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Tseng HC, Chen CB, Ho JC, Cheng YW, Huang HW, Sun PL, Lee CH. Clinicopathological features and course of cutaneous protothecosis. J Eur Acad Dermatol Venereol 2018; 32:1575-1583. [PMID: 29356140 DOI: 10.1111/jdv.14804] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 01/10/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Protothecosis is an uncommon infection caused by the achlorophyllic algae found more commonly in tropical areas. Only a limited number of cases have been reported. OBJECTIVE We aimed to evaluate the clinicopathological features and treatment outcomes of cutaneous protothecosis. METHODS We retrospectively identified 20 pathology-confirmed cases of cutaneous protothecosis based on skin biopsies in two tertiary medical centres in Taiwan from 1997 to 2015. RESULTS The age of the patients at the time of diagnosis ranged from 48 to 85 years (mean age of 74 years). All lesions developed on the limbs. Twelve (60%) patients had adrenal insufficiency, but no patients had active malignancy at diagnosis. Interestingly, four (20%) patients had concurrent scabies infestation. Clinically, most lesions were erythematous plaques studded with punctate ulcers. Microscopically, the most common finding was granulomatous inflammation. Nineteen (95%) cases were successfully treated with itraconazole for 14-148 days with only one case of recurrence. Concomitant scabies should be suspected if pruritus is recalcitrant despite itraconazole treatment. CONCLUSION Despite its rarity, cutaneous protothecosis has become more significant due to an increased prevalence of immunocompromised individuals. Steroid overuse or iatrogenic adrenal insufficiency predisposes individuals to high-risk infections. Neglecting the disease leads to a chronic and incurable state. Protothecosis should be suspected in chronic eczematous and ulcerative plaques on the limbs refractory to conventional antibacterial and antiviral treatments, especially in patients with adrenal insufficiency. Clinical suspicion should be confirmed by skin biopsies, and confirmed cases can be successfully treated with itraconazole.
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Affiliation(s)
- H-C Tseng
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,Department of Cosmetic Applications and Management, Yuh Ying Junior College of Healthcare and Management, Kaohsiung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - C-B Chen
- Department of Dermatology, Chang Gung Memorial Hospitals, Linkou, Taipei, and Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - J-C Ho
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Y-W Cheng
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - H-W Huang
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - P-L Sun
- Department of Dermatology, Chang Gung Memorial Hospitals, Linkou, Taipei, and Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - C-H Lee
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Khan ID, Sahni AK, Sen S, Gupta RM, Basu A. Outbreak of Prototheca wickerhamii algaemia and sepsis in a tertiary care chemotherapy oncology unit. Med J Armed Forces India 2017; 74:358-364. [PMID: 30449922 DOI: 10.1016/j.mjafi.2017.07.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 07/31/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Prototheca is an emerging, opportunistic, pathogenic, zoonotic achlorophyllous green alga, expanding in pathogenicity and host range, causing localized and disseminated infections. This outbreak of Prototheca wickerhamii algaemia and sepsis in a tertiary care 30-bedded chemotherapy oncology unit is the first human outbreak to the best of our knowledge. METHODS P. wickerhamii algaemia was confirmed on consecutive isolation. Person to person transmission was hypothesized considering all patients in the unit at risk. Clinico-demographic, diagnostic and treatment profile were correlated. Both manual and automated systems were used for blood culture, isolation, identification and susceptibility of Prototheca. Liposomal amphotericin B was given. Outbreak surveillance of faeces, fingertips and environmental reservoirs, retrospective surveillance during past 15 years and prospective surveillance was continued for two years. RESULTS The outbreak affected 12 neutropenic patients over 50 days. No specific clinical features were noted. The hypothesis could not be substantiated. P. wickerhamii was isolated as yeast-like colonies revealing Gram positive yeast-like cells without budding and pseudohyphae which were confirmed by automated system. Post amphotericin B blood cultures were negative for Prototheca. Surveillance studies were not contributory. CONCLUSION P. wickerhamii has no documented reservoirs or transmission. Endogenous colonization in the gut followed by translocation during chemotherapy induced immunosuppression is likely to cause algaemia and sepsis. Outbreaks are difficult to detect and control as incubation period is variable and clinical presentation is muted, emphasizing the need to strengthen hospital and laboratory based surveillance systems to ensure adequate preparedness, rapid detection and response to outbreaks.
