Successful treatment of antifungal- and cryotherapy-resistant subcutaneous hyalohyphomycosis in an immunocompetent case with topical 5% imiquimod cream

Abstract

Hyalohyphomycosis is an unusual opportunistic mycotic infection where the tissue morphology of the causative organism is mycelial. Etiological agents, which are not responsible for the otherwise-named infections like aspergillosis, are the species of non-dematiaceous hyaline hyphomycetes including Penicillium, Paecilomyces, Acremonium (formerly known Cephalosporium), Beauveria, Fusarium, and Scopulariopsis. Several cases of Acremonium infection have been described in immunocompromised patients; however it can cause invasive disease in an immunocompetent person very rarely. Optimum therapy of Acremonium infection is unclear because of the limited number of reported cases and conflicting results of therapies. Imiquimod, an imidazoquinoline with potent antiviral, antitumor and immunoregulatory properties, is currently approved for the topical treatment of external anogenital warts and actinic keratosis. Imiquimod has also been found to be effective for other virus-associated dermatologic lesions, including common and flat warts, molluscum contagiosum, and herpes simplex virus type-2 as well as for some cases of cutaneous leishmaniasis. We report herein, for the first time, a case of unusually recalcitrant hyalohyphomycosis of the face due to Acremonium strictum successfully treated with topical 5% imiquimod in an immunocompetent patient, who had failed to respond to various antifungals, including itraconazole, and cryotherapy.

Topical Application of Imiquimod as a Treatment for Chromoblastomycosis

“…Topical application of imiquimod overcomes this defect, enhancing inflammatory responses that lead to clearance of the pathogen and resolution of the infection. Such defects could also underlie susceptibility to other subcutaneous mycoses like eumycetoma, sporotrycosis, hyalohyphomycosis, and as such these mycoses may also benefit from administration of topical imiquimod [12]. …”

Imidazoquinoline Acts as Immune Adjuvant for Functional Alteration of Thymic Stromal Lymphopoietin-Mediated Allergic T Cell Response

“…Notably, on the basis of our results, R848 appears to exhibit its function not only in the priming phase of DCs by TSLP but also in the later phase of priming T cells by TSLP-DCs. In addition to these specialized roles of R848 for DCs in allergic responses, there may be a great advantage; that is, because imidazoquinoline has already been used to topically treat viral-mediated skin diseases by cream formulation (62)(63)(64)(65), this imidazoquinoline drug could be used without systemic side effects when R848 is clinically applied for the treatment of atopic dermatitis.…”

Thermotherapy in dermatologic infections

“…Hyalohyphomycosis is an opportunistic mycotic infection with nondematiaceous fungi, such as Fusarium, Penicillium, and Paecilomyces. 130 Thermotherapy. Superficial Fusarium infection on the middle finger was found to respond to thermotherapy, 131 with a later report detailing the use of thermotherapy in the form of chemical pocket warmers applied 30 minutes daily in order to successfully treat a deep cutaneous Fusarium infection.…”

“…Of note, there is a report of subcutaneous hyalohyphomycosis resistant to cryotherapy. 130 PARASITES Key points d A radiofrequency heating device is approved for thermotherapy of leishmaniasis d Cryosurgery, in combination with local standard of care antimonial therapy, works better for cutaneous leishmaniasis than does either modality used as monotherapy Cutaneous larva migrans Creeping eruptions, initially described by Lee in 1874, are characterized by pruritic mobile lesions corresponding to nematode larvae burrowing under the skin. 66 Cutaneous larva migrans is commonly caused by the animal hookworms Ancylostoma caninum and A braziliense.…”