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Subcutaneous exophiala jeanselmei infection in a heart transplant patient

European Journal of Dermatology. Volume 13, Number 5, September 2003, Clinical report

Author(s) : Donato CALISTA, Maurizio LEARDINI, Fabio ARCANGELI , Department of Dermatology, "M. Bufalini" Hospital, viale Ghirotti, 286, 47023 Cesena ‐ Italy. *Dermatology Unit, Ospedale di Stato, via La Toscana, 3, Cailungo, Repubblica San Marino .

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Auteur(s) :Donato CALISTA, Maurizio LEARDINI *, Fabio ARCANGELI

Department of Dermatology, "M. Bufalini" Hospital, viale Ghirotti, 286, 47023 Cesena ‐ Italy. *Dermatology Unit, Ospedale di Stato, via La Toscana, 3, Cailungo, Repubblica San Marino

A 55‐year‐old man came under our observation because of the onset of a nodule on his left wrist, which soon became ulcerated and discharged pus. There was no memory of any recent traumas. The patient‘s medical history was significant for hypertension, diabetes, chronic renal insufficiency, and a heart transplantation in 1998. At the time of the first observation, his daily medication included prednisone, cyclosporin A, omeprazole, and captopril.

On clinical examination, there was one round, 3.5 × 2.5 cm, ulcerated, crusted lesion on the dorsal aspect of his left wrist (Fig. 1) and four, well‐demarcated, nodules, 1 to 2 cm in diameter, on the lateral aspect of his arm and forearm. No associated lymphadenopathy was noticed. Direct mycological examination revealed branched, septate, pale‐brown hyphae. Cultural examination revealed the growth of round, dome‐shaped, olive‐black colonies. Histopathological examination showed epidermis hyperplasia, a suppurative granulomatous inflammation in the reticular dermis with micro‐abscesses, and pigmented fungal hyphae (Fig. 2). A diagnosis of subcutaneous exophiala jeanselmei infection was made. Abdomen echotomography, chest x‐ray and computed tomography examinations of the arm and forearm excluded visceral or bone involvement. All the lesions were surgically excised and treatment with itraconazole (400 mg daily) was started. A month later, this dose was lowered to 200 mg daily for a further 4 months. No recurrence was noticed after an 18 month follow‐up period.

Exophiala jeanselmei (EJ) is a rare dermatiaceous fungus that contaminates soil, thorns and wood splinters [1]. The yeast penetrates the skin, predominantly in the extremities, through sub‐clinical traumas [1, 2]. Immunosuppression, notably in cell‐mediated immunity, is considered a major cause of susceptibility. However, Exophiala species has been reported, albeit rarely, in subjects with no obvious predisposing factors [2, 3].

Clinical manifestations vary from localised infections of the superficial keratin, such as those occurring in tinea nigra or black piedra, to subcutaneous locations that present as slow growing, encapsulated, asymptomatic cysts or nodules [1‐3]. The course of the disease is chronic but usually self‐limiting. In rare instances, EJ may spread to the internal organs and, once there, may produce endocarditis and encephalitis [3, 4]. Cultural examination and Fontana‐Masson stain are helpful for differentiating phaeohyphomycosis from cutaneous aspergillosis, candidiasis, chromoblastomycosis, sporotrichosis, or Fusarium infections [2‐4].

Surgery, followed by prolonged systemic anti‐mycotic treatment is the therapy of choice.

References

1 . McCown HF, Sahn EE. Subcutaneous phaeohyphomycosis and nocardiosis in a kidney transplant patient. J Am Acad Dermatol 1997; 36: 863‐6.

2 . Sudduth EJ, Crumbley AJ, Farrar WE. Phaeohyphomycosis due to Exophiala species: clinical spectrum of disease in humans. Clin Infect Dis 1992; 15: 639‐44.

3 . Xu X, Low DW, Palewsky HI, Elenitsas R. Subcutaneous phaeohyphomycotic cysts caused by Exophiala jeanselmei in a lung transplant patient. Dermatol Surg 2001; 27: 343‐6.

4 . Gold WL, Vellend H, Salit IE, Campbell I, Summerbell R, Rinaldi M, et al. Successful treatment of systemic and local infections due to Exophiala species. Clin Infect Dis 1994;19: 339‐41.