Previous Article | Next Article 
Journal of Clinical Microbiology, May 2001, p. 1952-1955, Vol. 39, No. 5
0095-1137/01/$04.00+0 DOI: 10.1128/JCM.39.5.1952-1955.2001
Copyright © 2001, American Society for Microbiology. All rights reserved.
Phaeohyphomycosis Caused by Alternaria
infectoria in a Renal Transplant Recipient
Teysir
Halaby,1,*
Hans
Boots,2
Anton
Vermeulen,3
André
van
der Ven,1,2
Hugues
Beguin,4
Hans
van
Hooff,2 and
Jan
Jacobs1
Departments of Medical
Microbiology,1 Internal
Medicine,2 and Clinical
Pathology,3 Maastricht University Hospital,
Maastricht, The Netherlands, and Scientific Institute of Public
Health Louis Pasteur, Brussels, Belgium4
Received 25 September 2000/Returned for modification 22 November
2000/Accepted 26 January 2001
 |
ABSTRACT |
We report on a case of phaeohyphomycosis caused by Alternaria
infectoria in a renal transplant recipient with pulmonary
infiltrates and multiple skin lesions. Diagnosis was based on
microscopy and culture of the skin lesions. Treatment consisted of a
combination of surgical excision and systemic antifungal therapy, first
with itraconazole and subsequently with liposomal amphotericin B, for 39 days. At a 20-month follow-up visit, no recurrence of the skin lesions or the pulmonary infiltrates had occurred.
| |
TEXT |
Phaeohyphomycosis refers to a
subcutaneous and systemic infection caused by dark-walled hyphae in
culture and often in tissue (11). Agents that cause this
infection are primarily recognized as soil saprophytes, plant
pathogens, and contaminants living in the environment. With the growing
number of patients who are immunocompromised, phaeohyphomycotic agents
are increasingly being reported as the cause of human disease
(14, 16). More than 100 species belonging to at least 57 genera are known to be agents of phaeohyphomycosis (17).
Of these species, many have been reported only anecdotally, while
others, such as Bipolaris, Curvularia, Exserohilum, and
Alternaria species, have frequently been involved in human
infections (20, 25). Among the members of the last genus,
the most common species is Alternaria alternata. We report here on an immunocompromised patient with a documented
phaeohyphomycosis caused by Alternaria infectoria, which has
rarely been reported as a human pathogen before. The case presented
here reflects yet an additional example of the growing number of fungi
capable of eliciting phaeohyphomycosis in immunocompromised individuals.
Case report.
A 60-year-old male patient with end-stage renal
disease due to diabetic nephropathy underwent a cadaveric kidney
transplantation. The postoperative course was uneventful, and the
patient was discharged 25 days after transplantation. Five months after
transplantation he presented at the outpatient department with a
painless skin lesion on the right thumb. The patient did not recall any
local skin trauma since the transplantation. On the suspicion of
Kaposi's sarcoma, a punch biopsy specimen was taken from the lesion
for histological examination and the patient was sent home. Three days
later he developed a painful red swelling on his right foot. He also
suffered from a nonproductive cough. No dyspnea or fever was present.
Routine laboratory tests revealed a leukocyte count of
9,300/mm3 and a hemoglobin level of 6.8 mmol/liter. His
serum creatinine level was stable (133 µmol/liter). Chest X ray
revealed in the right and left lower lobes pulmonary infiltrates that
had been absent 5 months previously. The patient was admitted for
further evaluation.
On admission, immunosuppression consisted of prednisolone at 10 mg once
daily and tacrolimus, which inhibits interleukin-2 production and hence
T-cell activation (3). The whole-blood tacrolimus level
was 9.8 ng/ml (target level, 7 to 10 ng/ml). Mycophenolate mophetil
(another antirejection drug, which blocks both B and T lymphocytes by
inhibition of the de novo synthesis of guanosine nucleotides
[2]) was instituted as an experimental medication at
transplantation and had been stopped 2 months before. The patient was
also treated with felodipine posttransplantation for hypertension.
