Phaeohyphomycosis from Exophiala jeanselmei with Concomitant Nocardia asteroides Infection in a Renal Transplant Recipient: Case Report and Review of the Literature

Abstract

A 59-year-old black man who received a cadaveric renal transplant 15 months earlier developed subcutaneous nodules on his right upper extremity that were identified as phaeohyphomycosis caused by Exophiala jeanselmei. The man was admitted 4 weeks later with a swollen left arm and had Nocardia asteroides in this area and in the apex of his left lung. He was treated with surgical excision, and itraconazole, imipenem-cilastatin, and trimethoprim-sulfamethoxazole. With the potential presence of more than one microorganism in an immunocompromised patient, it is important to identify and differentiate them correctly to direct appropriate therapy.

Relapsing Exophiala jeanselmei phaeohyphomycosis in a lung-transplant patient

“…The treatment of solid organ transplant patients with E. jeanselmei pheomycotic cyst/subcutaneous phaeohyphomycosis has been incision and drainage, and surgical excision with (2, 3, 8–10) or without antifungal therapy (11). Antifungal agents used include amphotericin B, itraconazole, ketoconazole or 5‐fluorocytosine (2, 3, 8–10). However, there have been no previous reports regarding the use of fluconazole for the treatment of an E. jeanselmei pheomycotic cyst / subcutaneous phaeohyphomycosis.…”

“…The duration of therapy for solid organ transplant patients with an E. jeanselmei pheomycotic cyst / subcutaneous phaeohyphomycosis has ranged from 6 weeks to 2 years (2, 3, 8–10). Four post‐kidney‐transplant patients and two post‐heart‐transplant patients (2, 3, 8–11) with pheomycotic cysts/subcutaneous phaeohyphomycosis due to E. jeanselmei did well upon the completion of therapy (Table 1). There was no attributable mortality due to localized E. jeanselmei subcutaneous phaeohyphomycosis reported in these solid organ transplant recipients.…”

“…The genus Exophiala are widely distributed in the environment (2) and may cause infections in both immunocompromised and immunocompetent individuals (3). To date, pheomycotic cysts/subcutaneous phaeohyphomycosis in transplant recipients have only been reported in patients receiving renal and cardiac transplantations.…”

Case Study: Posaconazole Treatment of Disseminated Phaeohyphomycosis Due toExophiala spinifera

“…Its morphological and culture characteristics are very similar to those of Exophiala jeanselmei. In recent years, several new cases of phaeohyphomycosis caused by E. jeanselmei and E. spinifera have been reported, both in humans and cats, and have exhibited a variety of clinical patterns, including subcutaneous pseudocystic lesions, peritonitis, and systemic infections [1,[6][7][8][9][10][11][12][13][14][15]. A report of 5 serious cases caused by dematiaceous fungi noted not only that infection due to this group of organisms is increasing, but also that species such as E. jeanselmei are exhibiting unusual manifestations [16].…”

Onychomycosis due to <i>Exophiala jeanselmei</i>

“…E. jeanselmei produces two different tissue forms: grains are present in eumycetoma and hyphae are observed in internal organs [5, 6]. Most reports on E. jeanselmei showed cutaneous or subcutaneous lesions in immunocompromised hosts [3, 5, 6, 7, 8, 9, 10]. E. jeanselmei was rarely isolated in other organs, such as the lung, eye or esophagus [11, 12].…”