February 2016

Fig.3

Fig.4

 

Fig.5

 

 

Fig. 6

                                                                     

 

 


Diagnosis: Mycetoma due to Scedosporium species

 

Pathology:

Punch Biopsy of rash on right dorsal forearm: Dermal granulomatous and focally suppurative inflammation (Fig.3,Fig.4) with fungal elements (focal yeast forms w/ septation) also seen on GMS stain (Fig.5)

Culture: Superficial Fungal Swab = Scedosporium Species; Superficial Bacterial (aerobic/anaerobic) Swab = Negative; Tissue Culture (Fungal) = Scedosporium species; Tissue Culture (Anaerobic/Aerobic) = Negative; Tissue AFB Stain = Negative

Treatment: Voriconazole

 

Clinical Course: Patient had another lesion on the opposite arm to the main rash upon initial presentation that was possibly related to the primary fungal infection. After discussion with the pulmonary transplant team, the decision was made to admit patient to the hospital over concern for disseminated disease. Patient was admitted to Barnes-Jewish Hospital and started on IV voriconazole. Work up in the hospital was not concerning for disseminated disease and patient was transitioned to PO voriconazole. He was in stable condition and was subsequently discharged on Day 3 on PO Vvriconazole for 6 weeks. Patient’s other medications, including amiodarone, were adjusted for possible drug-drug interaction with voriconazole. On three-week follow up, the patient’s rash was almost clear and he denied any other skin lesions (Figure 6).

 

Discussion:

Scedosporium is a ubiquitous fungus found in soil and water worldwide and is endemic to tropical areas. It is considered an emerging pathogen especially in immunocompromised patients [2]. It usually causes local skin infections via direct inoculation, however recent cases have described invasive forms of Scedosporium that can affect multiple organs including the external ear canals, paranasal sinuses, and bronchi [4]. When it spreads systemically, Scedosporium can be difficult to treat, as there are high levels of resistance to antifungals including amphotericin B. Though there are no set guidelines on therapy, voriconazole has been reported to have favorable outcomes [1]. Disseminated disease is a major cause of morbidity and mortality though the exact percentages are difficult to discern as data is limited to case reports and series. Early recognition and prompt treatment has lead to an increased rate of survival [3].

  

References:

 

1) Blyth CC1, Gilroy NM, Guy SD, Chambers ST, Cheong EY, Gottlieb T, McGuinness SL, Thursky KA. Consensus guidelines for the treatment of invasive mould infections in haematological malignancy and haemopoietic stem cell transplantation, 2014. Intern Med J. 2014 Dec;44(12b):1333-49. doi: 10.1111/imj.12598

2) Campa-Thompson MM1, West JA1, Guileyardo JM1, Spak CW1, Sloan LM1, Beal SG1. Clinical and morphologic findings in disseminated Scedosporium apiospermum infections in immunocompromised patients. Proc (Bayl Univ Med Cent). 2014 Jul;27(3):253-6.

3) Johnson LS1, Shields RK, Clancy CJ. Epidemiology, clinical manifestations, and outcomes of Scedosporium infections among solid organ transplant recipients. Transpl Infect Dis. 2014 Aug;16(4):578-87. doi: 10.1111/tid.12244. Epub 2014 Jun 24.

4) Tessari G1, Cagalli A, Girolomoni G. Opportunistic deep cutaneous mycoses in solid organ transplant recipients. G Ital Dermatol Venereol. 2014 Aug;149(4):417-22.

 

Case presented by: Rishu Gupta MD, Andras Schaffer MD PhD, Sabra Abner MD, Ilana Rosman MD, Kara Sternhell-Blackwell MD,