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Affiliation(s)
- I D Khan
- Assistant Professor (Microbiology), Army College of Medical Sciences and Base Hospital, New Delhi 110010, India
| | - A K Sahni
- Brig Med, HQ 15 Corps, c/o 56 APO, India
| | - Sourav Sen
- Professor and Head, Department of Microbiology, Armed Forces Medical College, Pune 411040, India
| | - R M Gupta
- Consultant and Professor (Microbiology), Affiliated Faculty, Dept of Lab Sciences and Molecular Medicine, Army Hospital (R & R), New Delhi 110001, India
| | - Atoshi Basu
- Consultant, Department of Pathology, Apollo Gleneagles Hospital, Kolkata, India
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Ramírez I, Nieto-Ríos JF, Ocampo-Kohn C, Aristizábal-Alzate A, Zuluaga-Valencia G, Muñoz Maya O, Pérez JC. Protothecal bursitis after simultaneous kidney/liver transplantation: a case report and review. Transpl Infect Dis 2016; 18:266-74. [PMID: 26779785 DOI: 10.1111/tid.12496] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 09/16/2015] [Accepted: 11/01/2015] [Indexed: 01/18/2023]
Abstract
Solid organ transplantation is an accepted therapy for end-stage diseases of the kidneys, liver, heart, and lungs. Unfortunately, transplantation is associated with infectious complications. Here, we present a case report of Prototheca wickerhamii olecranon bursitis and review all of the cases in solid organ transplant (SOT) recipients published in the literature to date. In our patient, the infection resolved with surgical therapy and limited antifungal therapy, and no symptoms have recurred over 24 months of follow-up. A review of the literature suggests that 50% of SOT recipients with Prototheca infection present with disseminated infection, and the overall mortality is 75%. More studies are required to determine the optimal management of protothecosis in this population.
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Affiliation(s)
- I Ramírez
- Infectious Diseases, Department of Internal Medicine, Hospital Pablo Tobón Uribe, Universidad de Antioquia, Medellín, Colombia
| | - J F Nieto-Ríos
- Nephrology, Department of Internal Medicine, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - C Ocampo-Kohn
- Nephrology, Department of Internal Medicine, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - A Aristizábal-Alzate
- Nephrology, Department of Internal Medicine, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - G Zuluaga-Valencia
- Nephrology, Department of Internal Medicine, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - O Muñoz Maya
- Hepatology, Department of Internal Medicine, Hospital Pablo Tobón Uribe, Universidad de Antioquia, Medellín, Colombia
| | - J C Pérez
- Department of Pathology, Hospital Pablo Tobón Uribe, Dinámica IPS, Medellín, Colombia
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Prototheca wickerhamii algaemia presenting as cholestatic hepatitis in a patient with systemic lupus erythematosus: A case report and literature review. Med Mycol Case Rep 2012; 2:19-22. [PMID: 24432207 DOI: 10.1016/j.mmcr.2012.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 11/27/2012] [Accepted: 12/05/2012] [Indexed: 11/24/2022] Open
Abstract
Human protothecal infection is uncommon and could be localized or systemic disease. Disseminated Prototheca algaemia tends to occur in immunocompromised patients (solid organ transplants, hematological malignancies) with high mortality. Diagnosis could be missed or delayed due to unusual clinical presentation and/or under-recognition of characteristic microscopic features of Prototheca species. Combined approach that includes removal of source of infection and intravenous amphotericin B provides the best chance of cure.
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Todd JR, King JW, Oberle A, Matsumoto T, Odaka Y, Fowler M, Pore RS, Shahan TA, Yin L, Sanusi ID. Protothecosis: report of a case with 20-year follow-up, and review of previously published cases. Med Mycol 2012; 50:673-89. [DOI: 10.3109/13693786.2012.677862] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Zhang QQ, Li L, Zhu LP, Zhao Y, Wang YR, Zhu JH, Zhu M. Cutaneous Protothecosis in Patient with Diabetes Mellitus and Review of Published Case Reports. Mycopathologia 2011; 173:163-71. [DOI: 10.1007/s11046-011-9480-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Accepted: 09/15/2011] [Indexed: 11/27/2022]
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