On physical examination, a nodular lesion (3 by 4 cm) on the medical
right foot and a similar lesion (1 by 1 cm) on the left
foot were
found, in addition to the lesion (1 by 1.5 cm) on the
right thumb. The
lesions were painless, dark violaceous, elevated,
and unattached to the
underlying tissue; the overlying epidermis
was unaffected. Further
physical examination, including chest
auscultation, was unremarkable.
The large lesion on the medial
right foot was completely resected.
Histopathologic examination
of this lesion revealed findings similar to
those observed for
the previous punch biopsy specimen from the right
thumb. In both
specimens, multiple intradermal microabscesses were
seen, and
these were surrounded by a cellular infiltrate consisting of
epithelioid
macrophages and giant cells engulfing many fungal forms
(Fig.
1a). In the specimen stained with
hematoxylin-eosin, many refringent
hyaline capsules containing fungal
elements were observed when
the condensor diaphragm was narrowed (Fig.
1b) (
15). Fungal
elements appeared uncolored in tissue
sections stained with hematoxylin-eosin
(Fig.
2, top panel); however, in Fontana-Masson
melanin-stained
tissue sections, some of these fungal elements stained
brown (Fig.
2, bottom panels), leading to the diagnosis of subcutaneous
phaeohyphomycosis.
Twelve days after the skin lesions were first
noticed, itraconazole
was started at 200 mg twice daily. Because of the
pulmonary infiltrates
found on admission, diagnostic bronchoscopy was
performed 4 days
after the initiation of itraconazole therapy. Raw,
uncentrifuged
bronchoalveolar lavage (BAL) fluid samples were
quantitatively
cultured for bacteria and yeast by inoculation of 0.010- and 0.001-ml
volumes transferred with an adjustable air-displacement
pipette
(Pipetman P20; Gilson, Villiers-le-Bel, France)
(
8). Before
inoculation, BAL fluid samples were gently
mixed on a roller mixer
(Coulter Electronics Ltd., Luton, England). The
aliquots were
plated onto blood agar base supplemented with 5%
(vol/vol) sheep
blood, chocolate agar, cystine lactose
electrolyte-deficient agar,
and Shaedler agar supplemented with 5%
(vol/vol) sheep blood and
vitamin K (Becton Dickinson Microbiology
Europe, Meylan Cedex,
France). After incubation for 48 h, the
colonies were counted
on the plates, and the number of CFU per
milliliter was determined
by multiplying the number of colonies by the
dilution factor.
In addition, cytocentrifuged preparations were made as
described
previously (
9) and stained with
May-Grünwald Giemsa, Gram,
Grocott-Gomori methenamine silver, and
auramine-rhodamine stains.
BAL fluid samples were also cultured for
mycobacteria with the
MB/BacT process system (Organon Teknika, Durham,
N.C.). Finally,
the remaining BAL fluid samples (approximately 100 and
70 ml for
the first and the second samples, respectively) were divided
into
10-ml fractions, centrifuged at 1,500 ×
g for 10 min, and inoculated
onto Sabouraud dextrose agar plates, which were
incubated at 35°C
for a 6-week period. None of the cultures of BAL
fluid samples
revealed any growth.
View larger version (77K):
[in this window]
[in a new window]
|
FIG. 1.
Hematoxylin-eosin stain of a biopsy specimen from the
lesion of the right thumb. (a) Margin of an abscess with accumulation
of polymorphonuclear leukocytes (left lower corner) and numerous
multinucleated giant cells (arrow) engulfing fungal elements. (b) The
fungal elements are surrounded by hyaline capsules (arrows) which
become visible by lowering the condensor diaphragm. Bar, 10 µm.
|
|
View larger version (147K):
[in this window]
[in a new window]
|
FIG. 2.
Hematoxylin-eosin stain of a biopsy specimen form the
lesion of the right foot. Note the uncolored branching hyphae in the
center (top panel). Staining with the Fontana-Masson stain shows
brown-pigmented hyphal fragments, disclosing the dematiaceous nature of
the fungus (bottom panels). Bars, 10 µm.
|
|
After 14 days of treatment with itraconazole, the remainder of the
right thumb lesion was completely resected and submitted
for culture.
