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Corresponding Author: Setsuya Aiba, MD, PhD, Department of Dermatology, Tohoku University Graduate School of Medicine, Seriryomachi 1-1, Aoba-ku, Figure 1. Cutaneous Manifestation of Emmonsia pasteuriana Sendai, Miyagi, 980-8574, Japan ([email protected]). Published Online: May 27, 2015. doi:10.1001/jamadermatol.2015.0874. Conflict of Interest Disclosures: None reported. 1.PottP.Observations on the Nature and Consequences of Wounds and Contusions of the Head, Fractures of the Skull, Concussions of the Brain, & c. London, England: Hitch and Hawes; 1760. 2. Bannon PD, McCormack RF. Pott’s puffy tumor and epidural abscess arising from pansinusitis. J Emerg Med. 2011;41(6):616-622. 3. Bellaney GJ, Ryan TJ. Pott’s puffy tumour. Br J Dermatol. 1997;136(1):145-147. 4. Koch SE, Wintroub BU. Pott’s puffy tumor: a clinical marker for osteomyelitis of the skull. Arch Dermatol. 1985;121(4):548-549. 5. Kombogiorgas D, Solanki GA. The Pott puffy tumor revisited: neurosurgical implications of this unforgotten entity: case report and review of the literature. J Neurosurg. 2006;105(2)(suppl):143-149. 6. Singh B, Van Dellen J, Ramjettan S, Maharaj TJ. Sinogenic intracranial complications. J Laryngol Otol. 1995;109(10):945-950. Facial emmonsiosis lesion. Crusted nodule at the left corner of mouth.

Cutaneous Disseminated Emmonsiosis Due to Emmonsia pasteuriana in a Patient Findings of chest radiography and HIV antibody and serum With Cytomegalovirus Enteritis immunoglobulin and complement C3 and C4 evaluation Emmonsia pasteuriana is a newly emerging dimorphic fungal were normal. pathogen first isolated in 1998 from a cutaneous dissemi- A 2-month regimen of oral voriconazole resolved the cu- nated infection in an Italian patient with human immunode- taneous nodules, but the diarrhea persisted. After treatment ficiency virus (HIV) infection.1 In 2013, attention was drawn was begun with intravenous ganciclovir, the diarrhea im- to 13 cases of disseminated E pasteuriana infection in South proved significantly. There was no recurrence of skin erup- Africa.2 We present herein a case of cutaneous disseminated tion or diarrhea during the 3-month follow-up. E pasteuriana infection in a patient with cytomegalovirus (CMV) enteritis in China. Discussion | The Emmonsia genus contains 3 species: E parva, E crescens, and E pasteuriana. The first 2 are adiaspiromyco- Report of a Case | A woman in her 30s presented a 3-month his- sis pathogens in rodents and rarely in humans. In infected tis- tory of scattered asymptomatic cutaneous nodules. Medical his- sues, they usually present with distinctive adiaspores.3 To our tory was significant for urticaria of 8 years’ duration and diarrhea knowledge, except for 1 case each from Italy1 and Spain,4,5 of 14-months’ duration. She had received prednisone for 2 weeks E pasteuriana infection has been limited to HIV-infected pa- to treat urticaria before the onset of skin nodules. At the time of tients in South Africa.2 In the present case, negative HIV an- presentation, she was emaciated and had no other known chronic tibody results and normal lymphocyte counts and humoral im- medical conditions. She had not traveled recently but had had munity were found, while HIV viral load and T-cell function contact with a domestic hamster 1 month before skin lesion on- were not evaluated, which is a limitation of our report. The pa- set. Physical examination revealed four 1- to 2-cm diameter nod- tient’s cachexia and malnutrition, presumed to be from CMV ules with central ulceration or thick adherent crust on the left side colitis and recent prednisone treatment, likely contributed to of her face (Figure 1), left axilla, and bilateral forearms without her immunosuppression. lymphadenopathy.Findings of the general physical examination Emmonsia pasteuriana is present in infected tissue as in- were normal. trahistiocytic . It can be easily mistaken for other fun- Both skin lesion exudate smear and skin biopsy revealed gal characterized by the presence of histiocytes with numerous cells within histiocytes; the yeast cells were phagocytosed yeast cells, eg, capsulatum and Peni- rarely extracellular (Figure 2). Skin biopsy specimens yielded cillium marneffei. a thermally dimorphic ; morphologic characteristics The E pasteuriana infection transmission route remains and analysis by internal transcribed spacer sequence 5 DNA elusive. Our patient developed cutaneous nodules 1 month af- sequencing (GenBank accession number: sysu2014.sqn ter close contact with her hamster, and a successful experi- sysu2014 KP260922) identified it as E pasteuriana. Disk dif- mental animal model of E pasteuriana infection was con- fusion susceptibility testing revealed that the iso- structed only when hamsters were infected via intratesticular lated fungus was sensitive to voriconazole, fluconazole, itra- innoculation,6 suggesting that contact with hamsters could be conazole, and . Fungal cultures of blood, an E pasteuriana infection risk factor. urine, and stool clinical specimens were negative. Capsule The skin is the most commonly involved organ in Epas- endoscopy revealed ileal mucosa multiple hyperplasia and teuriana infection.2 Our patient presented only 4 discrete cu- ulceration. Intestinal biopsy and immunostaining results taneous nodules, and E pasteuriana was only isolated from skin were consistent with CMV enteritis; CD4+ and CD8+ lympho- biopsy specimens. This implies that direct inoculation of E pas- cyte counts were 570.96/mL and 287.92/mL, respectively. teuriana could have caused the cutaneous nodules.

