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Lactophenol cotton blue mount of the colonies revealed brown septate hyphae with annelides giving rise to small, single-celled conidia arranged in groups (×400). (Color figure online)
Source publication
We present a rare case of a 30-year-old woman who presented with a swelling on the lateral aspect of her left forearm, present since 6 months, adjacent to a 16-year-old burn scar. X-ray of elbow joint and forearm revealed the subcutaneous nature of the swelling. Giemsa and periodic acid-Schiff-stained smears and potassium hydroxide mount of fine-ne...
Citations
... Recently, Exophiala spp. has been frequently reported as an etiologic agent of phaeohyphomycosis in both immunocompromised and immunocompetent individuals [2][3][4][5], which highlights the importance of reviewing the characteristics of this pathogen related infections. In this study, we described one case of prolonged cutaneous infection due to E. jeanselmei and reviewed 84 cases published in PubMed database during 1980 to 2020. ...
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.
... However, they must not be disregarded as mere commensals or contaminants as they are also important opportunist pathogens causing systemic infections in immunosuppressed patients and subcutaneous or even fatal disseminated infections in otherwise healthy individuals (Fothergill, 1996;Zeng et al., 2007). Although Exophiala species are relatively uncommon, various reports of this genus as an etiologic agent of phaeohyphomycosis are being described from India in recent years (Sood et al., 2014;Venkateshwar et al., 2014;Bhardwaj et al., 2016;Haridasan et al., 2017). Despite the apparent virulence of these species and worrisome clinical scenario, there are no systematic studies on the Indian isolates of Exophiala species. ...
Introduction
Exophiala spp. are important opportunist pathogens causing subcutaneous or even fatal disseminated infections in otherwise both immunosuppressed and healthy individuals but there are no systematic studies on the isolates of Exophiala species from India.
Methods
Twenty-four isolates of Exophiala species were retrieved from the National Culture Collection of Pathogenic Fungi (NCCPF) and identified phenotypically and by molecular methods (ITS region sequencing) followed by antifungal susceptibility testing (AFST) as per CLSI-M38A3 guidelines. A review of the literature of cases from India was performed up to 1st January 2021 using the Medline and Cochrane database.
Results
E. dermatitidis (n = 8), E. jeanselmei (n = 6), E. spinifera (n = 6), E. mesophila (n = 1), E. oligosperma (n = 1), E. xenobiotica (n = 1) were identified and the sequencing of ITS, β-tubulin and β-actin revealed a novel species, E. arunalokei sp. nov. (n = 1). The ITS sequence phylogram of E. jeanselmei revealed that the majority (83%) formed a separate cluster close to type A while majority (75%) of E. dermatitidis were type B. The MIC50 (mg/L) of amphotericin, itraconazole, voriconazole, micafungin, caspofungin, anidulafungin, and posaconazole, was 1, 0.25, 0.125, 0.12, 0.125, 0.062, and 0.062, respectively. Sixteen more cases were identified on the literature review and a significant association of E. dermatitidis with history of surgical procedures (p = 0.013), invasive disease (p = 0.032) and of E. mesophila with tuberculosis (p = 0.026) was seen.
Conclusion
This, to the best of our knowledge is the first study from India elucidating the molecular and clinical characteristics of Exophiala species and the first Indian report of human infection due to E. xenobiotica and E. arunalokei.
... Finally, 36 case reports encompassing 44 burn patients were included for the final analysis. Of the 44 cases, 18 cases originated from the United States 10,12,13,16,18,22,23,30,31,[33][34][35]38,39,43,45 ; 18 cases originated from 5 Asian countries, including China, 17,20,29 Korea, 15 India, 36,[40][41][42] Iran, 26,39 and Vietnam 11,32 ; and the remaining 8 cases originated from France, 14 Australia, 19 Poland, 21 Jamaica, 24 German, 27 Switzerland, 25 Portugal, 28 and the Czech Republic, 44 respectively. The cases consisted of 31 males, 11 females, and 2 nonspecific sex identities. ...
... In 36 of the 44 cases, fungal infections were initially suspected and identified from the burn wound samples. [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][31][32][33][35][36][37][39][40][41][42][43][44][45] In the remaining 8 cases, presentations of fungal wound infection were not observed, whereas invasive fungal infections were found in other sites such as blood, arterial thrombosis, teeth, feces, urine, sputum, and tracheal fluid. [28][29][30]34,38 The most frequent fungal pathogens were Zygomycetes, which were found in 13 cases. ...
... 13,24,27,43 Of the remaining 2 cases, 1 refused specific antifungal therapy and left against medical advice, and eventually underwent below-knee amputation at other hospital 40 ; 1 was successfully treated with surgical debridement without antifungal treatment. 41 Amputation was reported in 10 cases due to the severe injury or infection of the extremities. 12,16,18,19,22,31,34,35,39,40 Of the 10 cases, 2 died due to sepsis and multiple system organ failure. ...
Objectives:
The aims of this study were to review recent fungal infection case reports published, evaluate the treatment regimens and clinical outcomes, and provide recommendations for future management.