Twenty-one days after the initiation of itraconazole,
the patient
gained 10 kg in weight due to fluid retention. He
became progressively
dyspneic, and his serum creatinine level
increased to 207 µmol/liter.
Repeat chest X rays showed progressive
pulmonary infiltrations in the
right lower lobe, with pulmonary
congestion and a right-sided pleural
effusion. Cultures of specimens
of a repeat BAL grew 2 × 10
3 CFU of oral flora per ml but no respiratory pathogens.
Cultures
from the pleural fluid were negative for microorganisms.
Treatment
was subsequently changed to amphotericin B in a liposomal
formulation.
The patient improved gradually and regained his normal
weight,
the dyspnea resolved, and the serum creatinine level returned
to the baseline
level.
After 28 days of treatment with amphotericin B, the remaining lesion on
the left foot was resected. Histological examination
of this lesion
showed no signs of mycosis. X ray of the chest
showed no pulmonary
infiltrate or pleural effusion. The patient
was subsequently discharged
from the hospital without antifungal
therapy. At a 20-month follow-up
visit, no recurrence of the skin
lesions or the pulmonary infiltrates
was
observed.
Mycological findings.
Grocott-Gomori methenamine silver
nitrate staining of touch preparations of a biopsy specimen from the
right foot obtained on the day of admission showed smooth, branched
hyphae. Biopsy specimens from the same lesion initially cultured in
Sabouraud broth at 35°C yielded mycelial growth after 4 days of
incubation and were subsequently cultured on Sabouraud agar at room
temperature. After approximately 7 days, brown woolly colonies were
seen. Examination of lactophenol preparations of these colonies showed
conidia and septate hyphae. Conidia were avoid, smooth walled, or
verrucose; some of them were muriform and often ended with apical
beaks. The strain was initially identified as an Alternaria
species, and a subculture was sent to the Scientific Institute of
Public Health Louis Pasteur, Brussels, Belgium, for species identification.
Specimens from the subculture were inoculated onto malt extract agar
for incubation at 25 and 35°C. After 7 days, scant growth
was noted
at 35°C. The samples incubated at 25°C showed readily
sporulating
olivaceous-black colonies with diameters of up to
5 cm. Conidiophores
were dark, septate, simple, or geniculate.
Conidia were ovoid or
ellipsoidal, mostly 10 to 44 by 8 to 11
µm, and smooth walled or
verrucose; some had one or more transverse
and sometimes longitudinal
or oblique septa. Some, mostly young,
conidia showed apical growth of
long, geniculate, secondary conidiophores
(pseudorostrata) (Fig.
3a). Chains of a few conidia separated
by
secondary conidiophores were also seen (Fig.
3b). On the basis
of the
last two characteristics, the species was identified as
A. infectoria (
22,
23). The strain is preserved at the
IHEM
Culture Collection (IHEM 16110), and its identification was
confirmed
by the Institute of the Royal Netherlands Academy of Arts and
Sciences (Centraalbureau voor Schimmelcultures), Baarn, The
Netherlands.
View larger version (45K):
[in this window]
[in a new window]
|
FIG. 3.
Lactophenol cotton blue mount of A. infectoria. (a) Microscopic appearance of conidia (open arrow)
with apical outgrowth of long, geniculate secondary conidiophore
(pseudorostrata) (closed arrow). (b) Chain formation of conidia,
separated by pseudorostrata. Bars, 10 µm.
|
|
The lesion on the right thumb was resected 2 weeks after itraconazole
treatment had been started, Culture of this lesion yielded
the same
fungus.
Discussion.
Phaeohyphomycosis is a fungal infection caused by
dematiaceous or darkly pigmented fungi (1). Among other
mycoses, this fungal infection is increasingly seen in
immunocompromised patients (25). Clinical manifestations
may range from local skin lesions to invasive and disseminated
infections (13).
Diagnosis is made by histopathological examination of tissue specimens.
