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Imported Mycoses: Some Diagnostic Problems W Postgrad Med J: first published as 10.1136/pgmj.55.647.598 on 1 September 1979. Downloaded from Postgraduate Medical Journal (September 1979) 55, 598-602 Imported mycoses: some diagnostic problems W. ST C. SYMMERS M.D. Charing Cross Hospital and Medical School, The Reynolds Building, St Dunstan's Road, London W6 8RP Summary Trichophyton and possibly of other fungi that cause Infections by actinomycetes or by true fungi may cause dermatophytosis may invade the subcutaneous diagnostic difficulties in countries where they are not tissues and eventually give rise to distant lesions as a familiar. Illustrative cases from a series of 353 result of spread by the lymphatics or in the blood instances are given together with rare indigenous stream. examples of the same infections. Early, accurate In any case of the infections listed above, and diagnosis is essential for rational and effective particularly in any case of those infections that occur treatment. less frequently in Europe than in other parts of the world, the possibility that infection took place while Introduction the patient was resident or travelling outside Europe The first, and in many cases the greatest, problem ought to be considered. None of the infections is in the correct clinical management of mycoses is their confined to Europe. In contrast, some important recognition. In general, delay in the diagnosis of mycoses do not occur naturally in north-westernProtected by copyright. mycoses results primarily from failure to consider Europe. that a fungal or actinomycetous infection may be the cause of a patient's symptoms. In this respect the Mycoses not indigenous in north-western Europe problem is a commonplace one, not confined to Blastomycosis (caused by Blastomyces dermati- mycoses: its solution lies in greater knowledge and tidis); coccidioidomycosis; histoplasmosis, including greater awareness of diagnostic possibilities. Among African histoplasmosis; lobomycosis; mycetomas the 353 cases of 'imported mycoses' in the accom- (except those caused by the fungi named in the list panying table, the possibility ofa mycosis was among of indigenous mycoses of north-western Europe, the initial diagnostic considerations in just under above); paracoccidioidomycosis; rhinoentomoph- 15%. thoromycosis; rhinosporidiosis. However, instances of all these diseases have been Mycoses in north-western Europe seen in patients in north-western Europe whose In north-western Europe (the area covered by infection originated while they were in parts of the Belgium, Denmark, France, the German Federal world where the condition is indigenous. Further, in Republic, the Irish Republic, Luxemburg, The exceptional circumstances, blastomycosis, coccidio- http://pmj.bmj.com/ Netherlands, Norway, Sweden, and the United idomycosis, histoplasmosis and lobomycosis have Kingdom), the indigenous mycoses (excluding super- been acquired in north-western Europe (Table 1) ficial mycoses of the skin, ocular mycoses and either through inadvertent exposure to infective otomycoses) that are liable to cause serious and forms of the causative organism in laboratories or as progressive disease, or that are potentially disabling a result of contact with imported goods contamin- or potentially life-threatening, include the following: ated with the fungus (or, in the case of lobomycosis, actinomycosis; adiaspiromycosis; aspergillosis; basi- in consequence of a needle prick while excising a on September 25, 2021 by guest. diobolomycosis; candidiasis; chromomycosis (cutan- biopsy specimen from an infected dolphin). eous and subcutaneous; cerebral and meningocere- bral; other visceral infections); cryptococcosis; Diagnostic awareness geotrichosis; mycetoma (caused by Acremonium spp., Although in comparison with the situation 10-20 Aspergillus nidulans and Petriellidium boydii); nocar- years ago there is now much more awareness among diosis (caused by Nocardia asteroides); penicilliosis; clinicians and in laboratories of the occurrence of petriellidiosis (pulmonary, see also mycetoma, mycoses, their recognition is still frequently delayed. above); phycomycosis (caused by Absidia spp., This is a world-wide shortcoming; even in North Rhizopus spp. and probably other genera); sporo- America, where we in Europe expect familiarity with trichosis. mycoses to be general, the diagnosis of those infec- It should also be remembered that species of tions that are endemic in parts of the continent is 0032-5473/79/0900-0598$02.00 © 1979 The Fellowship of Postgraduate Medicine Postgrad Med J: first published as 10.1136/pgmj.55.647.598 on 1 September 1979. Downloaded from Imported mycoses 599 very liable to be as much delayed, or almost so, mycoses as nocardiosis, the phycomycoses and through failure