Phaeohyphomycotic cyst of the skin caused by Exophiala jeanselmei

Cutaneous Phaeohyphomycosis of the Right Hand Caused by Exophiala jeanselmei: A Case Report and Literature Review

Exophiala spp. is increasingly reported as a pathogen causing the cutaneous, subcutaneous or invasive infection. In this report, we present a case of cutaneous phaeohyphomycosis due to E. jeanselmei on the right hand of a farmer, who suffered from this disease three years ago which had not been definitely diagnosed until he was admitted to our hospital. In our hospital, a potential fungal pathogen was observed by histopathological examination, and then was recovered and identified as E. jeanselmei by sequencing its internal transcribed spacer region. After 4 weeks of antifungal treatment, his hand recovered very well. To investigate the in vitro susceptibility of E. jeanselmei isolates to antifungal agents and compare the characteristics of their related infections among immunocompetent and immunocompromised patients, we reviewed 84 cases published in PubMed database between 1980 and 2020.

Management of a Dermocutaneous Black Mold Abscess of the Finger with Flexor Sheath Involvement

CASE

We present the case of a 76-year-old man with a black mold infection of the index finger. This granulomatous abscess uncharacteristically invaded the flexor sheath compartment, threatening proximal spread. Treatment consisted of excision of the abscess and drainage of the flexor sheath. The patient recovered unremarkably, maintaining digital function without recurrent infection.

CONCLUSION

The members of the fungal genus Exophiala are dark-pigmented mycoses commonly termed "black mold." Previously reported atraumatic black mold infections of the hand have been limited to subcutaneous involvement. To our knowledge, this is the first report of the successful treatment of a flexor sheath infection caused by the species E. jeanselmei.

[Cutaneous phaeohyphomycosis due to Cladophialophora bantiana]

BACKGROUND

Among dematiaceous fungi responsible for phaeohyphomycosis, Cladophialophora bantiana is an opportunistic pathogen that causes central nervous system infections, chiefly in immunocompromised patients. Only a few reports on skin involvements have been reported in the recent dermatological literature. Herein we report the case of an immunocompetent patient with cutaneous phaeohyphomycosis.

CASE REPORT

A 48-year-old male presented a nodular, painless and non-suppurative lesion with a diameter of 1cm on the right buttock that had developed since his return from a trip to Vietnam. A diagnosis of phaeohyphomycosis due to C. bantiana was made based on the histopathology and mycology examinations, which allowed the identification of C. bantiana, a dematiaceous (black) fungus from hyphomycete species.

DISCUSSION

C. bantiana is a neurotropic fungus that causes central nervous system infections in particular. Extracerebral involvement is rare and only a few cases of cutaneous phaeohyphomycosis have been reported. Furthermore, since immunocompromised hosts are more vulnerable, this mycosis is more commonly seen in immunocompromised patients. However in this particular case, an intramuscular injection of corticosteroids could have caused local immunosuppression. The prognosis depends on both localization and site. There are no guidelines for optimal treatment.

Phaeohyphomycosis caused by Exophiala jeanselmei in a patient with polymyalgia rheumatica

An 87-year-old man, a gardener in Okinawa, first noticed a tumor on the dorsum of his right hand in November 2005. He had been taking prednisolone for the treatment of polymyalgia rheumatica since 2000. A nearby dermatologist incised the tumor for pus drainage in February 2006. In April of the same year, the dome-like tumor reappeared. The same treatment was repeated. Because the culture of the pus revealed fungi at that time, terbinafine hydrochloride and minocycline were administrated under the diagnosis of a deep fungal infection. After a short remission, the tumor recurred in November of the same year and in May and August of 2007 regardless of the repeated incision and pus drainage. He was referred to our hospital on 27 September 2007. His first physical examination at our outpatient office showed a skin-colored, well-demarcated, multilocular, cystic subcutaneous tumor on the dorsum of his right hand. Histopathological examination revealed a pseudocyst with fibrous walls of connective tissue. Continuous, bead-like hyphae, positive with periodic acid-Schiff stain and Grocott stain, were found within the pseudocyst. Morphological and molecular biological examinations of the separately cultured specimens identified the causative agent as Exophiala jeanselmei. The entire cyst was removed under local anesthesia, and an artificial dermis made of silicon membrane was applied to the wound. Skin graft was performed in November after confirming no recurrence of the fungal infection. Terbinafine hydrochloride 125 mg/day has continued. No recurrence has been observed up to now.

Thermotherapy in dermatologic infections

The use of local induced hyperthermia or thermotherapy for dermatologic infections has not been fully explored in the more recent medical literature. Herein, we discuss the rationale behind the use of thermotherapy and review reported clinical experience with its use in the management of cutaneous infections.

Subcutaneous phaeohyphomycosis caused by Exophiala jeanselmei in a patient with advanced tuberculosis

We report a case of subcutaneous phaeohyphomycosis due to Exophiala jeanselmei in an 84-year-old Korean farmer suffering from pulmonary tuberculosis. He presented with six subcutaneous, fluctuant abscesses on the left distal forearm and wrist. Subcutaneous infections by E. jeanselmei mostly present as a solitary cyst or abscess on an extremity. The present case showed localized multiple abscesses suggesting metastatic tuberculous abscesses or other pyogenic bacterial infections.