The early histopathologic picture is one of multiple
stellate
abscesses, which progress to a single circumscribed lesion
with a
central cavity filled with pus and surrounded by a fibrous
wall
(
26). The margins of these abscesses and the granulomas
are composed of giant cells, epithelioid cells, histiocytes, plasma
cells, and lymphocytes; fungi are found in or adjacent to purulent
areas (
11). Despite the dematiaceous nature of the fungi,
the
brown pigment is not always apparent (
13) and hyphae
may appear
hyaline in lesions when hematoxylin-eosin stain is used
(
15),
such as was seen in our patient's specimen (Fig.
2,
top panel);
in contrast, the natural brown color of the hyphae is
masked by
the Grocott staining method. Therefore, confirmation of the
presence
of a dematiaceous mold can be achieved by using a
melanin-specific
stain, such as the Fontana-Masson stain (Fig.
2,
bottom panels)
(
7).
More than 100 fungal species have been documented as agents of
phaeohyphomycosis (
17). The genera most frequently
involved
in human infections include
Bipolaris, Curvularia,
Exserohilum,
and
Alternaria (
20,
25).
Among the members of the last genus,
the most commonly found species is
A. alternata (
4).
In this report we describe a case of phaeohyphomycosis caused by
A. infectoria. The microscopic characteristics typical of
A. infectoria include the presence of prominent
pseudorostrata
(secondary conidiophores) (Fig.
3a) and chains of
conidia separated
by secondary conidiophores (Fig.
3b) (
5,
24).
A. infectoria has been found to cause cutaneous lesions in a
cat (
18) and, to our knowledge, has previously been
reported
as a human pathogen in only two cases. Laumaillé et al.
(
12)
have described a cutaneous lesion caused by
A. infectoria in a
liver transplant recipient. Treatment consisted of
a total resection
without antifungal agents; however, recurrence of the
lesion was
noted 5 months later. In the second case,
Alternaria infection
presented as sinusitis and maxillary
osteomyelitis in an otherwise
healthy woman. (J. Garau, R. D. Diamond, L. B. Lagrotteria, and
S. A. Kabins, Letter, Ann.
Intern. Med.
86:747-748, 1977).
Culture of a biopsy
specimen grew a fungus that was identified
as the
Alternaria
state of
Pleospora infectoria (
6). Surgical
excision of the lesion was performed after a 7-week course of
treatment
with amphotericin B, but recurrence occurred 4 months
later, and
prolonged administration of amphotericin B was
needed.
In our patient described here, the diagnosis of phaeohyphomycosis was
confirmed by both microscopic and cultural evidence.
The presence of
microscopically confirmed lesions on three noncontiguous
body sites
(right thumb, right foot, left foot) strongly suggests
that the disease
was disseminated. Although the fungi could not
be detected in the BAL
fluid samples, we assume that a coexistent
pulmonary phaeohyphomycosis
was responsible for the pulmonary
infiltrates, since the abnormalities
noted on chest X ray normalized
after the initiation of antifungal
therapy. In addition, the pulmonary
infiltrates could not be explained
by fluid retention since no
signs of heart failure were present at the
time of
presentation.
Treatment of phaeohyphomycosis should include complete surgical
excision of accessible lesions combined with antifungal therapy,
especially when invasive or systemic infection is present
(
17).
The patient described here was successfully treated
with a combination
of surgery and systemic antifungal therapy.
Itraconazole has been
found to be as effective as amphotericin B in
patients with phaeohyphomycosis
(including those with skin and organ
involvement), ac-counting
for approximately 65% of successful outcomes
(
21). In our patient,
however, the clinical effectiveness
of itraconazole remained unclear.
Itraconazole therapy was prematurely
interrupted because of the
development of fluid retention and dyspnea,
which were considered
adverse effects (
19). Possible
interaction with felodipine may
also have contributed to the
development of fluid retention (
10).
Since amphotericin B
is nephrotoxic, the liposomal formulation
of this agent was given. This
treatment resulted in clinical and
histological
improvements.
In summary, this report presents the third case of human
phaeohyphomycosis caused by
A. infectoria. Diagnosis was
based on
cultural and histological examination of cutaneous lesions.