Methods:
A review of case reports published over the last decade was conducted. PubMed was searched to collect the relevant citations using a combination of the key words ("burn," "burned," "burns," "fungal," "fungi," and "fungus") in title or abstract. Case series, reviews, guidelines, and experimental and non-English studies were excluded. Statistical analyses were performed using Microsoft Excel 2019.
Results:
A total of 36 case reports encompassing a total of 44 burn patients with fungal infection were included in the final analysis. Ablative surgeries, including surgical excision, debridement, skin graft, vitrectomy, teeth extraction, valve replacement, or amputation, were performed in 38 cases after the suspicion or identification of fungal infection. Twenty-nine of them were eventually discharged, yielding a survival rate of 76.3%. In the remaining 6 cases, ablative surgery was not mentioned and 3 of them eventually died, yielding a survival rate of 50%. The total mortality was 27.27%. Among the 12 death cases, 1 was infected with Candida albicans, 1 with non-albicans Candida, 2 with Aspergillus spp, 2 with Fusarium spp, 4 with Zygomycetes, and 2 with other fungal species.
Conclusions:
The overall mortality of fungal wound infection is still high in burn patients around the world, especially those infected with non-Candida species. Early diagnosis of fungal infection, early initiation of appropriate antifungal therapy, and effective surgical intervention are key measures to improve the treatment effect and reduce the mortality of fungal infection in burn patients.
... Severe paracoccidioidomycosis in a 14-year-old boy 200 1/1 [63] a Google Scholar/Scopus [41,42], France [43,44], India [45,46], Italy [47], Iran [48], Japan [49], Malaysia [50], Poland [51], UK [52], and USA [53,54]. There were no other discernible features among this group of case reports to account for the high downloads and citations except for a novelty or rarity of fungal pathogens, for example reports of two cases of multidrug-resistant yeast (Fereydounia khargensis) and of black-grain eumycetoma caused by the rare fungal pathogen Medicopsis romeroi [50,52]. ...
Case reports describe the unusual occurrence and complications of diseases, diagnostic challenges, and notable therapeutic successes. Some journals have discontinued the case reports, while new case report journals have appeared in recent years. During the eightieth anniversary of Mycopathologia, it is fitting to examine the relevance of the case report since the journal continues to traverse the boundaries of basic and clinical sciences. A random sample of recent case reports and other articles were selected from Mycopathologia. Springer Nature individual article download statistics, and Google Scholar and Scopus citations numbers were compared to assess the reader access and bibliometric impact of case reports. Our analysis indicated that the case report format continues to be a vital element of publication in a cross-disciplinary journal such as Mycopathologia. Medical and veterinary case reports covering fungal pathogens are widely read as evident from their download numbers. The download numbers have a positive correlation with the completeness of the report, the topics and geographic origin of reports have a neutral influence, and the recency leads to lower downloads. There is no discernible trend between the download numbers and the citations of case reports as measured by Google Scholar and Scopus. A specially designed checklist for Mycopathologia case reports and new format MycopathologiaIMAGES are being introduced to improve the quality and relevance of case reports further.
... Treatment of infections caused by Exophiala species is difficult. Failure was reported even in immunocompetent patients using combined antifungals 22,37,38,48 Knowledge of in vitro susceptibility patterns might help guiding therapy. However, the reference susceptibility testing methods do not specifically include Exophiala species and clinical breakpoints or epidemiological cut-off values are not yet available to categorize the isolates in terms of susceptibility or possible existence of mutations related to resistance. ...
... We also used CLSI M38-A2 and found GM MICs of 0.28 and 0.07 µg/ml using MIC-0 and MIC-1 endpoints, respectively (Tables 1 and 2). Although these findings might suggest that terbinafine might be an option to treat superficial Exophiala infections, treatment failures with combination therapy including azoles have been reported 37,38 and data on terbinafine treatment of Exophiala infections are not conclusive. ...
Background
Exophiala is a genus of black fungi isolated worldwide from environmental and clinical specimens. Data on antifungal susceptibility of Exophiala isolates are limited and the methodology on susceptibility testing is not yet standardized.
Objectives
In this study, we investigated in vitro antifungal susceptibilities of environmental Exophiala isolates.
Methods
A total of 87 Exophiala isolated from dishwashers or railway ties were included. CLSI M38‐A2 microdilution method with modifications was used to determine antifungal susceptibility for fluconazole, voriconazole, posaconazole, itraconazole, amphotericin B, and terbinafine. Minimum inhibitory concentration (MIC) values were determined visually at 48h, 72h, and 96h. MIC‐0 endpoint (complete inhibition of growth) was used for amphotericin B and azoles, except fluconazole, for which MIC‐2 endpoint (~50% inhibition compared to growth control) was used. Both MIC‐0 and MIC‐1 (~80% inhibition compared to growth control) results were analysed for terbinafine, to enable comparison with previous studies.
