Atypical skin lesions caused by Curvularia sp. and Pseudallescheria boydii in two patients after allogeneic bone marrow transplantation

Abstract

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 ...

Nonpseudomonal ecthyma gangrenosum

“…22 Finally, there is one reported case of a patient with pneumonic plague who developed EG-like lesions. 23 Fungal pathogens causing EG include Candida albicans, 24,25 mucormycosis, 26,27 Aspergillus fumigatus, Fusarium species, [28][29][30][31] Scytalidium dimidiatum, 32 Pseudallescheria boydii, 33 and Curvularia species. 33 Patients with disseminated Fusarium infections who develop EG lesions often have high fever and severe muscle pain, an observation that has important clinical application.…”

Tiny keratotic brown lesions on the interdigital web between the toes of a healthy man caused by Curvularia species infection and a review of cutaneous Curvularia infections

“…Mahgoub (1973) described the first report of cutaneous Curvularia infection, caused by C. lunata. Thereafter, 25 reports of human skin infection cases in the English and Japanese literature were published (Mahgoub 1973;Rohwedder et al 1979;Barde and Singh 1983;Kiryu and Suenaga 1985;Duvic et al 1987;Gugnani et al 1990;Kamalam et al 1992;Grieshop et al 1993;Harris and Downham 1978;Lavoie et al 1993;Still et al 1993;Yvonne et al 1994;Agrawal and Singh 1995;Berg et al 1995;Torda and Jones 1997;Lopes and Jobim 1998;Fernandez et al 1999;Bonduel et al 2001;Tessari et al 2003;Tamaki et al 2006;Fan et al 2008;Garg et al 2008;Hiromoto et al 2008), including our patient (Table 2). Five species in the genus Curvularia were isolated from the skin lesions.…”

“…Those lesions were divided into two groups: the deep mycosis type and the superficial infected type. In the deep mycosis type, 16 cases were reported: abscess (mycetomas) (Mahgoub 1973), ulcer (Rohwedder et al 1979;Berg et al 1995, Torda andJones 1997;Hiromoto et al 2008), ecthyma gangrenosum-like lesion (Bonduel et al 2001), firm tender nodules and nodes (Tessari et al 2003;Garg et al 2008), papules (Kiryu and Suenaga 1985;Duvic et al 1987), macular lesion with central necrosis (Fernandez et al 1999), hemorrhagic bullous lesion (Lavoie et al 1993), and others [burn wound (Grieshop et al 1993;Still et al 1993), elevated hyperpigmented scaly lesion (Harris and Downham 1978), and surgical wound (Yvonne et al 1994)]. In the superficial infected type, 7 cases were reported: pigmented macules (Gugnani et al 1990;Agrawal and Singh 1995), scaling lesion (Lopes and Jobim 1998), and brown thick scales (present case) on the web between the toes and onychomycosis (Barde and Singh 1983;Kamalam et al 1992).…”

“…Twelve cases were patients with immunosuppressive conditions such as patients receiving immunosuppressive therapy systemically (Barde and Singh 1983;Berg et al 1995;Tessari et al 2003) or locally (Kiryu and Suenaga 1985), patients (Grieshop et al 1993;Still et al 1993) with severe burn, a neonate (Yvonne et al 1994), a premature baby (Fernandez et al 1999), an overdosage cocaine user (Lavoie et al 1993), a patient (Bonduel et al 2001) with anaplastic anemia undergoing bone marrow transplantation (BMT), a homosexual (Duvic et al 1987) with AIDS, and an immunocompetent man (Fan et al 2008). Three cases (Harris and Downham 1978;Rohwedder et al 1979;Tessari et al 2003) developed dissemination.…”

Thermotherapy in dermatologic infections

“…125 More rarely, these infections occur in immunocompetent patients. Amphotericin B and itraconazole, among other systemic antifungals, are often used in the treatment of these infections, while surgical excision may be sufficient for small, localized lesions.…”