ARTICLE
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.
|
Printable version
Version PDF