Severe disseminated phaeohyphomycosis in an immunocompetent patient caused by Veronaea botryosa.

We present a severe case of disseminated phaeohyphomycosis due to Veronaea botryosa. A 32-year-old female, native from Cuautla, Morelos, Mexico, presented a chronic dermatosis which started 10 years earlier with multiple exophytic, multilobulated, soft, and pedunculated or sessile neoformations of diverse sizes from 2 to 10 cm in diameter, which became verrucose and increased in size. The patient was immunocompetent, and no hereditary or familiar precedents of importance were known. No treatment was given, and the dermatosis remained relatively stable until the patient became pregnant in 2001 and 2003. The infection then exacerbated and worsened, leading to dissemination to the extremities, trunk, and face. The initial diagnosis was chromoblastomycosis which was treated with terbinafine and itraconazole but without visible improvement. Histopathology revealed pigmented, irregular, unbranched, and septate hyphae. Veronaea botryosa was isolated (CBS 127264 = JX566723), and its identity was confirmed by sequencing the internal transcribed spacer (ITS) rDNA. Therapy with posaconazole (800 mg/day) was started showing a gradual improvement of lesions with a reduction in size and flattening of the eruptions.

Opportunistic yeast infections: candidiasis, cryptococcosis, trichosporonosis and geotrichosis.

Opportunistic yeast infections are diseases caused by fungi which normally are saprophytic and do not cause disease in humans or animals. The prevalence of these diseases has been increasing due to immunosuppressive, corticosteroid, and long-term antibiotic treatment following organ transplantation or after serious metabolic, hematological, or immunological diseases. We review epidemiological, clinical, diagnostic, and therapeutic aspects of the four "big" opportunistic yeast infections: candidiasis, cryptococcosis, trichosporonosis, and geotrichosis.

Th-17 and the lack of efficacy of ustekinumab in pemphigus vulgaris.

Systemic corticosteroids represent an effective treatment for pemphigus vulgaris (PV). However, this treatment is related to many adverse side effects. Herein, we report a case of PV treated with ustekinumab.

Opportunistic filamentous mycoses: aspergillosis, mucormycosis, phaeohyphomycosis and hyalohyphomycosis.

Opportunistic filamentous mycoses are widely distributed all over the world. They are rarely observed in Europe but are common in developing countries. The most common are the aspergilloses (due to Aspergillus spp.) mostly in neutropenia and immunosuppression; the mucormycoses characterized by rapid progression in patients with diabetic ketoacidosis; the phaeohyphomycoses due to pigmented fungi causing either a mild superficial or a very serious deep disease and the hyalohyphomycoses due to hyaline filamentous fungi (Fusarium spp., Pseudallescheria spp., Scopulariopsis spp.). Cutaneous manifestations are usually secondary to dissemination from pulmonary or visceral disease; primary cases are less frequent and due to direct inoculation into the skin. We review epidemiological, clinical, diagnostic, and therapeutic data on the four most important opportunistic filamentous mycoses: aspergillosis, mucormycosis, phaeohyphomycosis and hyalohyphomycosis.

Acetylcholine receptor antibodies in patients with pemphigus vulgaris: correlation with disease extent at the time of diagnosis and during follow-up.

Several studies have tried to determine the relationship between autoantibodies against the acetylcholine receptor and the development of pemphigus vulgaris. In this study, we observed that antibody levels against the acetylcholine receptor are mildly elevated in pemphigus vulgaris (PV), and significantly correlate with disease severity on the initial diagnosis and during follow up. However, it is not clear if these antibodies are just an epiphenomenon or a potential trigger of the known pathogenic process in PV.

Actinomycetoma by Actinomadura madurae. Clinical and therapeutic characteristics of 18 cases with two treatment modalities.

BACKGROUND: Actinomycetoma due to Actinomadura madurae is susceptible to numerous chemotherapeutic agents, however, the response to those treatments is variable and closely related to several factors. OBJECTIVE: We aimed to evaluate the clinical-therapeutic characteristics of patients with actinomycetoma due to Actinomadura madurae with two treatment modalities. METHODS: This was a retrospective study of eighteen patients with a diagnosis of actinomycetoma. The most widely used therapeutic scheme was streptomycin 1 g every third day plus TMP/SMX 800 mg/160 mg/12h, followed by TMP/SMX with DDS 100 mg/day. In six patients (33%), ciprofloxacin 500 mg every 12 h was used instead of DDS. RESULTS: Conventional scheme achieved clinical and mycological cure in 58% of the cases, improvement in 16%, and 25% of the patients failed to treatment; in the cases treated with ciprofloxacin, clinical and microbiological cure was achieved in 83% of patients and clinical improvement in 16%. The treatment time to achieve clinical and mycological did not have a statistically significant difference (median 10 ± 1.38 vs. 12 ± 4.6). CONCLUSION: Treatment based on streptomycin + TMP/SMX with ciprofloxacin was found to be effective in treating patients with actinomycetoma, and comparable to the conventional treatment with DDS in actinomycetoma due to A. madurae with minimal bone involvement.

