A new pleosporalean fungus isolated from superficial to deep human clinical specimens.

Human infections by pleosporalean fungi (class Dothideomycetes, phylum Ascomycota) are rarely reported. Because their identification is challenging using morphological characterization, several phylogenetic markers must be sequenced for an accurate identification and taxonomical placement of the isolates. Three isolates of clinical origin were phenotypically characterized, but due to the absence of relevant morphological traits, D1-D2 domains of the 28S nrRNA gene (LSU), the internal transcribed spacer region (ITS) of the nrRNA, and fragments of the RNA polymerase II subunit 2 (rpb2) and translation elongation factor 1-alpha (tef1) genes were sequenced to allow a phylogenetic analysis that would solve their phylogenetic placement. That analysis revealed that these isolates did not match any previously known pleosporalean genera, and they are proposed here as the new fungal genus, Gambiomyces. Unfortunately, the isolates remained sterile, which, consequently, made the morphological description of the reproductive structures impossible. Future studies should try to understand the behaviour of this fungus in nature as well as its characteristics as an opportunistic fungal pathogen. Molecular identification is becoming an essential tool for proper identification of Dothideomycetes of clinical origin. LAY ABSTRACT: We describe a new pleosporalen pathogenic fungus, Gambiomyces profunda, found in superficial to deep samples from a human patient. Because all strains remained sterile, the fungus was finally identified following a phylogenetic analysis by using four different molecular markers.

Subcutaneous phaeohyphomycosis caused by a black pigmented mould (Rhytidhysteron species) in rural north-western New South Wales, Australia.

Invasive fungal infections are becoming increasingly more prevalent in clinical practice. This corresponds with more patients living with immunosuppression and improved techniques to identify fungal infections. Subcutaneous fungal masses can often masquerade and imitate common dermatological lesions such as cysts. Querying a fungal aetiology of a mass is important, as fungal elements can be missed on histological examination, and special stains may be needed to identify spores and hyphae to make the diagnosis. Skin trauma with inoculation of fungal elements contained in soil and vegetable matter is the most common source of subcutaneous fungal masses. While traditionally considered a disease of the tropics, subcutaneous fungal masses can present worldwide in both immunosuppressed and immunocompetent patients. This case study describes a subcutaneous knee mass in a 53-year-old immunosuppressed farmer in Australia. A subcutaneous phaeohyphomycosis was diagnosed with a black pigmented mould, Rhytidhysteron species. A latent period of 12 years was observed between traumatic inoculation with farm soil and wheat dust in north-western New South Wales and development of the knee mass. Rhytidhysteron is considered a disease of the tropics, most commonly reported in India. This case, to the author's knowledge, is the first case report of pathogenic Rhytidhysteron from Australia. Surgery and antifungal therapy are recommended to treat Rhytidhysteron infection. This patient's recommended antifungal treatment was shortened due to severe hepatic disease. The clinical course was complicated by three localised recurrences in the patient's knee over 14 months. At the time of the third localised recurrence, this patient could tolerate posaconazole therapy for a month only. Surgical excision using general anaesthesia, use of diathermy for excision and wound lavage with iodine, hydrogen peroxide and saline has coincided in remission of clinical disease for 3 years at the time of writing.

Efficacy of miltefosine therapy against subcutaneous experimental pythiosis in rabbits.

We evaluated the in vitro activity of miltefosine against 29 Pythium spp. and the in vivo therapeutic response of 2mg/kg/day of miltefosine given orally to rabbit with pythiosis induced experimentally. The MICs (in µg/mL) of miltefosine was medium-dependent and ranged from 0.5 to 2 and 32-64 on RPMI 1640 and Mueller Hinton broth, respectively. The treatment with miltefosine demonstrated significantly lower subcutaneous lesion areas compared to the control group but was not sufficient for the complete remission of the lesions. This study indicates that miltefosine has limited efficacy against pythiosis and furthers in vitro and in vivo studies are necessary to determine the possible potential of this drug in the treatment of pythiosis.

Mycobacterium abscessus subsp. abscessus empyema complicated with subcutaneous abscess.

