Rhinocladiella Aquaspersa, Proven Agent of Verrucous Skin Infection and a Novel Type of Chromoblastomycosis
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Medical Mycology August 2010, 48, 696–703 Rhinocladiella aquaspersa, proven agent of verrucous skin infection and a novel type of chromoblastomycosis H. BADALI *†‡, A. BONIFAZ§, T. BARRÓN-TAPIA#, D. VÁZQUEZ-GONZÁLEZ§, L. ESTRADA-AGUILAR#, N. M. CAVALCANTE OLIVEIRA+, J. F. SOBRAL FILHO$, J. GUARRO^, J. F. G. M. MEIS@ & G. S. DE HOOG*†~ *CBS-KNAW Fungal Biodiversity Centre, Utrecht, The Netherlands, †Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands, ‡Department of Medical Mycology and Parasitology, School of Medicine/Molecular and Cell Biology Research Center, Mazandaran University of Medical Sciences, Sari, Iran, §Mycology Department, Dermatology Service, General Hospital of Mexico, #Dermatology Service, Regional Hospital Lic. Adolfo López Mateos, Mexico, +Laboratório de Micologia, Departamento de Ciências Farmacêuticas, $Serviço de Dermatologia, Hospital Universitário Lauro Wanderley, Universidade Federal da Paraíba, Joao Pessoa, Brazil, ^Mycology Unit, Medical School, IISPV, Rovira i Virgili University, Reus, Spain, Downloaded from @Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands, and ~Peking University Health Science Center, Research Center for Medical Mycology, Beijing, China We report a case of chromoblastomycosis which resembled sporotrichosis due to the presence of warty nodules and lymphatic distribution on the forearm in a 56-year-old http://mmy.oxfordjournals.org/ male. Mycological and histopathological investigation of exudates and biopsy tissue samples revealed a granulomatous lesion with muriform cells, the hallmark of chromo- blastomycosis. The infection showed only localized expansion with verrucous plaques suggesting a new clinical type of the disease. The causative agent was identifi ed as Rhinocladiella aquaspersa. This case prompted a study of the clinical spectrum of R. aquaspersa, through which we identifi ed a second case caused by this fungus in a 62-year-old Brazilian female. The case was unusual in that R. aquaspersa exhibited hyphae rather than muriform cells in tissue. Given the diffi culties treating chromoblas- at University of Manchester on January 14, 2016 tomycosis and other infections caused by melanized fungi, we evaluated the in vitro activities of extended-spectrum triazoles, amphotericin B, and echinocandins against these clinical isolates of R. aquaspersa. Itraconazole (MIC; 0.063 mg/l) and posacon- azole (MIC; 0.125 mg/l) had the highest in vitro activities, while voriconazole and isavuconazole had somewhat lower activities (MICs; 2 mg/l) against the isolates. Amphotericin B and anidulafungin each had an MIC of 1 mg/l, whereas the MIC of caspofungin was 8 mg/l. Keywords chromoblastomycosis, Rhinocladiella aquaspersa, Rhinocladiella phaeo- phora, ITS rDNA, black yeasts Introduction wart-like lesions eventually leading to emerging, cauli- fl ower-like forms [1]. Infections occur primarily in immu- Chromoblastomycosis is a chronic, progressive cutane- nocompetent individuals and are supposed to originate by ous and subcutaneous disorder histologically characterized traumatic implantation of fungal elements into the skin. by nodular and verrucous skin lesions. Tissue prolifera- The fungus multiplies in the tissue producing muriform tion usually occurs around the area of traumatic inocula- cells, which represent the invasive form of fungi causing tion of the etiologic agent, producing crusted, verrucose, chromoblastomycosis [1]. The most common etiological agents of chromoblastomycosis are the melanized fungi Received 17 August 2009; Received in fi nal revised form 16 October namely Fonsecaea pedrosoi, F. monophora, Cladophialo- 2009; Accepted 8 November 2009 Correspondence: G. S. de Hoog, CBS-KNAW Fungal Biodiversity Cen- phora carrionii and Phialophora verrucosa, all members tre, PO Box 85167, NL-3508 AD, Utrecht, The Netherlands. Tel: +31 30 of the ascomycete order Chaetothyriales in the family 2122663; fax: +31 30 2512097; E-mail: [email protected] Herpotrichiellaceae [2–3]. There are occasional reports © 2010 ISHAM DOI: 10.3109/13693780903471073 Chromoblastomycosis and phaeohyphomycosis due to R. aquaspersa 697 of chromoblastomycosis involving other members of the presented with a localized dermatosis affecting the dorsum order such as Exophiala jeanselmei, E. spinifera, E. der- of the left hand and the ipsilateral forearm. The lesions matitidis [4–6] and Cladophialophora samoënsis [3]. A consisted of multiple, well-defi ned verrucous plaques with few species outside the order Chaetothyriales have been the same color as the skin or slightly grayish. They followed implicated in chromoblastomycosis-like infections, such the path