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Journal of Clinical Microbiology, September 1998, p. 2763-2765, Vol. 36, No. 9
0095-1137/98/$04.00+0
Copyright © 1998, American Society for Microbiology. All rights reserved.
Phaeohyphomycosis Caused by
Phaeoacremonium inflatipes
Arvind A.
Padhye,1,*
Miriam S.
Davis,2
Dale
Baer,2
Anne
Reddick,2
Kaushal K.
Sinha,3 and
Juliana
Ott3
Mycotic Diseases Branch, Division of
Bacterial and Mycotic Diseases, National Center for Infectious
Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
303331;
South Carolina Department of
Health and Environmental Control, Columbia, South Carolina
292022; and
Lexington Medical
Center, West Columbia, South Carolina 291693
Received 2 March 1998/Returned for modification 8 April
1998/Accepted 1 June 1998
 |
ABSTRACT |
Phaeoacremonium inflatipes, one of three species
previously classified as strains of Phialophora parasitica,
was identified as the causal agent of a subcutaneous infection of the
left foot of an 83-year-old woman from South Carolina. The patient had
a granulomatous growth over the anteromedial aspect of her left foot.
It was surgically excised, which led to complete healing without complications. Tissue sections of the excised mass stained with hematoxylin and eosin and Gomori's methenamine silver
strains showed many septate hyphal elements of
various lengths, some exhibiting brownish pigment in the cell walls
of the hyphae. Portions of the tissue, when cultured, yielded many
colonies which were initially glabrous, off white becoming velvety,
greyish brown on aging. Microscopically, their hyphae were septate,
branched, and phaeoid and bore lateral and terminal, erect, septate
conidiophores. The conidiogenous cells (phialides) were terminal or
lateral, mostly monophialidic, subcylindrical to spinelike in shape,
and constricted at their bases and bore funnel-shaped,
inconspicuous collarettes at their tips. The conidia were
subhyaline, oblong, and ellipsoid to allantoid.
| |
TEXT |
In 1996, Crous et al. (3)
proposed the new hyphomycete genus Phaeoacremonium with
Phaeoacremonium parasiticum (= Phialophora parasitica) as its type species. Morphologically, the genus
Phaeoacremonium is intermediate between the genera
Acremonium and Phialophora. It is distinguished
from Acremonium by its phaeoid vegetative hyphae and
conidiophores and from Phialophora by its narrow, spinelike (aculeate) conidiogenous cells and inconspicuous collarettes. A detailed study by Crous et al. (3) of a large number
of isolates originally identified as P. parasitica
made it obvious that it represented a cluster of related and
morphologically well-defined species producing subcylindric to aculeate
phialides with inconspicuous collarettes not at all resembling
those of other Phialophora species. An earlier
analysis of restriction fragment length polymorphism and rRNA gene
sequence data from isolates of Phialophora
americana, P. verrucosa, P. richardsiae, and nine isolates of P. parasitica by Yan et al. (11) revealed that six of the
nine P. parasitica isolates belonged to one
distinct group. The other three isolates each exhibited a
unique restriction map. However, they were closer to
P. parasitica than to any other species of
Phialophora studied. Crous et al. (3) proposed to
accommodate the isolates that caused human infections, previously
grouped under Phialophora parasitica, in three species
including Phaeoacremonium parasiticum and two new species,
P. inflatipes and P. rubrigenum. They
also described three additional species (Phaeoacremonium
aleophilum, P. angustius, and P. chlamydosporum) that are not known to cause human infections. We
report a subcutaneous, granulomatous infection of the left foot of a
woman from South Carolina and describe salient features of the causal
agent, P. inflatipes.
Case report.
An 83-year-old Caucasian woman reported pain in
her left knee, difficulty in walking and weight bearing, and the need
to sit down for long periods of time. She also had pain in her left
foot with a large lump on its medial side; this lump had been
enlarging. On examination, she was found to have fusiform swellings
over both knees and had marked patellofemoral crepitation on both
sides. However, it was more pronounced on the left than on the
right side. There was no ligamentous instability, and she had good
neurovascular status in both lower extremities. Examination of the left
foot revealed a soft mass over the anteromedial aspect of her
foot. It was minimally tender on deep palpation. When surgically
excised, the mass looked like a foreign body surrounded by a granuloma. Sections of the excised tissue stained with hematoxylin and eosin, periodic acid-Schiff, and Gomori's methenamine silver (GMS) stains revealed dense, proliferated, fibrous connective tissue showing an
inflammatory reaction composed of proliferated capillary cells. Multinucleated foreign body-type giant cells were present. Epithelioid cells were prominently seen in the reactive process. Sections stained
by periodic acid-Schiff and GMS stains demonstrated numerous septate,
hyphal fragments of various lengths measuring 2.0 to 3.0 µm in
diameter (Fig. 1). Sections stained by
hematoxylin and eosin showed a few phaeoid hyphal elements, consistent
with the diagnosis of phaeohyphomycosis. As has been the case with many other localized phaeohyphomycotic lesions, in this case, total excision
of the granulomatous mass led to complete healing of the lesion without
complications or relapse.