There have been no case reports of thoracic subcutaneous abscess after surgery for Mycobacterium abscessus complex associated empyema. We herein report a case of Mycobacterium abscessus subsp. abscessus (M. abscessus subsp. abscessus) induced subcutaneous abscesses following surgical treatment for concurrent M. abscessus subsp. abscessus -associated empyema and pneumothorax. A 75-year-old woman had M. abscessus subsp. abscessus -associated empyema and pneumothorax. She underwent surgical treatment of decortication and fistulectomy and suffered from M. abscessus subsp. abscessus -associated subcutaneous abscesses after thoracentesis/drainage. A multidisciplinary approach combined with surgical care, thermal therapy, and multidrug chemotherapy contributed to a successful result. An early multidisciplinary approach is believed to be important in cases of M. abscessus subsp. abscessus -associated empyema and subcutaneous abscess.

Rare indolent zygomycosis caused by subcutaneous Saksenaea vasiformis infection.

We report an immunocompetent male child with chronic, indolent subcutaneous limb infection akin to basidiobolomycosis, but was shown by PCR method to be caused by a mucoralean fungus Saksenaea vasiformis. Treatment with oral potassium iodide solution was effective. This finding highlights the consideration of treatment decision according to the phenotypic severity as opposed to species identified.

Successful treatment with isavuconazole of subcutaneous phaeohyphomycosis in a kidney transplant recipient.

Phaeohyphomycosis is a diverse group of uncommon mycotic infections caused by dematiaceous fungi which appears to be increasing in incidence, particularly in transplant recipients. Alternaria is the most frequent isolated genus. Subcutaneous, pulmonary and disseminated disease are the most common sites of Alternaria infection in solid organ transplant recipients. We report the first case, to our knowledge, of a kidney transplant recipient with Alternaria alternata subcutaneous infection who was successfully treated with isavuconazole.

Munchausen syndrome mimicking refractory subcutaneous abscess with bacteremia, diagnosed by repetitive element sequence-based polymerase chain reaction: a case report.

BACKGROUND: Rapid diagnosis and appropriate treatment of Munchausen syndrome is important not only for the patient but also for health care workers because a delay in diagnosis can worsen patients' clinical outcomes, and result in a substantial medical cost. CASE PRESENTATION: A young and previously healthy 24-year-old Japanese woman, a nurse, presented with complaints of refractory abscess on her left upper limb for 3 months. A physical examination on admission revealed low-grade fever and a subcutaneous abscess in her left forearm. Laboratory data suggested mild systemic inflammation and liver dysfunction, but no abnormalities of the immune system, including changes in the number of lymphocytes and neutrophils, neutrophil phagocytic capacity, and natural killer (NK) cell activity, were observed. A human immunodeficiency virus test was also negative. Multiple modalities, including positron emission tomography-computed tomography, failed to detect any cause and focus of infection except her left upper limb. Streptococcus mitis and Prevotella buccae were detected from the wound, but no microorganisms were detected in a blood culture. The cellulitis promptly resolved; however, exacerbation of the subcutaneous abscess with polymicrobial bacteremia repeatedly occurred unexpectedly. Because of this puzzling clinical course, the possibility of self-injury was finally suspected. Three syringes with needles, with a turbid liquid, were found in our patient's bag. Enterobacter cloacae and Enterococcus faecalis were detected in the liquid, and an analysis via repetitive element sequence-based polymerase chain reaction determined that Enterococcus faecalis in the wound and syringe contents were genetically identical. She was diagnosed as having Munchausen syndrome and treated with the collaboration of a psychiatrist. She finally confessed that she had injected her own saliva and toilet water into the drip line and wound. CONCLUSIONS: This case report is valuable in that it is the first case in which this syndrome was diagnosed by a genetic method. Munchausen syndrome should not be neglected as a possible cause of refractory and recurrent infection.

Disseminated nocardiosis with cerebral and subcutaneous lesions on low-dose prednisone.