Encapsulated eumycetoma caused by Biatriospora mackinnonii.

Eumycetoma is a chronic infection due to filamentous fungi. Herein, we report a case of eumycetoma presenting as a subcutaneous encapsulated lesion on the right leg with no previous traumatic implantation. From microscopic morphological characteristics and molecular analysis, the pathogenic fungal species were identified as Biatriospora mackinnonii. Surgical excision of the entire lesion was performed to reduce the fungal load and improve antifungal therapy response.

Tinea imbricata in the Americas.

PURPOSE OF REVIEW: The aim is to provide an overview on tinea imbricata, or Tokelau, a superficial mycosis caused by Trichophyton concentricum, a strictly anthropophilic dermatophyte with a well-defined geographic distribution and predisposing factors that include genetic, racial and immunologic susceptibility patterns and a specific environment. RECENT FINDINGS: This review covers the most interesting aspects of the infrequent disease tinea imbricata, including the historical background, the epidemiologic aspects, highlighting the genetic and racial patterns of susceptibility to the acquisition of the disease, and the immunologic aspects that help to explain its clinical behavior. We also present a clinical description of the disease, the differential diagnosis and how currently some other emerging diseases such as syphilis in immunocompromised patients can mimic tinea imbricata. The therapeutic options are still griseofulvin and nowadays terbinafine, but the access to the treatments in the endemic zones and the changes in habits of the affected population make control and prevention of the disease difficult. SUMMARY: Tinea imbricata, or Tokelau, remains an infrequent superficial mycosis restricted to endemic zones in the South Pacific islands (Polynesia and Melanesia), South Asia and some specific areas of South America. Migration phenomena and global changes in the climate may modify the incidence and characteristics of the disease.

Endemic systemic mycoses: coccidioidomycosis, histoplasmosis, paracoccidioidomycosis and blastomycosis.

Endemic deep or systemic mycoses are common in specific geographical areas of the world. Coccidioidomycosis is present in semi-desert areas, histoplasmosis and paracoccidioidomycosis in tropical regions and blastomycosis belongs to temperate climates. The two former are widely distributed in the American continent and some tropical regions of the world; the third is limited to Central and South America, and the last to North America and Central and East Africa. These mycoses all have a similar pathogenesis, as the inoculum enters the host through the respiratory tract. Cutaneous manifestations are secondary to lymphatic and hematogenous dissemination. These deep mycoses are exceptional in Europe. Most cases are observed in returning travelers from endemic areas, aid workers, archaeologists, speleologist and immigrants. However, there have been some autochthonous cases of histoplasmosis due to Histoplasma capsulatum var. capsulatum reported in European countries such as Italy and Germany. In this article, we provide up-to-date epidemiological, clinical, diagnostic and therapeutic data on the four most important imported systemic mycoses in Europe.

Actinomycetoma by Actinomadura madurae: Clinical Characteristics and Treatment of 47 Cases.

CONTEXT: Mycetoma is a chronic, granulomatous disease caused by fungi (eumycetoma) or aerobic filamentous actinomycetes (actinomycetoma). Actinomadura madurae is one of the most frequent actinomycetes. AIM: The study aims to provide an update on clinical, diagnostic, therapeutic, and outcome data for patients with actinomycetoma in a single center in Mexico. SETTINGS AND DESIGN: This was a retrospective study of 47 cases diagnosed with actinomycetoma. SUBJECTS AND METHODS: The cases were selected from a total of 536 mycetoma obtained during 35 years (from 1985 to 2019). Clinical data were retrieved from the clinical records of our department. Microbiological data were obtained from our Mycology laboratory. STATISTICAL ANALYSIS: Frequencies and percentages were used for categorical variables. Normality was determined with the Kolmogorov-Smirnov test. We used means and medians to describe the variables. RESULTS: Forty-seven patients with actinomycetoma were included; female:male ratio 1.9:1; median age 38 years. The foot was the most affected region in 76.5% of cases. The bone invasion was observed in 89%. The time between symptoms onset and diagnosis was 5.5 years. Grain detection by direct examination was positive in 95% of cases. The most commonly used, as well as the most effective treatment scheme was streptomycin + sulfamethoxazole-trimethoprim with dapsone. Sixty-three percent (30 patients) achieved clinical and mycological cure, and 10.6% (5 patients) had treatment failure. CONCLUSIONS: We highlight the importance of designing therapeutic strategies to standardize treatments and gain more experience to improve the care of these patients.

Subcutaneous mycoses: chromoblastomycosis, sporotrichosis and mycetoma.

Subcutaneous mycoses are common in subtropical and tropical regions of the world. They are rarely observed in Europe. These mycoses are heterogeneous, but all are caused by penetrating trauma of the skin. Most cases in Europe are observed in returning travelers, aid workers, archaeologists and immigrants. Therefore, a careful, thorough history is essential in order to reach a proper diagnosis. We provide up-to-date epidemiological, clinical, diagnostic, and therapeutic data on the three most important imported subcutaneous mycoses in Europe: chromoblastomycosis, sporotrichosis and mycetoma.

