Infections due to Penicillium species other than P.marneffei are rare. We identified a boy with X-linked chronic granulomatous disease (X-CGD) with a pulmonary nodule and adjacent rib osteomyelitis caused by Penicillium piceum. The only sign of infection was an elevated sedimentation rate. P. piceum was isolated by fine needle aspirate and from excised infected tissues. Surgical removal and one year of voriconazole treatment were very well tolerated and led to complete recovery. Microbiological, microscopic and molecular studies support the fungal diagnosis. P. piceum should be considered as a relevant pathogen in immunocompromised patients.

Summary:We report two patients who developed atypical skin lesions caused by Curvularia sp. and Pseudallescheria boydii after allogeneic bone marrow transplantation for severe aplastic anemia. The first patient (female, 18-year-old) had multiple hemorrhagic vesicles on day +30 after her second BMT for graft failure. Pseudallescheria boydii was isolated from a skin biopsy. The patient died of respiratory failure probably as a consequence of systemic fungal infection. The second patient (male, 9-yearold) developed an ecthyma gangrenosum-like lesion on his right palm on day +8. Curvularia sp. was isolated from a skin biopsy. Liposomal amphotericin was given to achieve a total dose of 30 mg/kg and followed by oral itraconazole until steroids were discontinued. The infection resolved completely and the patient has remained disease-free. We conclude that emerging fungal organisms such as those described in this report are increasingly recognized in this setting. Early recognition and biopsy of these cutaneous lesions will allow prompt initiation of therapy to prevent systemic infection. Bone Marrow Transplantation (2001) 27, 1311-1313. Keywords: Curvularia sp.; Pseudallescheria boydii; bone marrow transplantation; fungal infection Fungal infections cause significant morbidity and mortality in bone marrow transplant recipients. 1 Candida and Aspergillus sp. are the most common fungal pathogens in this setting although new fungal opportunists (hyalohyphomycoses and phaeohyphomycoses) may occasionally be isolated and identified as being responsible for local or systemic infections. 2,3 The purpose of this report is to describe the clinical manifestations and the mycological findings of two patients after allogeneic BMT who developed atypical skin lesions caused by unusual opportunistic fungi. Case reports Patient 1An 18-year-old woman diagnosed with hepatitis-associated severe aplastic anemia underwent BMT from her HLAidentical brother. Serologic tests for hepatitis A, B and C virus were negative. Conditioning consisted of CY 200 mg/kg and horse antilymphocyte globulin (PasteurMérieux, Lyon, France) 90 mg/kg. GVHD prophylaxis was a combination of CsA and short-course MTX. On day +5 a tender erythematous nodule was detected on her right leg. The patient was experiencing severe myalgia and flu-like symptoms. Direct examination of the skin biopsy revealed the presence of septate hyphae, so amphotericin B deoxycholate was administered. Fusarium solani was identified in the culture obtained from the skin biopsy. For the first 5 days, the lesion developed into a violet nodule with a necrotic center and then improved gradually leaving a hypopigmented scar. The patient's condition improved gradually. Amphotericin B deoxycholate was replaced by itraconazole 200 mg/day after engraftment and it was continued up to day +90. No recurrence of fungal infection was noted.However, the patient experienced graft failure 4 months after BMT. A second BMT was performed from another HLA-identical brother after conditioning with TBI 12 Gy and ...

These data indicate that posaconazole is a potentially effective antifungal agent for the treatment of mycoses caused by yeasts.

Sensititre is a colorimetric microdilution method for in vitro antifungal susceptibility testing based on the M27-A document (National Committee for Clinical Laboratory Standards) for yeasts. Difference between both methods is the presence of Alamar-blue and RPMI 1640 (glucose 2%) as culture medium. Antifungal susceptibility to amphotericin B, fluconazole, itraconazole, ketoconazole and flucytosine, 100 opportunistic filamentous fungi (Aspergillus spp., Fusarium spp., Scedosporium spp.) obtained from pathological samples was determined by the Sensititre method. Induction to conidium and sporangiospore formation at 35 degrees C was used to get inoculum and plates were covered by 1 ml of saline and suspensions were made by gently probing by a sterile loop. Optical densities of the conidial suspensions were adjusted to 80-82% transmittance for Aspergillus spp. and 68-70% for the rest of strains tested. Final inoculum concentration size was 0.4 x 10(4)-5 x 10(4) CFU ml(-1). Readings were made at 72 h of incubation at 35 degrees C; amphotericin B and itraconazole was active against Aspergillus fumigatus with CMI90 1 and 0.5 microg ml(-1), respectively, opposite to Scedosporium prolificans and Scedosporium apiospermum. As it was expected, a CMI90 of 256 microg ml(-1) for fluconazole and CMI90 for flucytosine amounting to 64 g ml(-1) were obtained. Sensititre Yeast One is a useful method and an alternative to reference methods to determine antifungal susceptibility of filamentous fungi for clinical laboratory routine. Correlation with microdilution results is studied. New triazole derivatives should be included as soon as their clinical use will be feasible.

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