This case report is of a septuagenarian man on chronic low-dose prednisone who presented with disseminated nocardiosis (Nocardia cyriacigeorgica) that was initially mistaken for metastatic brain cancer. Neurologists should be aware of the potential for opportunistic infections with steroid use and to consider a definite tissue diagnosis with culture and histopathology prior to treatment.

PCR detection of Mycobacterium ulcerans-significance for clinical practice and epidemiology.

Introduction: Buruli ulcer (BU) is a neglected disease which has been reported from mostly impoverished, remote rural areas from 35 countries worldwide. BU affects skin, subcutaneous tissue, and bones, and may cause massive tissue destruction and life-long disabilities if not diagnosed and treated early. Without laboratory confirmation diagnostic and treatment errors may occur. This review describes the application of IS2404 PCR, the preferred diagnostic test, in the area of individual patient management and clinico-epidemiological studies. Areas covered: A Medline search included publications on clinical sample collection, DNA extraction, and PCR detection formats of the past and present, potential and limitations of clinical application, as well as clinico-epidemiological studies. Expert commentary: A global network of reference laboratories basically provides the possibility for PCR confirmation of 70% of all BU cases worldwide as requested by the WHO. Keeping laboratory confirmation on a constant level requires continuous outreach activities. Among the potential measures to maintain sustainability of laboratory confirmation and outreach activities are decentralized or mobile diagnostics available at point of care, such as IS2404-based LAMP, which complement the standard IS2404-based diagnostic tools available at central level.

Tissue reaction to Aroeira (Myracrodruon urundeuva) extracts associated with microorganisms: an in vivo study.

Based on aroeira's (Myracrodruon urundeuva) antimicrobial activity and a future trend to compose intracanal medication, the aim of this study was to assess in vivo inflamatory tissue response to the extracts by edemogenic and histological analysis containing inactivated facultative and anaerobic microorganisms. For edema quantification, eighteen animals were divided into three groups (n = 3, periods: 3 and 6 hours) and 0.2 mL of 1% Evans blue per 100 g of body weight was injected into the penile vein under general anesthesia. After 30 min the animals received a subcutaneous injection in the dorsal region of aqueous or ethanolic extract of aroeira or saline (control) containing inactivated bacteria. Samples were collected, immersed in formamide for 72h, and evaluated by spectrophotometry (630 m). For histological analysis, polyethylene tubes with the extracts were implanted in the dorsal of 30 male rats. Analysis of the fibrous capsule and inflammatory infiltrate were performed after 7 and 30 days. The aqueous extract group induced less edema in both postoperative periods compared to the other groups, but the differences were not significant (p > 0.05). Tissue repair was significantly better after 30 days than after 7 days (p < 0.01). The aqueous solution showed less inflammatory response than the ethanolic solution (p < 0.05), with tendency for better results than control after 7 days. After 30 days, the response to both extracts was similar to control. The aqueous and ethanolic aroeira extracts containing inactivated microorganisms showed a trend for better results than saline, even when associated with microorganisms, and facilitated the tissue repair process.

A new microsporidium Percutemincola moriokae gen. nov., sp. nov. from Oscheius tipulae: A novel model of microsporidia-nematode associations.

Here, we describe a new microsporidium Percutemincola moriokae gen. nov., sp. nov., which was discovered in the intestinal and hypodermal cells of a wild strain of the nematode Oscheius tipulae that inhabits in the soil of Morioka, Iwate Prefecture, Japan. The spores of Pe. moriokae had an average size of 1.0 × 3.8 µm and 1.3 × 3.2 µm in the intestine and hypodermis, respectively, and electron microscopy revealed that they exhibited distinguishing features with morphological diversity in the hypodermis. Isolated spores were able to infect a reference strain of O. tipulae (CEW1) through horizontal transmission but not the nematode Caenorhabditis elegans. Upon infection, the spores were first observed in the hypodermis and then in the intestine the following day, suggesting a unique infectious route among nematode-infective microsporidia. Molecular phylogenetic analysis grouped this new species with the recently identified nematode-infective parasites Enteropsectra and Pancytospora forming a monophyletic sister clade to Orthosomella in clade IV, which also includes human pathogens such as Enterocytozoon and Vittaforma. We believe that this newly discovered species and its host could have application as a new model in microsporidia-nematode association studies.

