrier.

METHODS

This paper presents the first case report from Romania of an itraconazole nonresponsive cutaneous alternariosis in a patient without any type of immunosuppression.

RESULTS

After an initial misdiagnosis regarding the etiology of the patient's skin infection, two successive punch biopsies, followed by mycologic examination, lead to the final diagnosis of cutaneous alternariosis. Treatment guided by antifungal susceptibility testing has been instituted, leading to the gradual healing of the patient's skin ulcerations.

CONCLUSIONS

The ability of Alternaria alternata to infect immunocompetent human hosts and to develop resistance to antifungal drugs highlight the importance of correctly diagnosing the etiology of skin ulcerations and instituting appropriate treatment guided by antifungal susceptibility testing whenever the suspicion of a fungal skin infection is plausible.