The
simultaneous presence of multiple skin lesions and pulmonary
infiltrates
which responded to effective antifungal therapy strongly
suggest
a disseminated infection. Therapy consisted of surgical
excision
of the lesions in combination with itraconazole and
amphotericin
B. We conclude that
A. infectoria should be
considered in the
differential diagnosis of cutaneous and deep-seated
phaeohyphomycosis.
| |
FOOTNOTES |
*
Corresponding author. Mailing address: Maastricht
University Hospital, P.B. 5800, 6202 AZ, Maastricht, The Netherlands.
Phone: 31-43-3874644. Fax: 31-43-3876643. E-mail:
AHAL{at}LMIB.AZM.NL.
| |
REFERENCES |
| 1.
|
Ajello, L.
1981.
The gamut of human infections caused by dematiaceous fungi.
Jpn. J. Med. Mycol.
22:1-5.
|
| 2.
|
Allison, A. C., and E. M. Eugui.
2000.
Mycophenolate mofetil and its mechanisms of action.
Immunopharmacology
47:85-118[CrossRef][Medline].
|
| 3.
|
Almawi, W. S., and O. K. Melemedjian.
2000.
Clinical and mechanistic differences between FK506 (tacrolimus) and cyclosporin A.
Nephrol. Dial. Transplant.
15:1916-1918[Free Full Text].
|
| 4.
|
Anaissie, E. J.,
G. P. Bodey, and M. G. Rinaldi.
1989.
Emerging fungal pathogens.
Eur. J. Clin. Microbiol. Infect. Dis.
8:323-330[CrossRef][Medline].
|
| 5.
|
Andersen, B., and U. Thrane.
1996.
Differentiation of Alternaria infectoria and Alternaria alternata based on morphology, metabolite profiles, and cultural characteristics.
Can. J. Microbiol.
42:685-689.
|
| 6.
|
De Hoog, R. D., and J. Guarro.
1995.
Atlas of clinical fungi.
Centraalbureau voor Schimmelcultures, Baarn, The Netherlands.
|
| 7.
|
Fothergill, A. W.
1996.
Identification of dematiaceous fungi and their role in human disease.
Clin. Infect. Dis.
22:S179-S184.
|
| 8.
|
Jacobs, J. A.,
E. I. De Brauwer,
E. I. Cornelissen, and M. Drent.
2000.
Accuracy and precision of quantitative calibrated loops in transfer of bronchoalveolar lavage fluid.
J. Clin. Microbiol.
38:2117-2121[Abstract/Free Full Text].
|
| 9.
|
Jacobs, J. A.,
E. I. De Brauwer,
G. Ramsay,
N. A. Cobben,
S. S. Wagenaar,
A. J. van der Ven,
C. A. Bruggeman, and M. Drent.
1999.
Detection of non-infectious conditions mimicking pneumonia in the intensive care setting: usefulness of bronchoalveolar fluid cytology.
Respir. Med.
93:571-578[CrossRef][Medline].
|
| 10.
|
Jalava, K. M.,
K. T. Olkkola, and P. J. Neuvonen.
1997.
Itraconazole greatly increases plasma concentrations and effects of felodipine.
Clin. Pharmacol. Ther.
61:410-415[CrossRef][Medline].
|
| 11.
|
Kwon-Chung, K. J., and J. E. Bennett.
1992.
Phaeohyphomycosis, p. 620-677.
In
K. J. Kwon-Chung, and J. E. Bennett (ed.), Medical mycology. Lea & Febiger, Philadelphia, Pa.
|
| 12.
|
Laumaillé, C.,
F. Le Gall,
B. Degeilh,
E. Gueho, and M. Huerre.
1998.
Cutaneous Alternaria infectoria infection after liver transplantation.
Ann. Pathol.
18:192-194[Medline].
|
| 13.
|
McGinnis, M. R.
1983.
Chromoblastomycosis and phaeohyphomycosis: new concepts, diagnosis, and mycology.
