Beyond Skin Tumors: A Systematic Review of Mohs Micrographic Surgery in the Treatment of Deep Cutaneous Fungal Infections.

BACKGROUND: Deep cutaneous fungal infections (DCFIs) can cause significant morbidity in immunocompromised patients and often fail medical and standard surgical treatments because of significant subclinical extension. Although rarely considered in this setting, Mohs micrographic surgery (MMS) offers the advantages of comprehensive margin control and tissue conservation, which may be beneficial in the treatment of DCFIs that have failed standard treatment options. OBJECTIVE: To review the benefits, limitations, and practicality of MMS in patients with DCFIs. METHODS: A systematic review of PubMed and EMBASE was conducted to identify all cases of fungal skin lesions treated with MMS. RESULTS: Eight case reports were identified consisting of a total of 8 patients. A majority of patients had a predisposing comorbidity (75%), with the most common being a solid organ transplant (n = 3, 37.5%). The most commonly diagnosed fungal infection was phaeohyphomycosis (n = 5, 62.5%), followed by mucormycosis (n = 2, 25%). No recurrence or complication post-MMS was noted at a mean follow-up of 11.66 months. CONCLUSION: Although not a first-line treatment, MMS can be considered as an effective treatment alternative for DCFIs in cases of treatment failure and can be particularly helpful in areas where tissue conservation is imperative.

[Subcutaneous infection by Curvularia pallescens in a lung transplant recipient: First report in Spain]. / Micosis cutánea por Curvularia pallescens en un paciente trasplantado pulmonar: primer caso descrito en España.

BACKGROUND: Curvularia is a filamentous dematiaceous fungus increasingly recognized as a pathogen in immunocompromised patients. The most common clinical entities associated with this fungus are allergic sinusitis, cutaneous infection and keratitis. In this article, a report on the first clinical case of Curvularia pallescens cutaneous infection in Spain and its treatment is described. CASE REPORT: A 68 year-old man with a history of lung transplantation presented to Dermatology Unit due to a skin lesion in the knee that had been evolving for 6 months. A skin biopsy was performed for its study. In the histopathological study, an intense and non-specific inflammatory reaction in the dermis was observed, and with Grocott stain and periodic acid Schiff abundant septate hyphae and spores were found in the dermis. The culture of the sample revealed a filamentous fungus whose microscopic examination allowed to identify the genus as Curvularia. Using MALDI-TOF mass spectrometry and molecular identification, the fungus was finally identified as Curvularia pallescens. The patient underwent surgical resection of the lesion and was treated with posaconazole, evolving favorably. CONCLUSIONS: The species of Curvularia should be considered causal agents of fungal skin infections in immunosuppressed patients. This clinical case, which showed good clinical response after surgical resection and treatment with posaconazole, is the first described in Spain due to this species.

Pseudomycetoma of the scalp caused by Microsporum canis

Abstract Pseudomycetoma is an extremely rare deep mycosis, caused by dermatophytic fungi that penetrate the tissue from infected follicles of tinea capitis. Both clinically and histopathology are similar to eumycetoma, being distinguished through the isolation of the fungus, which in the case of pseudomycetoma can be Microsporum spp. or Trichophyton spp. genre. We present a 24-year-old man with an exuberant tumor in the occipital region with fistula, whose histopathological examination evidenced grains composed of hyaline hyphae and the culture for fungi isolated the agent Microsporum canis. Combined treatment of surgical excision followed by oral griseofulvin for two years was performed, with resolution of the condition.

Pseudomycetoma of the scalp caused by Microsporum canis.

Pseudomycetoma is an extremely rare deep mycosis, caused by dermatophytic fungi that penetrate the tissue from infected follicles of tinea capitis. Both clinically and histopathology are similar to eumycetoma, being distinguished through the isolation of the fungus, which in the case of pseudomycetoma can be Microsporum spp. or Trichophyton spp. genre. We present a 24-year-old man with an exuberant tumor in the occipital region with fistula, whose histopathological examination evidenced grains composed of hyaline hyphae and the culture for fungi isolated the agent Microsporum canis. Combined treatment of surgical excision followed by oral griseofulvin for two years was performed, with resolution of the condition.

Invasive Curvularia Infection in Pediatric Patients With Hematologic Malignancy Identified by Fungal Sequencing.

Curvularia is a saprophytic dematiaceous mold and a rare human pathogen. Here, we report three severely immunocompromised pediatric patients who developed invasive Curvularia infection. Diagnosis was achieved or confirmed in all cases by fungal ribosome sequencing, which hastened species identification and targeted treatment for the patients reported. There are no treatment guidelines for invasive Curvularia infection, though we report three patients who were cured of their infection through a combination of surgical resection and various anti-fungal therapies, indicating a relatively low virulence and good prognosis in comparison to other angioinvasive molds.

A human subcutaneous infection by Microascus ennothomasiorum sp. nov.