Results and Conclusions
Fungal growth was sufficient for determination of MICs at 48h for all isolates except two Exophiala dermatitidis strains. At 72h, most active antifungal agents according to GM MIC were voriconazole and terbinafine, followed by posaconazole, itraconazole, and amphotericin B in rank order of decreasing activity. While amphotericin B displayed adequate in vitro activity despite relatively high MICs, fluconazole showed no meaningful antifungal activity against Exophiala.
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... It commonly presents as a single, wellencapsulated, subcutaneous mass or a nodule at the site of previous trauma, commonly on the extremities. The common causative organisms reported include Exophiala, Alternaria, Phialophora, Cladophialophora, and Curvularia/Bipolaris species [5,7]; however, many others have been implicated on occasion [8,9]. ...
... Phaeohyphomycosis is an uncommon fungal infection, although its incidence has been reported to be on the rise globally [1,2]. Most phaeohyphomycosis infections are caused by Exophiala, Alternaria, Cladophialophora, Phialophora or Curvularia/Bipolaris species; however, many others have been implicated on occasion [5,7]. Infection is most often acquired from traumatic implantation of the causative agent into subcutaneous tissue. ...
An 88-year-old man, receiving prednisolone for sarcoidosis, presented with a discrete keratotic lesion on the dorsum of his right hand following the placement of an intravenous cannula a month prior to its appearance. Medicopsis romeroi was isolated from the tissue and identified by sequencing the internal transcribed spacer region ITS-1 and the D1-2 fragment of the 28S rDNA gene. Histopathological examination showed fungal hyphae in the internal inflammatory cells layer and within the histocyte-macrophage layer, highly suggestive of deep mycosis. The patient was successfully treated with surgical excision of the cyst. M. romeroi exhibited high MIC values for echinocandin drugs in vitro, but appeared susceptible to newer triazole agents, amphotericin B and terbinafine. This is the first report of a subcutaneous phaeohyphomycotic cyst occurring following the placement of an intravenous cannula. This report highlights the potential role of M. romeroi as an emerging cause of deep, non-mycetomatous infection in immunocompromised patients.
Background:
Melanized fungi are a distinct group of pathogens that cause infections like chromoblastomycosis and phaeohyphomycosis, especially in a state of immunosuppression including solid organ transplant recipients. Guidelines for the treatment of these infections are lacking, and there is no available standard recommendation.
Objective:
To evaluate the therapeutic aspects of subcutaneous melanized fungal infections in kidney transplant recipients.
Methods:
A retrospective medical record was performed for kidney transplant recipients with melanized fungal infection evaluated in a single institution from January 1996 to December 2018.
Results:
Eighty-two episodes were noticed in our series. The treatment of subcutaneous phaeohyphomycosis was managed by surgical excision without antifungal therapy in 34 cases (34/68; 50%), and the association of both methods occurred in 18 cases (18/68; 26.5%). A complete surgical excision without antifungal therapy was observed in six (6/14; 42.9%) episodes of chromoblastomycosis, and combined treatment was possible in three (3/14; 21.4%) cases. Five episodes of chromoblastomycosis and 16 episodes of phaeohyphomycosis were managed only with antifungal therapy.
Conclusion:
Management depends on the dermatologic lesion, immunosuppression condition, and anatomical cleavage plane. The sample size is still small in order to dictate a guideline, but it can be hard to execute a larger study given the rarity of this group of infections.
Background: Exophiala is the main genus of black fungi comprising numerous opportunistic species. Data on antifungal susceptibility of Exophiala isolates are limited while infections are potentially fatal.
Materials and methods: In vitro activities of eight antifungal drugs (AMB, five azoles, two
echinocandins) against 126 clinical (n=76) and environmental (n=47) isolates from around the world were investigated. E. oligosperma (n=58), E. spinifera (n=33), E. jeanselmei (n=14), and E. xenobiotica (n=21) were included in our dataset.
Results: The resulting MIC90s of all strains were as follows, in increasing order: posaconazole 0.063 μg/mL, itraconazole 0.125 μg/mL, voriconazole and amphotericin B 1 μg/mL, isavuconazole 2 μg/mL, micafungin and caspofungin 4 μg/mL, and fluconazole 64 μg/mL. Posaconazole, itraconazole, and micafungin were the drugs with the best overall activity against Exophiala species. Fluconazole could not be considered as a treatment choice. No significant difference could be found among antifungal drug activities between these four species, neither in clinical nor in environmental isolates.
Conclusion: Antifungal susceptibility data for Exophiala spp. is crucial to improve the
management of this occasionally fatal infection and the outcome of its treatment.
Chromoblastomycosis is a subcutaneous, chronic, granulomatous mycosis that occurs more frequently in tropical and subtropical countries. Herein, we describe a case of a 90-year-old female patient with diagnosis of chromoblastomycosis by Exophiala jeanselmei with a 22-year evolution who developed a squamous cell carcinoma. In the meantime, She underwent two misdiagnoses and an unnecessary operation. This case is also the fifth case of E. jeanselmei caused CBM in history.