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Figure 2. Fungal Morphological Features in Skin Lesion Exudate and Biopsy Specimen

A Skin lesion exudate B Skin lesion biopsy specimen

10 µm

A, Numerous oval yeast cells within histiocytes; extracellular yeast cells were rare (Wright’s stain of skin lesion smear, original magnification ×100). B. Numerous oval yeast cells within histiocytes and some narrow-based budding yeast cells; extracellular yeast cells were rare (Grocott methenamine silver stain of skin biopsy specimen, original magnification ×40).

In conclusion, E pasteuriana can infect immunocompro- 5. Pelegrín I, Ayats J, Xiol X, et al. Disseminated adiaspiromycosis: case report mised patients. There is potential risk that more Asian cases of a liver transplant patient with human infection, and literature review. Transpl Infect Dis. 2011;13(5):507-514. may emerge. Further investigation of E pasteuriana geo- 6. Drouhet E, Huerre M. Yeast tissue phase of Emmonsia pasteuriana graphic distribution and reservoirs would reveal more infor- inoculated in golden hamster by intratesticular way. Mycoses. 1999;42(suppl 2): mation. 11-18.

Xu Hua Tang, MD, PhD A Case of Dominant Dystrophic Epidermolysis Hui Zhou, MD, PhD Bullosa Responding Well to an Old Xing Qi Zhang, MD, PhD Epidermolysis bullosa (EB) is an inherited disease character- Jian De Han, MD ized by fragile skin and bullae or erosion formation, either spon- Qian Gao, MD taneously or on minor skin trauma. Molecular defects within the epidermis or the skin’s basement membrane indicate which Author Affiliations: Department of Dermatology, The First Affiliated Hospital, subtype of EB a patient has. Collagen VII is affected in dystro- Sun Yat-sen University, Guangzhou, China. phic EB.1,2 The mainstay of disease management involves Corresponding Author: Qian Gao, MD, Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, wound care, symptom palliation, and prevention or treat- Guangzhou, China, 510080 ([email protected]). ment of complications. However, there is still no consistently Conflict of Interest Disclosures: None reported. effective treatment that minimizes or prevents formation of Published Online: July 22, 2015. doi:10.1001/jamadermatol.2015.1792. bullae on minor skin trauma. Author Contributions: Drs Tang and Zhou contributed equally to this work. Additional Contributions: We are indebted to the mycological laboratory staff Report of a Case | A 58-year-old man with a history of biopsy- of Sun Yat-sen University, Sun Yat-sen Memorial Hospital, including Li Yan Xi, diagnosed dominant dystrophic EB since childhood pre- MD, PhD; Chang Ming Lu, MD; Sha Lu, MD, PhD; and Ying Hui Liu, MD, without sented to the dermatology clinic with a 6- to 8-month history whose invaluable assistance this study could not have been performed. These persons received no payment for their contributions beyond that received in of increasing spontaneous bullae formation. Clinical manifes- the normal course of their employment. tations were primarily cutaneous, acral in distribution, and af- 1. Gori S, Drohuet E, Guebo E, et al. Cutaneous disseminated in a fecting mainly his hands, legs, feet, and nails. His eyes, oral patient with AIDS due to a new . J Mycol Med. 1998;8(2):57-63. cavity, gastrointestinal tract, and genitourinary tract were not 2. Kenyon C, Bonorchis K, Corcoran C, et al. A dimorphic fungus causing involved. Family history revealed that his father and older disseminated infection in South Africa. N Engl J Med. 2013;369(15):1416-1424. brother were also affected, and there was no history of con- 3. Anstead GM, Sutton DA, Graybill JR. Adiaspiromycosis causing respiratory sanguinity. Patient was treated with oral minocycline, 100 mg, failure and a review of human infections due to Emmonsia and twice daily. spp. J Clin Microbiol. 2012;50(4):1346-1354. At a 6-week follow-up appointment, the erosions were 4. Pelegrín I, Alastruey-Izquierdo A, Ayats J, Cuenca-Estrella M, Cabellos C. A second look at Emmonsia infection can make the difference. Transpl Infect Dis. healing, and he had not had any new bullae formation. At a sub- 2014;16(3):519-520. sequent 6-week follow-up appointment, the patient reported

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