A 60-year-old woman presented with a nodular granulomatous skin lesion on her right thumb. It had developed after inoculation of a splinter of wood. Because it was resistant to various therapies, the nodule was finally excised. Complete healing followed this surgery and a melanised filamentous fungus with scopulariopsis-like morphology was recovered from the dermal tissue. Fitting with no known species, the fungus was subjected to extensive morphological, physiological and genetic investigations. It was characterised by resistance to cycloheximide, growth at 37°C, branched conidiophores with cylindrical annellides in brush-like groups producing dark conidia in basipetal chains, and cleistothecia with ellipsoidal to slightly reniform ascospores. Genetically it clustered in a well-supported clade together with Microascus (M.) brunneosporus, Microascus chinensis, Microascus intricatus, Microascus longicollis, Microascus micronesiensis and Microascus onychoides, but formed an independent branch distant from the other Microascus species. Based on its unique genetic characteristics and morphological findings, the isolate is proposed as a new species, Microascus ennothomasiorum. Morphologically it differs from its phylogenetically closest species by its branched conidiophores and ascomata with a peridium of textura intricata. Our observation once again emphasises that dermal granulomas can be caused by uncommon fungi; diagnostics should therefore include appropriate mycological investigations.

Successful Treatment by Surgery of a Primary Cutaneous Mucormycosis Caused by Mucor irregularis.

We report a case of primary cutaneous mucormycosis caused by Mucor irregularis. A 66-year-old man was presented to our hospital with a history of gradually enlarging plaque on the right leg for about a year. The identification of pathogen based on the fungus morphology and DNA sequencing revealed M. irregularis as the responsible fungus for skin lesion. The lesion was removed incidentally by a surgery procedure, and no recrudescence was seen during a follow-up of 24-month observation.

[Contribution of histopathology in the diagnosis of mycetoma in a Cameroonian trader and possibility of an urban contamination]. / Mycétome : apport de l'histopathologie au diagnostic chez un commerçant camerounais, et possibilité d'une contamination urbaine.

BACKGROUND: Mycetoma are rare cutaneous affections caused by pathogens such as fungi or bacteria. They settle preferentially on limb extremities. We are going to talk about an original case of mycetoma in a young Cameroonian trader. OBSERVATION: A cutaneous mass with multiple draining sinuses was received at the anatomy and cytopathology laboratory. That mass was from a 30-year-old male trader, with no particular medical history and living in Yaounde, who was received for a lesion at the sole of the foot, which appeared some months before. This lesion started like a tough and painless nodule, which later showed draining sinuses to the skin. The surgical resection of the tissue mass was performed. The histopathological analysis with special staining procedures, which was later on performed, revealed mycetoma caused by fungi. DISCUSSION: This observation describes an original case of fungal mycetoma, which occured in a Cameroonian trader living in an urban milieu away from any mycetoma endemic zone. This case confirms the undeniable or undisputable contribution of histopathology in diagnosis of certainty. To our knowledge and according to available data, it is a premiere to find a case of mycetoma described in an urban milieu in Cameroon.

A Patient with Cystic Granuloma Trichophyticum who Required Surgical Resection.

A 62-year-old male with numerous subcutaneous nodules in the lower extremities was referred to The University of Tokyo Hospital. The patient suffered from systemic lupus erythematosus (SLE), diabetes mellitus, and persisting hepatic dysfunction, and had been treated for SLE with oral prednisolone 20 mg/day and oral cyclosporine 3 mg/kg/day. The culture of scales collected from the patient's skin surface on Sabouraud's dextrose agar medium showed features of Trichophyton rubrum. Topically applied bifonazole cream was effective for tinea corporis, but oral griseofulvin 500 mg/day was discontinued after 2-month administration because of deteriorated liver function. All the nodules were resected surgically. Histologically, resected granulomas showed dermal abscesses that were tightly encapsulated by fibrous capsules. Grocott staining revealed numerous fungal elements within abscesses. The patient's condition indicated the need to perform histopathological examination of granuloma trichophyticum in order to determine whether it is tightly encapsulated. Namely, the presence of cystic granuloma trichophyticum with abscesses encapsulated by fibrous capsules suggested that the patient should be treated by surgical resection of the lesions.

Primary cutaneous mucormycosis in an immunocompetent patient.

Mucormycosis is most common in immunocompromised patients, but it can also occur in healthy hosts, most frequently as primary cutaneous mucormycosis (PCM) and predominantly as a result of skin trauma. We present an uncommon case of PCM in a healthy, young man with no previous history of local trauma. Despite rapid progression of the infection, the patient was successfully treated through surgical intervention and by administering liposomal amphotericin B and posaconazole. He made a full recovery without the need for skin grafting.

Phaeohyphomycosis Due to Exophiala jeanselmei: An Emerging Pathogen in India--Case Report and Review.