Subcutaneous phaeohyphomycosis and nocardiosis in a kidney transplant patient

Phaeohyphomycosis and nocardiosis are uncommon infections that are more frequently reported in immunocompromised patients. To our knowledge, this is the first report of subcutaneous phaeohyphomycosis caused by Exophiala jeanselmei in association with systemic infection with Nocardia asteroides. The patient's phaeohyphomycosis responded to surgical excision and multi-drug therapy, and the patient underwent prolonged therapy with trimethoprim/sulfamethoxazole for treatment of the nocardiosis.

Mycetoma due to Exophiala jeanselmei and Mycobacterium chelonae in a 73-year-old man with idiopathic CD4+ T lymphocytopenia

Exophiala jeanselmei and Mycobacterium chelonae were isolated from cutaneous nodules in a 73-year-old man with mycetoma of the right lower leg. Further evaluation revealed CD4+ lymphocytopenia without evidence of HIV infection. Antibodies to HIV 1/2, p24 antigen and HIV 1/2 (PCR) and reverse transcriptase activity were not detectable. The patient was not a member of any HIV risk group. He had not previously undergone therapy or suffered from immunodeficiency. This case clearly demonstrates that infections with opportunistic moulds and/or atypical mycobacteria should be taken into consideration not only in patients with classical immundeficiency diseases but also in apparently healthy patients because infection with these agents can be the first sign of underlying immunodeficiency.

Feo-hifomicose subcutânea por Exophiala jeanselmei: registro de três casos em transplantados renais

São registrados três casos de feo-hifornicose subcutânea em transplantados renais provocados pela Exophiala jeanselmei (Langeron) McGinnis et Padhye 1977, fungo demácio capaz, também, de produzir raramente eumicetoma de grãos pretos. Este fungo, segundo KWON-CHUNG & BENNETT, 1992(27) é antigenicamente muito heterogêneo, sendo identificados até o presente momento três sorotipos com subgrupos dentro de cada um deles. A feo-hifomicose subcutânea vem se tornando cada vez mais freqüente em transplantados renais, submetidos a terapêutica imunodepressora. Como a Exophiala jeanselmei já foi isolada do meio ambiente, torna-se dificil explicar a patogenia desses casos por um despertar ou reativação de processos quiescentes. Os Autores fizeram ampla revisão da literatura, registrando principalmente os casos de feo-hifomicose publicados no Brasil. Sugerem também, eventual ação fungistática da ciclosporina A sobre a Exophiala jeanselmei.

Primary cutaneous phaeohyphomycosis: report of seven cases

We report seven cases of primary cutaneous phaeohyphomycosis. There were five males and two females, ranging in age from 42-65 years (mean 57.7 years). Two patients were otherwise healthy, but five were immunocompromised. One patient had rheumatoid arthritis and was on oral prednisone; two were renal transplant recipients, one was a heart transplant recipient, and the fifth had dermatomyositis. No history of trauma was elicited from any of the patients, but in two cases, foreign material was seen in the tissue sections. All lesions were on the extremities. In two cases, tissues were cultured, and these grew Exophiala jeanselmei. The others were not cultured because fungal infection was not clinically suspected. No systemic disease developed in any of the cases, and all were cured by the simple, complete excision of the lesions.

Hyalohyphomycosis masquerading as squamous cell carcinoma

A case of primary cutaneous hyalohyphomycosis in a healthy individual is presented. The initial clinical impression was keratoacanthoma or squamous cell carcinoma. Upon excision, the lesion proved to be an example of cutaneous hyalohyphomycosis due to an unidentified, non-pigmented fungal organism. The lesion was completely excised, and the patient was treated with saturated solution of potassium iodide. To date, there has been no evidence of recurrence. The clinical, histologic and mycologic aspects of hyalophyphomycosis are discussed.

Histopathology of chromoblastomycosis

A study aimed at determining the histopathologic appearance of chromoblastomycotic lesions was undertaken. Biopsies from 26 patients with the disease were examined. It was found that 23 cases (88.46%) exhibited the organized mixed mycotic granuloma - OMMA -, a granuloma modified by the presence polymorphonuclear neutrophils - PMN's. An equal proportion of cases exhibited pseudoepitheliomatous hyperplasia, with the epithelium playing an important role in the transepidermic elimination of the fungus. Healing of the lesions took place by fibrosis which was observed in 21 (80.77%) patients; this type of reaction was more common in the deeper areas of the dermis.

Fungal infections of the immunocompromised host: clinical and laboratory aspects

Fungal infections of the immunocompromised host are being seen with greater frequency than ever before. In addition, a growing list of unusual and unexpected etiologic agents presents a unique and difficult challenge to the clinician and microbiologist. The clinical manifestations of opportunistic fungal infections are often not characteristic and, in many instances, may prevent a rapid diagnosis from being made. Clinical microbiology laboratories should consider any organism as a potential etiologic agent. This requires that all fungi recovered from immunocompromised patients be thoroughly identified and reported so that their clinical significance may be assessed. This review presents a brief discussion of the clinical and laboratory aspects of some fungal infections seen in this important group of patients.