LETTERS and Federal University of Bahia, Salvador, Apophysomyces 9 patients has been reported (4). The Brazil (M.G. Teixeira) 4 isolates were sent to the Universitat variabilis Infections Rovira i Virgili (Reus, Spain) for mo- DOI: 10.3201/eid1701.100321 in Humans lecular analysis. The internal transcribed spacer References To the Editor: The fungus Apo- region of these isolates was sequenced 1. World Organization Health. Dengue and physomyces elegans (order Mucorales) and compared with those of type dengue haemorragic fever fact sheet 217. is a thermotolerant species that causes strains of Apophysomyces spp. Fungi 2009 [cited 2010 Aug 10]. http://www. severe infections among humans. In were identifi ed by morphologic (Fig- who.int/mediacentre/factsheets/fs117/en/ contrast to other fungi that cause zy- index.html. ure, panel A) and molecular analysis as 2. Halstead SB. Dengue in the Americas and gomycosis, which have a worldwide A. variabilis (99.6%–99.7% sequence Southeast Asia: do they differ? Rev Pan- distribution and are rarely found in identity with sequence of type strain am Salud Publica. 2006;20:407–15. DOI: immunocompetent hosts, A. elegans CBS 658.93 [FN556436]). GenBank 10.1590/S1020-49892006001100007 has been reported mainly in areas with 3. Siqueira JB Jr, Martelli CM, Coelho GE, accession nos. of the 4 isolates are Simplício AC, Hatch DL. Dengue and warm climates as an emerging patho- FN813491, FN813490, FN556442, dengue hemorrhagic fever, Brazil, 1981– gen that causes mostly cutaneous in- and FN813492. 2002. Emerg Infect Dis. 2005;11:48–53. fections after injury to the skin (1). Another patient was also infected 4. Teixeira MG, Costa Mda C, Barreto F, This fungus was discovered in 1979 Barreto ML. Dengue: twenty-fi ve years with A. variabilis fungi. The patient since reemergence in Brazil. Cad Saude (2) and until recently was considered was a 45-year-old woman with dia- Publica. 2009;25(Suppl 1):S7–18. DOI: the only species in the genus. betes from Derabassi (Punjab), India, 10.1590/S0102-311X2009001300002 A polyphasic study of clinical and who was hospitalized because of swell- 5. Teixeira MG, Costa MC, Coelho GE, Bar- environmental strains of A. elegans, reto ML. Recent shift in age pattern of ing in her right breast and blackening dengue hemorrhagic fever, Brazil. Emerg including analysis of several genes, of overlying skin. A diagnosis of right Infect Dis. 2008;14:1663. DOI: 10.3201/ showed that the genus contained 4 breast gangrene was made. Therefore, eid1410.071164 well-characterized species (3). Of local debridement of the swelling was 6. Cavalcanti LP, Coelho IC, Vilar DC, Ho- 16 isolates tested in this study, only landa SG, Escóssia KN, Souza-Santos R. conducted, and tissue samples were Clinical and epidemiological characteriza- 2 from soil in India were A. elegans. tested by microbiologic culture and tion of dengue hemorrhagic fever cases in Most of the isolates were A. variabi- histopathologic analysis. northeastern Brazil. Rev Soc Bras Med lis. The incidence of A. variabilis in A KOH wet mount showed broad Trop. 2010;43:355–8. humans is unknown and diffi cult to 7. Vilar DC. Aspectos clínicos e epide- aseptate hyphae with right-angled miológicos do dengue hemorrágico no ascertain because most cases had iso- branching. The fungal isolate was Ceará, no período de 1994 a 2006. Disser- lates that were not properly preserved. tentatively identifi ed as A. elegans. tação (Mestrado). Ceará (Brazil): Escola These fungi usually cause necrotizing Histopathologic analysis confi rmed Nacional de Saúde Pública; 2008 [cited fasciitis, but rhino-orbito-cerebral or 2010 Aug 10]. http://bvssp.icict.fi ocruz. a diagnosis of zygomycosis. The pa- br/lildbi/docsonline/4/3/1734-Vilardclfm. renal infections have also been report- tient was treated under local anesthe- pdf ed (1). Whether these infections are sia by debridement of infected tissue 8. Brasil, Ministério da Saúde. Datasus [cited produced by different Apophysomyces and some of the healthy surrounding 2010 Aug 10]. http://www2.datasus.gov. spp., have different responses to an- br/DATASUS/index.php?area=0206 tissue (Figure, panel B). However, an 9. Oliveira MF, Araújo JM, Ferreira OC Jr, tifungal drugs, or have differences in antifungal regimen could not be given Ferreira DF, Lima DB, Santos FB, et al. virulence is unknown. because she had disturbed renal func- Two lineages of dengue virus type 2, Bra- To assess incidence of Apophy- tion. Her condition deteriorated, sep- zil. Emerg Infect Dis. 2010;16:576–8. somyces spp. in a tertiary hospital 10. Halstead SB. The Alexander D. Langmuir ticemia was observed, and she died lecture. The pathogenesis of dengue. Mo- (Government Medical College Hospi- from sudden cardiac arrest on the sixth lecular epidemiology in infections disease. tal, Chandigarh, India), which usually day after admission. The fungal iso- Am J Epidemiol. 1981;114:632–48. receives patients with zygomycosis, late was also identifi ed as A. variabilis a retrospective study was conducted (98.9% identity, GenBank accession Address for correspondence: Luciano P. during November 2001–April 2009. no. FN556443). Cavalcanti, Department of Community Health, Nine patients were identifi ed as having Although most cases of infection School of Medicine, Federal University of primary cutaneous zygomycosis. For with A. variabilis fungi have been Ceará, St. Prof. Costa Mendes 1608, 5th 4 patients, fungal isolates were mor- reported in India (5), infections with Floor, Fortaleza, CE 60430-140, Brazil; email: phologically identifi ed as A. elegans. this fungus may have a wider distribu- [email protected] A description of clinical fi ndings, their tion. A recent study demonstrated that management, and outcomes for these this species represented 0.5% of fungi