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FIG. 1.
Short, septate hyphal elements of P. inflatipes in biopsied tissue stained by GMS. Original
magnification, ×875.
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|
Portions of the excised tissue were cultured on Sabouraud glucose agar
with chloramphenicol (Sab+c) and Sab+c containing cycloheximide.
Morphology was studied on potato dextrose agar (PDA). Cultures
were
incubated at 25 and 37°C in the dark. Initially, colonies
on Sab+c
and PDA were glabrous, creamy to off white, and raised,
becoming
greyish brown after 8 days at both temperatures of incubation.
Colonies
on Sab+c and PDA at 25°C after 2 weeks were velvety,
flat, olivaceous
brown to grey, and 26 to 28 mm in diameter. Hyphae
were septate,
branched, and smooth walled to warty, becoming light
brown, and
measured 2.0 to 3.0 µm in diameter. Conidiophores were
erect,
simple or branched, subcylindrical, phaeoid in the lower
portions, and
lighter brown toward the tips. They were smooth,
zero- to four-septate,
and variable in length. Conidiogenous cells
were terminal or
lateral, mostly monophialidic, also polyphialidic,
smooth walled,
hyaline to pale brown, elongated, and subcylindric
and were constricted
at their bases. Occasionally, percurrent
growth of phialides was
also observed. At the tips, they bore
narrow, cylindric to
funnel-shaped, inconspicuous collarettes.
Conidia aggregated into
slimy heads at the tips of the phialides
or slid down along their
sides. The conidia were subhyaline and
oblong-ellipsoid to allantoid
(sausage shaped) and measured 3.0
to 5.0 by 1.5 to 2.5 µm (Fig.
2 and
3).
The isolate grew well
at 25 and 37°C (8 to 11 mm in 2 weeks) but
failed to grow at 40°C.
It hydrolyzed gelatin. Based on the
inflated phialides with basal
constrictions (near the basal
septum), the isolate (96-034129
= CDC B-5747) was
identified as
P. inflatipes. It was sent to
G. S. de Hoog, Centraalbureau voor Schimmelcultures (CBS), Baarn,
The
Netherlands, who confirmed our identification. It was deposited
in the
CBS collection as CBS 729.97.
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FIG. 2.
Slide culture on PDA of P. inflatipes
showing subcylindric phialides that are constricted at their bases and
have inconspicuous collarettes and ellipsoid to allantoid conidia.
Original magnification, ×1,000.
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FIG. 3.
Slide culture on PDA showing polyphialidic and
percurrent (arrow) conidiogenous cells of P. inflatipes
and conidia. Original magnification, ×1,000.
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Three species of
Phaeoacremonium that cause human
infections, namely,
P. parasiticum,
P. inflatipes, and
P. rubrigenum, were
formerly
recognized under the genus
Phialophora as strains of
P. parasitica. The majority of human infections
caused by these
species that have been described in the literature were
in the
nature of subcutaneous abscesses, cysts, or chronic or acute
arthritis
in immunocompromised and immunocompetent hosts (
1,
4,
6-9,
12) and were acquired through traumatic inoculation.
Systemic
infections, fungemia or endocarditis, have been rare (
5,
10).
In the present case, the host was apparently immunocompetent
but
did not remember having sustained any obvious trauma to her left
foot.
P. inflatipes can be distinguished from
P. parasiticum by its slightly larger conidia and, more importantly,
by its inflated
phialides, which are constricted at their bases. Those
of
P. parasiticum are more spinelike and
not constricted at their bases.
P. inflatipes has a
wide geographic distribution, and it has been isolated from
plants
such as
Nectandra sp. in Finland, stems of oak trees
(
Quercus virginiana),
Vitis vinifera in Costa
Rica and the United States,
stems and roots of
Sorbus
intermedia in Germany, and soil in Tahiti.
It has been
isolated from a
Pyracantha thorn (
8) and from
synovial
fluid from a patient in the United States (
3),
toenails of
a patient from Finland (
3), and white granules
from a eumycotic
mycetoma in a patient from Venezuela (
2).
When subcutaneous lesions caused by
P. parasiticum or
P. inflatipes were localized
and diagnosed early, total surgical excision
often led to uncomplicated
healing. However, therapy for infections
caused by
P. parasiticum,
P. inflatipes, and
P. rubrigenum in
immunocompromised hosts is not satisfactory.
Antifungal agents
such as amphotericin B, 5-fluorocytosine,
ketoconazole, and terbinafine
have been used in the past with variable
success (
5,
8,
9). In the present case, surgical excision
led to uncomplicated
cure of the infection.
| |
FOOTNOTES |
*
Corresponding author. Mailing address: Fungus Reference
Laboratory, Mail Stop G-11, Centers for Disease Control and Prevention, Atlanta, GA 30333. Phone: (404) 639-3749. Fax: (404) 639-3546. E-mail:
AAP1{at}cdc.gov.
| |
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Journal of Clinical Microbiology, September 1998, p. 2763-2765, Vol. 36, No. 9
0095-1137/98/$04.00+0
Copyright © 1998, American Society for Microbiology. All rights reserved.
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