Masa indolora en muslo de crecimiento lento / Slow growing painless mass in the lower limb

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Tissue reaction to Aroeira (Myracrodruon urundeuva) extracts associated with microorganisms: an in vivo study

Abstract: Based on aroeira's (Myracrodruon urundeuva) antimicrobial activity and a future trend to compose intracanal medication, the aim of this study was to assess in vivo inflamatory tissue response to the extracts by edemogenic and histological analysis containing inactivated facultative and anaerobic microorganisms. For edema quantification, eighteen animals were divided into three groups (n = 3, periods: 3 and 6 hours) and 0.2 mL of 1% Evans blue per 100 g of body weight was injected into the penile vein under general anesthesia. After 30 min the animals received a subcutaneous injection in the dorsal region of aqueous or ethanolic extract of aroeira or saline (control) containing inactivated bacteria. Samples were collected, immersed in formamide for 72h, and evaluated by spectrophotometry (630 m). For histological analysis, polyethylene tubes with the extracts were implanted in the dorsal of 30 male rats. Analysis of the fibrous capsule and inflammatory infiltrate were performed after 7 and 30 days. The aqueous extract group induced less edema in both postoperative periods compared to the other groups, but the differences were not significant (p > 0.05). Tissue repair was significantly better after 30 days than after 7 days (p < 0.01). The aqueous solution showed less inflammatory response than the ethanolic solution (p < 0.05), with tendency for better results than control after 7 days. After 30 days, the response to both extracts was similar to control. The aqueous and ethanolic aroeira extracts containing inactivated microorganisms showed a trend for better results than saline, even when associated with microorganisms, and facilitated the tissue repair process.

Cutaneous manifestations of subcutaneous and systemic fungal infections in tropical regions: a retrospective study from a referral center in southern Taiwan.

BACKGROUND: Deep cutaneous fungal infections, including subcutaneous mycoses and systemic fungal infection with cutaneous involvement, cause significant morbidity and mortality in light of increasing immunocompromised patients and global warming. Although a few studies reviewed deep fungal infections in temperate regions, a relevant study in tropical regions is lacking. We evaluated features of deep cutaneous fungal infections in southern Taiwan among the tropical regions. METHODS: We retrospectively reviewed all histopathological specimens with deep cutaneous fungal infections in a single referral center from 2001 to 2014 and successfully identified 23 cases. Medical chart review revealed patient demographic data, clinical presentation, underlying disease, microbiological culture reports, and treatment outcomes. RESULTS: The average patient age was 52 years. Fourteen cases had primary subcutaneous mycoses, and nine had systemic mycoses. Fifteen patients were immunocompromised, including hematological malignancies. Acquired immune deficiency syndrome (AIDS) and long-term steroid use were most commonly associated with deep fungal infections. The positive culture growth rate was 63%. Fonsecaea sp. was most frequently identified by tissue culture. Aspergillosis, mucormycosis, and disseminated cryptococcosis were particularly fatal. CONCLUSIONS: Diabetes and long-term steroid use appear as major risk factors for advanced mycoses in this region. Rapid diagnosis with skin biopsy and tissue culture along with appropriate treatment of deep cutaneous fungal infection are necessary.

Diagnosis and treatment of diffusible Penicillium marneffei in human immunodeficiency virus-negative patients: A challenge for the physician.

Penicillium marneffei infection in human immunodeficiency virus (HIV)-negative patients is addressed far less often. In this article, a small cohort of HIV-negative patients who disseminated P. marneffei infection was included. Sites of infection were found from blood culture, as subcutaneous nodules, or from lymph node biopsy. Fever, rash, swollen lymph nodes, anaemia and weight loss were common characteristics in most infected patients. The signs and symptoms are diverse and create challenges for accurate diagnosis. This paper will assist our understanding of this disease and contribute to an appropriate regime of therapy, thus improving the health of P. marneffei-positive patients.