of lymphatic vessels of the arm, with mild pruritus as Chaetomium funicola (order Sordariales, family (Fig. 1A,B). The dermatosis reportedly had begun 15 years Chaetomiaceae) [7], Catenulostroma chromoblastomyco- prior to his presentation. The patient referred to several sum (order Capnodiales, family Teratosphaeriaceae [8], work-related traumata. Prior treatment included topical and an unidentifi ed capnodialean fungus [9]. However, the ketoconazole. The entire biopsied tissue was subjected to latter were primarily concerned with infections with hyphae mycological and histopathological investigation. Direct and chlamydospore-like cells in tissue which does not fi t examination of scales of the verrucous plaques in KOH with the concept of chromoblastomycosis. (20%) demonstrated multiple dark brown muriform cells, Chromoblastomycosis is currently classifi ed into five approximately 6 μm in diameter. Section of the biopsied clinical types [1]; nodular, plaque, tumoral, cicatricial and material stained with hematoxylin and eosin (H&E) revealed Downloaded from verrucous, based on the description of Carrión in 1950 pseudoepitheliomatous hyperplasia and a granulomatous [10]. Queiroz-Telles et al. [1] graded lesions according to infl ammatory infi ltrate with lymphocytes, multinucleated their expansion, viz. mild, moderate and severe, and noted giant (Langhan’s type) and muriform cells (Fig. 1D). Clin- that, chronic lymphedema and ankylosis developed in the ical specimens were inoculated onto Sabouraud’s glucose most severe cases. However, some atypical cases of chro- agar (SGA; Difco) and on SGA supplemented with chloram- http://mmy.oxfordjournals.org/ moblastomycosis show lymphatic dissemination, a trait phenicol (0.5 mg/l) and were incubated at 27–30°C for two usually associated with sporotrichosis [11,12]. For exam- weeks. Growth of a melanized fungus was observed repeat- ple, Muhammed et al. [13] reported a case of lymphangitic edly and the mold was provisionally identifi ed as a Rhin- chromoblastomycosis due to F. pedrosoi in a 40-year-old ocladiella sp. on the basis of morphological criteria, and a male who presented with a non-healing ulcer on the right voucher strain was deposited in the CBS-KNAW culture big toe and multiple nodules over the anterior aspect of the collection (accession number CBS 122635). The patient right leg and foot. Interestingly, Ogawa et al. 2003 [11] was treated successfully with oral terbinafi ne (500 mg/day), used lymphoscintigraphy as an objective method to show with good clinical response (signifi cant reduction of the the morphology of the lymph vessels and to assess affected area) after six months of therapy. He was then put at University of Manchester on January 14, 2016 lymphedema secondary to chromoblastomycosis. on maintenance therapy with oral itraconazole solution Lymphatic dissemination leads to a different appearance (200 mg/day) for 3 months. The patient also had bimonthly of chromoblastomycosis, as illustrated in the present case cryosurgery sessions for one year. Follow-up showed reports of a Mexican male and a Brazilian female infected improvement of the dermatosis, with residual hypochromic by Rhinocladiella aquaspersa [14–16]. The chaetothyri- areas and recovery of terminal hair in the previously ver- alean fungus R. aquaspersa is a rare cause of chromoblas- rucous plaques, though a 5-mm lesion remained in the dis- tomycosis with cases generally confi ned to Latin America. tal third of the forearm (Fig. 1C). The infections caused by species of the genus Rhinocla- diella are clinically diverse. R. aquaspersa is associated Case report 2 with skin infections, while Rhinocladiella mackenziei causes brain infections in otherwise healthy individuals which are A 62-year-old black female agricultural worker from associated with high mortality [17,18]. The aforementioned Solânea in the state of Paraiba in the north east of Brazil cases of R. aquaspersa chromoblastomycosis prompted a consulted the hospital in 2001 because of the presence of study on the clinical spectrum of R. aquaspersa, based on multiple verrucose lesions measuring 2–8 cm in diameter, strains verifi ed by sequencing and an analysis of infections forming plaques on her left foot (Fig. 2A). The patient had caused by related species. This led us to evaluate the in vitro a history of puncture injury due to an unidentifi ed cactus activities of amphotericin B, fl uconazole, itraconazole, vori- approximately 20 years prior to her examination. Myco- conazole, posaconazole, isavuconazole, caspofungin, and logical and histopathological investigations of the biopsied anidulafungin against this fungal pathogen. verrucous lesion by direct examination in KOH (20%) and KOH supplemented with lactophenol revealed dark brown septate hyphae (Fig. 2B).