Successful Terbinafine Treatment for Cutaneous Phaeohyphomycosis Caused by Trematosphaeria grisea in a Heart Transplanted Man: Case Report and Literature Review

Phaeohyphomycosis is a chronic infectious disease caused by dematiaceous fungi. It is characterized by the presence of pigmented septate mycelia within tissues. In the case of superficial infection, the lesion(s) chronically evolve(s) toward painless pseudo-tumor(s) of the soft parts. We report herein the original case of a heart transplanted man who exhibited phaeohyphomycosis of the left hand, with no mention of travels in endemic areas. Trematosphaeria grisea was identified as the causative agent, which is quite innovative since this species has been rather described in mycetoma. The antifungal treatment initially based on isavuconazole alone was not sufficient to cure the patient. In contrast, its association with local terbinafine ointment allowed total clinical improvement. This finding is unusual as diagnosis of phaeohyphomycosis caused by T. grisea is uncommon in nontropical countries, and as the outcome appeared successful by the means of add-on therapeutic strategy with terbinafine.

Exserohilum rostratum Keratitis in a Patient with Human Immunodeficiency Virus

Purpose

To report a case of fungal keratitis infected by Exserohilum rostratumin a human immunodeficiency virus (HIV) patient.

Method

A retrospective study of the HIV patient with keratomycosis caused by E. rostratumwas reviewed for history, clinical characteristics, risk factors, laboratory findings, treatments, and outcomes.

Results

A 48-year-old man with HIV infection presented with a history of trauma with an unknown species of insect in the right eye. He also had redness and blurred vision in the right eye. Biomicroscopic examination showed white infiltrate in the right cornea. A feathery edge, satellite lesion, and brownish pigmented deposits in the epithelial surface and anterior stroma were noted. Corneal scraping specimen showed numerous large dematiaceous septate hyphae and polymerase chain reaction (PCR) identified E. rostratum.Treatment was started with 5% natamycin eyedrops and oral itraconazole. The corneal lesion responded well to medication and debridement.

Conclusions

Corneal phaeohyphomycosis caused by Exserohilumwas noted in an immunocompromised patient with ocular trauma. A brown pigmented lesion in an otherwise white infiltrate due to Exserohilumwas diagnosed with corneal scrapings and polymerase chain reaction. Antifungal medications and debridement were the mainstay of corneal fungal infection treatment.

A fatal case of Exophiala dermatitidis disseminated infection in an allogenic hematopoietic stem cell transplant recipient during micafungin therapy

Exophiala dermatitidis is a dematiaceous fungus that is increasingly becoming the cause of fungal infection in immunocompromised patients. However, the risk factors and optimal treatment modality for E. dermatitidis infection are unknown to date. Herein, we present a fatal case of E. dermatitidis infection in an adult patient that developed after allogeneic hematopoietic stem cell transplantation for chronic active Epstein-Barr virus infection. The dematiaceous fungus caused a breakthrough fungemia despite prophylactic administration of micafungin. Although the patient was intensively treated with liposomal-amphotericin B and voriconazole, serum level of beta-D-glucan continuously increased, and the patient eventually died because of cerebral hemorrhage. An autopsy found multiple involvements of the fungal infection at the bilateral lungs, thoracic cavities, diaphragm, and thyroid. To the best of our knowledge, this is the first reported case of E. dermatitidis infection involving these tissues as determined via autopsy. This case highlights the importance of attention for Exophiala infection in immunocompromised individuals in those given antifungal therapy with echinocandins.

[First report of a case of fungal keratitis due to Curvularia hominis in Spain]

BACKGROUND

Dematiaceous fungal genus Curvularia is a causal agent of keratitis, onychomycosis, and skin infections. In 2014, using DNA sequencing techniques, five new species, including Curvularia hominis, were described. In this article, a report is presented on the first clinical case of C.hominis infection in Spain. It concerns a corneal ulcer caused by this recently described species.

CASE REPORT

A 46 year-old male patient with a corneal ulcer in his left eye went to the Emergency Department. Specimens were obtained from the lesion, and the patient was admitted due to the risk of corneal perforation. The fungal culture of the specimens revealed a filamentous fungus that was identified by microscopic examination as Curvulariaspp. Using mass spectrometry (MALDI-TOF) the isolate was identified as Curvularia lunata. To confirm the identification, the isolate was sent to the National Centre of Microbiology in Spain, where ITS region sequencing was performed, and it was finally identified as C.hominis. The patient received voriconazole and progressed favourably. To repair the corneal damage, the patient received an amniotic membrane transplantation.

CONCLUSIONS

C.hominis should be considered a causal agent of keratitis and sequencing techniques are now necessary for species-level identification of Curvularia isolates. This is the first case report in Spain caused by this species.

A rare case of scleral buckle infection with Curvularia species

BACKGROUND

Scleral buckling is an established modality of treating retinal detachment. Being an external implant the buckle may be prone to infections. We report such a case with a delayed presentation and a rare etiology.

