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ESCMID Online Lecture Library © by Author ESCMID Online Lecture Library Splendore-Hoeppli Phenomenon (H &E) and Broad, Aseptate Hyphal Fragments (GMS) CULTURE

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ESCMID Online Lecture Library © by Author ESCMID Online Lecture Library Splendore-Hoeppli Phenomenon (H &E) and Broad, Aseptate Hyphal Fragments (GMS) CULTURE MYCOTIC INFECTIONS IN THE MIDDLE EAST (Basidiobolus and Rhinocladiella) Ziauddin Khan, PhD Professor© of by Medical author Mycology Department of Microbiology ESCMID OnlineFaculty of Lecture Medicine Library Kuwait University Basidiobolus and Basidiobolomycosis © by author ESCMID Online Lecture Library TAXONOMICAL CONSIDERATIONS Zygomycota underwent major taxonomic changes in 2007. Hibbet and others proposed to eliminate Zygomycota and the taxa conventionally placed in Zygomycota were distributed among the phylum Glomeromycota. Mucorales and Entomophthorales, which contain zoopathogenic© by authorfungi, and 2 other orders including Kickxellales and Zoopagales were raised to the rank of subphyla: ESCMIDMucoromycotina Online, LectureEntomophthoromycotina Library , Kickxellomycotina and Zoopagomycotina. TAXONOMIC CLASSIFICATION OLD NEW © by author ESCMID Online Lecture Library Kwon-Chung Clin Infect Dis. 2012;54:S8-S15 A proposed new classification schemes of the kingdom Fungi © by author ESCMID Online Lecture Library Basidiobolomycetes Neozygitomycetes Entomophothoromycetes Basidiobolus spp. Neozygitis spp. Conidiobolus spp. Humber, 2012 Phylogenetic classification of entomophthoroid fungi Phylum: Entomophthoromycota Class: Basidiobolomycetes Order: Basidiobolales Family:©Basidiobolaceae by author Genus: Basidiobolus ESCMID Online Lecture Library Gryganskyi et al. Persoonia 2013; 30;94-105. Maximum likelihood phylogeny of Basidiobolomycotina (secondary conidiogenesis) © by author ESCMID Online Lecture Library Basidiobolus and the still formally undescribed genera Schizangiella and Drechslerosporium (LSU, SSU, RPB2, mtSSU, ITS). Gryganskyi et al. Persoonia 2013; 30;94-105 Life Cycle of © by author ESCMID Online Lecture Library Adapted from Mendoza et al. 2015 Basidiobolus ranarum in intestinal tract of bats, reptiles and amphibians Intestinal contents of 14 (7%) of 200 bats belonging to Rhinopoma hardwickei hardwickei Gray ('the lesser rat- tailed bat'), an insectivorous species captured from Delhi area. Chaturvedi et al. Sabouraudia. 1984;22:185-9. Intestinal tract of 50©% of bytrapped authorreptiles and amphibians from Florida were found colonized with a Basidiobolus species. ESCMID OnlineOkafor Lectureet al. Sabouraudia Library. 1984;22:47-51. Epidemiology • Most cases of basidiobolomycosis have been reported from tropical and subtropical regions of Africa, South America, and Asia • It usually causes subcutaneous infections • Infections caused by B. ranarum are mainly diagnosed in children (80% under the age of 20 years) with a male/female© by authorratio of 3 :1. • B. ranarum also causes chronic granulomatous ESCMIDinfection of theOnlinegastrointestinal Lecturetract Libraryin apparently immunocompetent patients, mostly from Arizona (USA) and Middle East Basidiobolus is a ubiquitous fungus © by author The majority of cases have been reported in South America, Africa and tropical Asia. However, recently this fungus has been classified as an emerging invasive ESCMIDfungal infection in desertOnline regions of theLecture US Southwest and Library Middle East causing gastrointestinal basidiobolomycosis. Basidiobolomycosis: Clinical types Subcutaneous “Bathing suit distribution” Gastrointestinal ©Colorectal by author involvement ESCMID Online Lecture Library Complications: Small bowel, Liver, Gall bladder, Kidney, Pancreas, other intraabdominal organs Clinical Manifestations: Basidiobolomycosis The presenting feature is a single painless, unilateral, well-circumscribed subcutaneous mass that usually affects the buttock or the thigh but can also be seen in the arm, the neck, the face or the trunk. © by author The disease starts as a single nodule that progressively grows. The swelling is often ESCMIDdescribed as Onlinewoody and Lecturehard. Library The swelling over thigh in an 18-month-old female of three months duration© bycaused authorby Basidiobolus ranarum (culture and histopathology proven). Treated ESCMIDwith KI (3 times Onlinea day) and Lecturelesion resolved Librarywithin 1 month Naniwadekar et al. 2009 A case from Karad, Karnataka Induration and multiple nodules ©in the by authorButtock (toilet leaves?) perineum and labia (biopsy site seen) Radjou & Rajesh Ind J Microbiol. 2011; 29:186-188 ESCMIDA case fro Puducherry Online Lecture Library Histopathology Chronic inflammatory process can be seen with small abscesses surrounded by a granulomatous tissue reaction. A strong eosinophilic perihyphal reaction is often observed (Splendore-Hoeppli phenomenon) that is variable in size (2-6 µm). Board irregular hyphae (4-30µm) with thin walls and rare septation can©be byseen, authorsingly or in clusters. There is no invasion of blood vessels or infection of tissue. ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Splendore-Hoeppli phenomenon (H &E) and Broad, aseptate hyphal fragments (GMS) CULTURE Biopsy specimen should be cultured immediately as B. ranarum dies quickly in tissues kept in a refrigerator. Tissue biopsy should be minced and not homogenized. Homogenization in a tissue grinder should be avoided, because it decreases culture yield by destroying© hyphaeby author. SDA with antibiotics can be used. Cycloheximide ESCMIDshould not be Onlineused in SDA Lecture. Library Incubation at 25°-30° C for 2-5 days. Gastrointestinal Basidiobolomycosis © by author ESCMID Online Lecture Library CASE 1: A 30-year-old Bangladeshi with rectal bleeding • Rectal mass ~10 cm large polypoid mass on lower third of rectum • Provisional diagnosis: Piles, rectal carcinoma • First biopsy: epithelioid cell granuloma infiltrated with eosinophils- Crohn’s disease Histopathology:© Fungal by author elements were missed • ESCMIDSecond biopsy: Online Histopathology: Lecture FungalLibrary elements missed, culture yielded a fungus Khan et al. Clin Infect Dis. 1998;26:521-3 B. ranarum colonies on SDA © by author ESCMID Online Lecture Library Khan et al. Clin Infect Dis 1998;26:521 © by author ESCMID Online Lecture Library Zygospores © by author ESCMID Online Lecture Library Immunodiffusion test Case 2: A 41-year-old Indian male with history of repair of a left inguinal hernia • Examination: palpable, nodular mass near rt. hypochondrium, • Ultrasound: thickening of ascending colon and cecum and renal involvement • Provisional diagnosis:© by author Intestinal tuberculosis ESCMID Online Lecture Library Khan et al. J Clin Microbiol. 2001 ;39:2360-3 © by Hematoxylinauthor-and -eosin-stained section An open segment of large intestine of intestinal mucosa showing a cross showing a thick-walled mucosa with a section of a B. ranarum hypha (arrow) cobblestone appearance mimicking ESCMID Online Lecturesurrounded by the LibrarySplendore-Hoeppli Crohn's disease phenomenon and many eosinophils © by author KOH-calcofluor white mount showing broad, non- septate, branched hyphae in urine sediment ESCMID Online Lecture Library The isolate was resistant to Amphotericin B (4 µg/ml) and itraconazole (8 µg/ml) Serodiagnosis Ag © by author Ab-I Ab-II ESCMID Online Lecture Library Ag-whole cell homoginate; patients’ sera Ab-I and Ab-II A case from Yemen/SA A 12-year-old Yemeni boy,©living byin SaudiauthorArabia, was referred with a 2-month history of diffuse abdominal pain, non-bilious vomiting, poor appetite and weight loss. percutaneous liver biopsy under ESCMIDultrasound guidance Onlineand sent for histopathological Lecture evaluation,Librarywhich revealed granulomatous lesions rich in eosinophils with broad aseptate fungal hyphae surrounded by eosinophilic material (Splendore–Hoeppli phenomenon). Saeed et al. JMM CR 2014 © by author ESCMIDAbdominal CT showing Online multiple Lecture small, low- attenuationLibrary lesions scattered throughout both lobes of the liver, some showing ring enhancement Saeed et al. JMM CR 2014 © by author ESCMID Online Lecture Library Liver CT after treatment with itraconazole treatment. Complete resolution after 12 months. Saeed et al. JMM CR 2014 A case from Iran Gastrointestinal basidiobolomycosis accompanied by liver Involvement Gross Pathology of the Granuloma, Eosinophilic Infiltration and Terminal Ileum and Right Splendore-Hoeppli Phenomenon (Arrow) Colon Shows Ulceration in the Cecum (Arrow) © by author A 41-year-old lady from Shiraz, south of Iran. CT-scan of the abdomen and pelvic showed increased thickness of the cecum with infiltrative process and hypoattenuating lesionsESCMIDin the liver, supporting Onlineliver abscessesLectureor metastasis Librarywith central necrosis Diagnosis was based on histopathologic observation and response to itraconazole therapy (200 mg twice a day for 4 months) Ejtehadi et al. Iran Red Crescent Med J. 2014; 16: e14109. A case from Saudi Arabia Gastrointestinal basidiobolomycosis with liver Involvement A 24-year-old woman from Saudi Arabia with type I diabetes mellitus presented to the emergency department with a 4-day history of severe abdominal pain, nausea, vomiting, abdominal distension, and constipation. Magnetic resonance imaging of the abdomen showed 2 long segments of circumferential heterogeneous enhancing soft tissue masses involving the descending colon and descending sigmoid colon Lactophenol cotton blue stain of © by authorand multiple different-size hepatic growth from fine needle aspiration lesions. Isolate identified by D1/D2 material from the liver lesion, X400 sequencing. Treated with ESCMID Online Lecturevoriconazole. Library Alhuraiji et al. Clin Infect Dis. 2014; 58:990 Eosinophilic granulomatous gastrointestinal and hepatic abscesses attributable to basidiobolomycosis
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