to consider the possibility of a sporotrichosis. mycosis. A basic knowledge of some of the exotic mycoses including histoplasmosis, and less often of Geographical considerations coccidioidomycosis, is quite usual among young The importance of enquiring about a patient's British doctors. Yet the same doctors, and their geographical history and relating it to the presenting seniors, tend to be at best only vaguely and insuffi- clinical problem cannot be stressed too strongly. ciently informed about such infrequent indigenous Failure to do this may result in ignoring the possi- bility of an exotic fungal disease; this may lead to the patient's death. TABLE 1. Three hundred and fifty-three cases of non- Illustrative cases indigenous and rarely indigenous mycoses seen personally in Britain from 1946 to 1977 (figures in parentheses indicate the Only a brief sketch of some causes of delayed number of cases with firm evidence or good circumstantial recognition of 'imported' mycoses can be included evidence that infection was acquired in Britain or elsewhere here. The cases are from the series summarized in in north-western Europe) Table 1. Number of Mycosis cases (A) Diagnostic delay through failure to consider the Basidiobolomycosis 5 (2*) possibility of mycosis Blastomycosis ('North American') caused Case 1. Madurella mycetomatis mycetoma of the by Blastomyces dermatitidis 32 (2t) tibia. A boy whose home was in India was struck Blastomycosis, South American; see over the tibial tuberosity by a cricket ball while at papacoccidioidomycosis. school in England. The unexpectedly severe pain Chromomycosis 63 (21) Protected by copyright. cutaneous 31 (6*) that this caused led to X-ray examination which subcutaneous (phaeosporotrichosis) showed a large osteolytic lesion with some new bone caused or presumptively caused by formation. The radiological diagnosis was 'probable Phialophora gourgerotii 18 (6*) osteosarcoma'. and central nervous system, caused or Radiotherapy amputation were presumptively caused by Cladosporium advised. The child's guardians refused permission trichoides in most cases 11 (7*) for such treatment The lesion enlarged and showed other visceral infections (heart and/or signs of extension into the skin, with imminent lungs 3 (2*) ulceration. was then undertaken and Coccidioidomycosis 41 (27-22t; 5t) Biopsy showed Histoplasmosis, caused by Histoplasma colonies of M. mycetomatis in a chronic inflamma- capsulatum 101 (3-1t; 2t) tory mass. There was no neoplasm. For the first time Histoplasmosis, African, caused by a careful history was taken: this disclosed that the H. duboisii 14 (0) Lobomycosis (occupational contact with child had accidentally run an acacia thorn into the naturally infected dolphin that had leg at the site of the eventual mycetoma. The remains been captured in European waters) of the thorn were found in tissue removed during Mycetoma: 71 (2) further conservative surgical treatment. Recovery http://pmj.bmj.com/ actinomycetous: 24 (0) followed. A. madurae 6 (0) Actinomadura pelletieri 3 (0) Case 2. Nocardia brasiliensis mycetoma of the Nocardia brasiliensis 10 (0) shoulder region. A Mexican student in London was Streptomyces somaliensis 5 (0) treated over many months for 'chronic furunculosis' fungal: 47 (2) of the skin of the back of one There was Acremonium falciforme 2 (0) shoulder. Aspergillus spp. 2 (0) little effect from a wide range of antibacterial anti- Leptosphaeria senegalensis 4 (0) biotics and fresh lesions continued to appear over an Madurella grisea 3 (0) increasingly wide area. Eventually, the patient con- on September 25, 2021 by guest. M. mycetomatis 19 (0) sulted a fellow was on Microsporum ferrugineum 4 (0) countryman who a post- Petriellidium boydii 5 (2*) graduate course in England: the latter made an Phialophora jeanselmei 7 (0) immediate diagnosis of N. brasiliensis infection on Zopfia rosatii 1 (0) clinical grounds; this was soon confirmed both Paracoccidioidomycosis 9 (0) Penicilliosis presumptively caused by histologically and by isolation of the organism. Penicillium marneffei 1 (0) Treatment with a sulphone resulted in cure. Rhinoentomophthoromycosis 2 (0) Case 3. N. brasiliensis mycetoma of foot. An Rhinosporidiosis 13 (0) English student gave a history of transfixion of one * Naturally occurring indigenous infections. foot by a thorn, which pierced it from the sole to the t Infections presumptively mediated by fomites. dorsum in the region of the head of the metatarsal L$aboratory infections. bones of the fourth and fifth toes. The thorn was Postgrad Med J: first published as 10.1136/pgmj.55.647.598 on 1 September 1979. Downloaded from 600 W. St C. Symmers immediately withdrawn intact. Some months later a at school in Europe was looked after by a succession 'boil' appeared at the
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