Cutaneous blastomycosis. An imported case with good response to itraconazole.

BACKGROUND: Blastomycosis is a subacute or chronic deep mycosis caused by a dimorphic fungus called Blastomyces dermatitidis, which generally produces a pulmonary form of the disease and, to a lesser extent, extra-pulmonary forms such as cutaneous, osteoarticular and genitourinary, among others. Cutaneous blastomycosis is the second clinical presentation in frequency. It is considered as primary when it begins by inoculation of the fungus due to traumas, and secondary when the lung fails to contain the infection. CASE-REPORT: We present the case of a 57 year-old male who had a 5 year-history of an irregularly shaped verrucous infiltrative plaque related to and insect bite and posterior trauma due to the manipulation of the lesion. B. dermatitidis was identified using direct examination, stains, isolation in culture media, histopathology, and molecular studies. An antifungal susceptibility test was performed using method M38-A2 (CLSI). Clinical and mycological cure was achieved with itraconazole. CONCLUSIONS: This cutaneous blastomycosis case acquired in the United States (Indianapolis) is rather interesting and looks quite similar to other mycoses such as coccidioidomycosis or sporotrichosis. The presented case shows one of the multiple issues concerning migration between neighboring countries.

Botryomycosis.

Botryomycosis is a chronic, granulomatous, infectious disease caused by several genera of bacteria with the formation of grains. The factors involved in its development are low virulence, an intermediate inoculum, and the immunologic status of the host. The pathogenesis of the disease is not well established, but the Splendore-Hoeppli phenomenon, which explains the formation of grains and the antigen-antibody reaction that characterizes the disease, is involved. Diagnosing botryomycosis includes clinical suspicion and microbiologic studies. Isolation of the causative agent and susceptibility tests are essential to provide appropriate treatment.

Cutaneous zygomycosis.

Cutaneous zygomycosis is a fungal infection caused by zygomycetes that affects the skin. It occurs in uncontrolled diabetic patients and immunosuppressed individuals. It has 2 clinical forms: primary cutaneous zygomycosis and secondary cutaneous zygomycosis. The first is characterized by necrotic lesions and the fungus is usually inoculated by trauma. If diagnosed early, it generally has a good prognosis. Secondary zygomycosis is usually a complication and extension of the rhinocerebral variety that starts as a palpebral fistula and progresses to a necrotic lesion with a poor prognosis. The diagnosis is made by identification of the fungus by direct KOH examination, culture, and biopsy. Treatment for the primary disease is surgical debridement plus amphotericin B. The secondary type is treated with amphotericin B and/or posaconazole.

Serum lactate is a useful predictor of death in severe sepsis in patients with pemphigus vulgaris.

BACKGROUND: Serum lactate is a useful prognostic marker in severe sepsis; high levels of serum lactate in critically ill patients are related to high mortality risk; assessing serum lactate levels in patients with pemphigus vulgaris is justified. The objective was to determine the role of serum lactate as a predictor of shock and its outcome in patients with pemphigus vulgaris and severe sepsis without acute organ dysfunction. METHODS: Thirty-seven patients with pemphigus vulgaris, 22 with severe sepsis and 15 without sepsis. Blood lactate levels were analyzed. The outcome was recorded as survival or non-survival. RESULTS: High serum lactate levels, compared with intermediate and low levels, were significantly associated with increased 28-day mortality in patients with severe sepsis. The 28-day mortality for the cohort was 27.3%. CONCLUSIONS: Initial serum lactate was associated with mortality in pemphigus vulgaris with severe sepsis. Patients with severe sepsis and with high serum lactate levels (≥ 4 mmol/L) constitute a potential risk group that may benefit from more aggressive treatment.

Oral geotrichosis: report of 12 cases.

Oral geotrichosis is an uncommon opportunistic infection caused by Geotrichum candidum, a habitual contaminant and component of the flora of various parts of the body. This communication reports both a 20-year retrospective study of clinically and mycologically proven cases of oral geotrichosis, and a prospective study of fungal oral flora in 200 individuals divided into two groups: normal individuals and individuals with associated conditions. Twelve patients with proven oral geotrichosis were included: 9 females and 3 males, with a mean age of 48.5 years; the associated conditions were diabetes mellitus (66.6%), leukemia, Hodgkin's lymphoma and HIV/AIDS infection. The oral geotrichoses showed three clinical varieties: pseudomembranous (75%), hyperplastic, and palatine ulcer. G. candidum was isolated in 11 cases and G. capitatum in one. Positive fungal cultures were obtained from the two groups, and 48% and 78% of cultures were positive, respectively, for Candida spp. In 2.8% and 6.33% of the cases, G. candidum was isolated, respectively, together with one strain of G. capitatum. Oral geotrichosis is an exceptional infection that clinically presents, and is treated, as oral candidiasis. G. candidum may be isolated from the oral flora of a small proportion of patients, either normal individuals or those with associated conditions.