CASE PRESENTATION

A 45 year old male presented with redness, foreign body sensation and discharge for one month in his right eye. The patient had undergone a retinal detachment surgery elsewhere 14 years back without any visual gain. Right eye demonstrated no perception of light and the best corrected visual acuity in the left eye was 6/6, N6. On downgaze an exposed and anteriorly displaced scleral buckle was identified with black deposits and mucopurulent material overlying the buckle. Scleral buckle removal was done. On microbiological examination Curvularia species was identified. Successful treatment with antifungals was done.

CONCLUSIONS

Scleral buckle infection with dematiaceous fungi is a rare occurrence. To the best of our knowledge this is the first case report describing a buckle infection caused by the curvularia species.

Dematiaceous fungal endophthalmitis: report of a case and review of the literature

Background

Pleurostomophora richardsiae (formerly Phialophora richardsiae) is a dematiaceous fungus that is an uncommon cause of ocular infection. Herein, we present a case of endogenous endophthalmitis associated with disseminated P. richardsiae infection.

Findings

This is a descriptive case report with a brief review of literature. A 43-year-old male admitted to the hospital following an acute cerebellar hemorrhage was found to have a swollen and tender wrist. The patient was afebrile with leukocytosis. Visual acuity was hand motion in the right eye and 20/20 in the left. Right eye examination noted anterior chamber cells and flare, vitreous haze and multiple large, and fluffy retinal infiltrates. Diagnostic vitrectomy revealed a mixed inflammatory cell infiltrate with numerous fungal elements. Blood cultures were negative, multiple transesophageal echocardiography studies revealed no vegetations, and synovial fluid aspiration of the wrist and biopsy of the radius were unremarkable. The patient was treated with intravitreal cefazolin, vancomycin, and amphotericin B, topical ciprofloxacin and natamycin, and intravenous amphotericin B and voriconazole. Visual acuity in the right eye declined to light perception, and examination revealed increasing anterior and posterior chamber inflammation. The patient died several weeks after presentation due to a massive intracranial hemorrhage. Fungal culture results from the vitrectomy were received post mortem and were positive for P. richardsiae.

Conclusions

P. richardsiae endophthalmitis is rare, and outcomes are typically poor. Infections typically occur following traumatic skin inoculation; however, a long refractory period may occur before symptoms develop. Early diagnosis and combination antimicrobial therapy are essential to optimize visual outcomes.

Corneal Phaeohyphomycosis Caused by Bipolaris hawaiiensis

Purpose

To report a rare case of keratitis infected by Bipolaris hawaiiensis.

Methods

A patient who was diagnosed as fungal keratitis caused by B. hawaiiensis was retrospectively reviewed for history, clinical characteristics, risk factors, laboratory findings, treatments, and outcomes.

Results

A 63-year-old man with a history of trauma and saw dust in the left eye presented with a corneal ulcer. Eye examination revealed whitish infiltration with a feathery edge and small brownish deposits in the anterior stroma of the left cornea. Numerous septate hyphal fragments were detected in a corneal specimen, and nucleotide sequence analysis identified B. hawaiiensis. Treatment was started with 5% natamycin eyedrops and oral itraconazole. Subsequently, a corneal plaque developed which did not respond to medication and debridement. The patient underwent therapeutic penetrating keratoplasty.

Conclusions

B. hawaiiensis is a rare cause of corneal phaeohyphomycosis. A brownish pigmented infiltration is an important diagnostic clue, however microbiologic studies are required to obtain a definite diagnosis. Although antifungal medication and debridement are the mainstay of most corneal fungal infection, therapeutic penetrating keratoplasty can prevent morbidity related to this fungal infection.

Corneal Chromoblastomycosis Caused by Fonsecaea pedrosoi

Purpose

To report 2 unusual cases of fungal keratitis due to Fonsecaea pedrosoi.

Methods

Two patients were diagnosed with Fonsecaea pedrosoi keratitis. Their files were reviewed for predisposing factors, clinical characteristics, microbiological study, treatment, and outcome.

Results

Two consecutive patients presented with brownish pigmented corneal ulcers in their eyes after sustaining eye trauma from vegetative matter. In both cases, corneal scrapings were collected for microscopic examination and culture. Dematiaceous hyphae were seen on the smears, and dark pigmented colonies grew on the culture media, identified as F. pedrosoi. Both patients were treated and cured with combined topical antifungal agents and oral itraconazole. The first patient required an amniotic membrane patch, while the second received an intracameral amphotericin B injection.

Conclusions

Pigmented infiltrates can be an important diagnostic clue, but a microscopic evaluation and culture are required to obtain an accurate diagnosis of Fonsecaea keratitis. The prompt diagnosis and combined antifungal treatment can prevent morbidity associated with this fungal infection.