We present a rare case of a 30-year-old woman who presented with a swelling on the lateral aspect of her left forearm, present since 6 months, adjacent to a 16-year-old burn scar. X-ray of elbow joint and forearm revealed the subcutaneous nature of the swelling. Giemsa and periodic acid-Schiff-stained smears and potassium hydroxide mount of fine-needle aspirate of the swelling revealed dematiaceous, branching, and septate fungal hyphae. Fungal culture of the aspirated pus showed growth of Exophiala jeanselmei. Histopathological examination revealed brown-coloured hyphae with foreign body giant cell reaction and palisading granulomas in the surrounding tissue. The patient was successfully treated with surgical excision of the swelling. All the cases of phaeohyphomycosis due to Exophiala spp. in India are also reviewed.

Fungal necrotizing fasciitis, an emerging infectious disease caused by Apophysomyces (Mucorales).

BACKGROUND: The mucoralean fungi are emerging causative agents of primary cutaneous infections presenting in the form of necrotizing fasciitis. AIMS: The aim of this study was to investigate a series of suspected necrotizing fasciitis cases by Apophysomyces species over one-year period in a northern Indian hospital. METHODS: The clinical details of those patients suspected to suffer from fungal necrotizing fasciitis were recorded. Skin biopsies from local wounds were microscopically examined and fungal culturing was carried out on standard media. The histopathology was evaluated using conventional methods and special stains. Apophysomyces isolates were identified by their morphology and by molecular sequencing of the internal transcribed spacer (ITS) region of the ribosomal genes. Antifungal susceptibility testing was carried out following EUCAST guidelines and treatment progress was monitored. RESULTS: Seven patients were found to be suffering from necrotizing fasciitis caused by Apophysomyces spp. Six isolates were identified as Apophysomyces variabilis and one as Apophysomyces elegans. Five patients had previously received intramuscular injections in the affected area. Three patients recovered, two died and the other two left treatment against medical advice and are presumed to have died due to their terminal illnesses. Posaconazole and terbinafine were found to be the most active compounds against A. variabilis, while the isolate of A. elegans was resistant to all antifungals tested. CONCLUSIONS: Apophysomyces is confirmed as an aggressive fungus able to cause fatal infections. All clinicians, microbiologists and pathologists need to be aware of these emerging mycoses as well as of the risks involved in medical practices, which may provoke serious fungal infections such as those produced by Apophysomyces.

[Post-traumatic mucormycosis due to Lichtheimia corymbifera: three case reports]. / Mucormycoses post-traumatiques à Lichtheimia corymbifera: à propos de 3 cas.

We report 3 cases of post-traumatic cutaneous mucormycosis caused by Lichtheimia corymbifera, two of them occurring after a farm working accident. Management of post-traumatic mucormycoses consists of a wide excision of the infected tissue, combined with immediate antifungal therapy. Liposomal amphotericin B is the recommended first line treatment. Few studies have evaluated the efficacy of posaconazole. All 3 patients received a surgical debridement and liposomal amphotericin B, which was followed by posaconazole in 2 cases. The duration of the antifungal treatment is not yet well defined. All three patients received a treatment of five weeks with a favorable outcome.

[Cutaneous infection due to Fusarium oxysporum in a female diabetic: molecular biological detection of the mold from formalin-fixed paraffin embedded tissue using sequencing of the ITS region of the rDNA]. / Kutane Infektion durch Fusarium oxysporum bei einer Diabetikerin: Molekularbiologischer Schimmelpilznachweis aus Formalin-fixiertem, Paraffin-eingebettetem Gewebe mittels Sequenzierung der ITS-Region der rDNA.

BACKGROUND: Skin lesions due to Fusarium spp. occur either secondarily following hematological spread in systemic infection or represent primary cutaneous infections following traumatic inoculation. CASE REPORT: A 34-year-old woman with insulin-dependent diabetes mellitus presented with a most likely posttraumatic leg ulcer present for 4 weeks. The ulcer showed superficial necrosis with cellular debris, neutrophils, and leukocytoclasia. Septate hyphae were detected both in the necrotic area and between the collagen fibers on initial H & E stained sections. Using PAS and Grocott-Gomori silver staining, the dichotomous branching hyphae were clearly visible. Unfortunately, cultural detection of the fungi was impossible. After extraction and purification of the fungal DNA from formalin-fixed and paraffin embedded (FFPE) tissue sections, the amplification of the ITS region of rDNA was done. Using sequencing and comparison with reference sequences of a gene bank, Fusarium oxysporum was identified. THERAPY: Therapy was performed by surgical excision of the entire ulcer followed by topical antiseptic treatment and wound conditioning. No systemic antifungal treatment was given. The lesion healed without any problems. DISCUSSION: Cutaneous fusarium infections are rare but emerging opportunistic infections. Histological examination represents the quickest diagnostic method for detection of the fungal infection. An alternative approach represents the species identification based on molecular techniques.