134 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 1, January 2011 LETTERS

Figure. A) Sporangiophore (center) and sporangiospores of Apophysomyces variabilis fungi. Scale bar = 10 μm. B) Clinical manifestations in a woman infected with A. variabilis fungi in the upper part of the chest and the breast. A color version of this fi gure is available online (www.cdc.gov/EID/content/17/1/ 134-F.htm).

of the order Mucorales isolated from Josep Guarro, 6. Alvarez E, Sutton DA, Cano J, Fother- clinical samples in the United States Jagdish Chander, gill AW, Stchigel A, Rinaldi MG, et al. Spectrum of zygomycete species identi- (6). Furthermore, a high mortality rate Eduardo Alvarez, fi ed in clinically signifi cant specimens and the fact that most of these infec- Alberto M. Stchigel, in the United States. J Clin Micro- tions involve otherwise healthy pa- Kaushik Robin, Usha Dalal, biol. 2009;47:1650–6. DOI: 10.1128/ tients make this a serious infection. Hena Rani, Rajpal S. Punia, JCM.00036-09 7. Padhye AA, Ajello L. Simple method of The number of infections with and José F. Cano inducing sporulation by Apophysomyces Apophysomyces spp. is underestimated Author affi liations: Universitat Rovira i Virgi- elegans and Saksenaea vasiformis. J Clin because these fungi do not usually spo- li, Virgili, Reus, Spain (J. Guarro, E. Alvarez, Microbiol. 1988;26:1861–3. rulate on standard fungal culture me- A.M. Stchigel, J.F. Cano); and Government dia used in clinical laboratories. These Medical College Hospital, Chandigarh, In- Address for correspondence: José F. Cano, fungi require special nutrient-defi cient dia (J. Chandler, K. Robin, U. Dalal, H. Unitat de Microbiologia, Facultat de Medicina growth medium (Czapek agar), a high Rani, R.S. Puna) i Ciències de la Salut, Institut d’Investigació temperature in comparison to other Sanitària Pere i Virgili, Universitat Rovira DOI: 10.3201/eid1701.101139 human pathogens (37°C–42°C), and i Virgili, C/Sant Llorenç 21, 43201 Reus, prolonged incubation (7–10 days) (7). Tarragona, Spain; email: [email protected] References A difference in mortality rate was observed when we compared patients 1. Meis JF, Chakrabarti A. Changing epi- in our study (80%) with those reported demiology of an emerging infection: Letters by Chakrabarti et al. (5) (28.5%) in zygomycosis. Clin Microbiol Infect. 2009;15(Suppl 5):10–4. DOI: 10.1111/ Letters commenting on recent articles India, even though treatment was gen- j.1469-0691.2009.02973.x as well as letters reporting cases, erally similar, i.e., local débridement 2. Misra PC, Srivastava KJ, Lata K. Apophy- outbreaks, or original research are and amphotericin B. Other differences somyces, a new genus of the Mucorales. welcome. Letters commenting on ar- in our study were that the infection in Mycotaxon. 1979;8:377–82. 3. Alvarez E, Stchigel AM, Cano J, Sut- 4 patients was preceded by intramus- ticles should contain no more than ton DA, Fothergill AW, Chander J, et al. 300 words and 5 references; they are cular injection, and these 2 patients Molecular phylogenetic diversity of the had diabetes mellitus. emerging mucoralean fungus Apophy- more likely to be published if submitted In conclusion, A. variabilis is somyces: proposal of three new species. within 4 weeks of the original article’s Rev Iberoam Micol. 2010;27:80–9. DOI: publication. Letters reporting cases, an emerging pathogenic fungus that 10.1016/j.riam.2010.01.006 can cause rapid and fatal infections 4. Chander J, Kaur J, Attri A, Mohan H. outbreaks, or original research should in humans. As more isolates of Apo- Primary cutaneous zygomycosis from a contain no more than 800 words and tertiary care centre in north-west India. physomyces fungi become available, 10 references. They may have 1 Indian J Med Res. 2010;131:765–70. molecular typing studies must be con- 5. Chakrabarti A, Ghosh A, Prasad GS, David Figure or Table and should not be di- ducted to better understand the epide- JK, Gupta S, Das A, et al. Apophysomy- vided into sections. All letters should miology and distribution of different ces elegans: an emerging zygomycete in contain material not previously pub- Apophysomyces spp. India. J Clin Microbiol. 2003;41:783–8. DOI: 10.1128/JCM.41.2.783-788.2003 lished and include a word count.

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