J. Am Acad. Dermatol.
8:1-16[Medline].
|
| 14.
|
Morrison, V. A.,
R. J. Haake, and D. J. Weisdorf.
1993.
The spectrum of non-Candida fungal infections following bone marrow transplantation.
Medicine
72:78-89[Medline].
|
| 15.
|
Ramos, A. M.,
A. de O. Sales,
M. C. de Andrade,
J. F. Bittencourt, and C. C. Ramos.
1995.
A simple method for detecting subcutaneous phaeohyphomycosis with light-colored fungi. A study of eight cases.
Am. J. Surg. Pathol.
19:109-114[Medline].
|
| 16.
|
Rees, J. R.,
R. W. Pinner,
R. A. Hajjeh,
M. E. Brandt, and A. L. Reingold.
1998.
The epidemiological features of invasive mycotic infections in the San Francisco Bay area, 1992-1993: results of population-based laboratory active surveillance.
Clin. Infect. Dis.
27:1138-1147[Medline].
|
| 17.
|
Rinaldi, M. G.
1996.
Phaeohyphomycosis.
Dermatol. Clin.
14:147-153[CrossRef][Medline].
|
| 18.
|
Roosje, P. J.,
G. S. de Hoog,
J. P. Koeman, and T. Willemse.
1993.
Phaeohyphomycosis in a cat caused by Alternaria infectoria E.
G. Simmons. Mycoses
36:451-454.
|
| 19.
|
Rosen, T.
1994.
Debilitating edema associated with itraconazole therapy.
Arch. Dermatol.
130:260-261[Abstract/Free Full Text].
|
| 20.
|
Schell, W. A.
1995.
New aspects of emerging fungal pathogens.
Clin. Lab. Med.
15:365-387[Medline].
|
| 21.
|
Sharkey, P. K.,
J. R. Graybill,
M. G. Rinaldi,
D. A. Stevens,
R. M. Tucker,
J. D. Peterie,
P. D. Hoeprich,
D. L. Greer,
L. Frenkel,
G. W. Counts, et al.
1990.
Itraconazole treatment of phaeohyphomycosis.
J. Am. Acad. Dermatol.
23:577-586[Medline].
|
| 22.
|
Simmons, E. G.
1986.
Alternaria themes and variations (22-26).
Mycotaxon
25:287-308.
|
| 23.
|
Simmons, E. G.
1993.
Alternaria themes and variations (73).
Mycotaxon
48:109-140.
|
| 24.
|
Simmons, E. G.
1994.
Alternaria themes and variations (106-111).
Mycotaxon
50:409-427.
|
| 25.
|
Vartivarian, S. H.,
E. L. Anaissie, and G. P. Bodey.
1993.
Emerging fungal pathogens in immunocompromised patients: classification, diagnosis, and management.
Clin. Infect. Dis.
17:S487-S491.
|
| 26.
|
Ziefer, A., and D. H. Connor.
1980.
Phaeomycotic cyst. A clinicopathologic study of twenty-five patients.
Am. J. Trop. Med. Hyg.
29:901-911.
|
Journal of Clinical Microbiology, May 2001, p. 1952-1955, Vol. 39, No. 5
0095-1137/01/$04.00+0 DOI: 10.1128/JCM.39.5.1952-1955.2001
Copyright © 2001, American Society for Microbiology. All rights reserved.
This article has been cited by other articles:
-
Lo Cascio, G., Ligozzi, M., Maccacaro, L., Fontana, R.
(2004). Utility of Molecular Identification in Opportunistic Mycotic Infections: a Case of Cutaneous Alternaria infectoria Infection in a Cardiac Transplant Recipient. J. Clin. Microbiol.
42: 5334-5336
[Abstract]
[Full Text]
-
Ferrer, C., Montero, J., Alio, J. L., Abad, J. L., Ruiz-Moreno, J. M., Colom, F.
(2003). Rapid Molecular Diagnosis of Posttraumatic Keratitis and Endophthalmitis Caused by Alternaria infectoria. J. Clin. Microbiol.
41: 3358-3360
[Abstract]
[Full Text]
Top
Abstract
Text
