Agent of Disseminated Infection

Received: 16 August 2016 | Revised: 17 September 2016 | Accepted: 11 October 2016 DOI: 10.1111/myc.12583

ORIGINAL ARTICLE

A novel dimorphic pathogen, Emergomyces orientalis (Onygenales), agent of disseminated infection

1Division of Clinical Microbiology, P.U.M.C.H., Beijing, China Summary 2Sexually Transmitted Infection A novel dimorphic fungus, Emergomyces orientalis sp. nov. a close relative of systemic Unit, Institute of Tropical Medicine, pathogens in the family Ajellomycetaceae (Blastomyces, Histoplasma). The fungus is re- Antwerp, Belgium ported in a 64-year-old male from Shanxi, China. The patient developed disseminated 3CBS-KNAW Fungal Biodiversity Centre, Utrecht, The Netherlands skin lesions, productive cough with fever and showed nodular opacities in his left lung 4Division of Internal Medicine, P.U.M.C.H., on chest radiography. The patient had no identified cause of immunodeficiency apart Beijing, China from type-2 diabetes mellitus. Clinical, histopathological and mycological characteris- 5Division of Pathology, P.U.M.C.H., Beijing, China tics of the agent are given, and its phylogenetic position is determined with multilocus 6Division of Bioinformatics, Academy of sequence data. Military Medical Science, Beijing Institute of Radiation Medicine, Beijing, China KEYWORDS 7 Division of Fungi, Academy of Military AIDS-related mycosis, diabetes, dimorphic fungi, Emergomyces, Emmonsia, endemic mycosis Medical Science, Beijing Institute of Radiation Medicine, Beijing, China 8Department of Dermatology, The Affiliated Hospital, Guizhou Medical University, Guiyang, China

Correspondence Yingchun Xu, Division of Clinical Microbiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China. Email: [email protected]

1 | INTRODUCTION found globally in humans rather than in rodents, and may occur in the form of outbreaks with dozens of cases, such as in South Africa.1 This A new clinical entity is emerging among the thermally dimorphic fungi1,2 has led to new visions on the pathology of the dimorphic pathogens, and by species that have provisionally been identified as “Emmonsia”. obviously the taxonomy of the Ajellomycetaceae has to be revised con- Previously, “emmonsiosis” was thought to only affect humans via inha- siderably. In this paper, we present a fungus from a disseminated human lation of fungal elements which swell in the lungs to form large adia- infection presented in 2005 that could not be identified with any known spores, leading to respiratory symptoms that can be mild to severe.1 species; it was provisionally reported3 in 2009. Phylogenetically, it clus- The classical species Emmonsia parva and E. crescens mainly colonise tered among members of the recently described (Dukik K, Muñoz J, the respiratory tract of small subterranean mammals, human infections Jiang Y et al; Unpublished data) genus Emergomyces in Ajellomycetaceae only being exceptional. In contrast, the novel emmonsia-like species are and is reported below as a novel species, Emergomyces orientalis.

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silver (GMS) stains, but Mayer’s mucicarmine stain was negative. 1.1 | Case report Despite these conflicting data, a provisional diagnosis of dis- In 2005, a 64-year- old male from Shanxi, China, with no previ- seminated cryptococcosis was made and the patient was treated ous medical history, presented with a productive cough, fever and with intravenous fluconazole 200 mg twice a day for 3 weeks. pustular lesions on his neck. Within a week, similar lesions had He showed no improvement on this therapy and was therefore appeared on his face, trunk and scalp. He also developed subcu- transferred to the Peking Union Medical College Hospital. On taneous nodules throughout his body (Figure 1A,B). A computer- admission, he was febrile (38.5°C) and physical examination re- ised tomographic (CT) scan of his chest revealed multiple nodular vealed cervical and axillary lymphadenopathy and multiple new densities in the left lower lung (Figure 2 Left). He showed no papules (~1 cm in diameter) all over his body (Figure 1). He was therapeutic response to 5 days of intravenous ceftriaxone and diagnosed with type-2 diabetes mellitus and appropriate therapy penicillin G, and was therefore transferred to a tertiary hospital in was instituted. Cryptococcal antigen testing of the serum and cer- Beijing. Histopathological evaluation of a CT-guided percutaneous ebrospinal fluid were both negative. His therapy was changed to pulmonary biopsy revealed chronic granulomatous changes and amphotericin B deoxycholate plus fluconazole (200 mg twice a day a negative Ziehl-Neelsen stain. Histopathology of a subcutane- intravenous) to treat an uncharacterised invasive fungal infection. ous nodule showed fungal cells similar to those of Cryptococcus After 3 weeks, sputum fungal culture yielded a dimorphic fungus, by periodic acid-Schiff (PAS) (Figure 3) and Gomori methenamine which was provisionally identified as an emmonsia-like species.

(A) (B)

(C)

FIGURE 1 A-C, Clinical aspect of disseminated cutaneous lesions on torso and legs

(A) (B) (C)

FIGURE 2 Chest computerised tomography showing evolution of left lung lesions, A, before treatment with dense areas of consolidation visible in the left lower lobe, B, after 5 months of therapy with reduction of the lesions, and C, 10 years after therapy with only residual linear opacification Wang et al. | 3

(A) (B)

FIGURE 3 A, B, Histopathology (PAS) of bronchial biopsy showing multiple yeast cells

FIGURE 4 Declining trend in body temperature during antifungal therapy. Temperature declined 0.8°C after 8 months. The second and third of five temperature peak values were concomitant with Enterobacter sakazakii bacteraemia, while the causes of remaining temperature peaks remained unknown

TABLE 1 Clinical presentation and Presentation Follow-up Follow-up Normal laboratory parameters 24/01/2005 25/8/2005 10 years range

White cell count×10−9/L 20.26 11.92 9.22 4.00-10.00 Neutrophil count×10−9/L 17.07 9.57 6.5 2.00-7.50 Lymphocyte count×10−9/L 1.44 1.19 1.73 0.8-4.00 Platelet count×10−9/L 285 315 197 100-360 Alanine aminotransferase 28 15 24 5-40 U/L Aspartate aminotransferase 19 13 25 5-37 U/L Alkaline phosphatase U/L 377 238 111 27-107 Haemoglobin g/L 112 103 170 110-160 Creatinine μmol/L 1.11 1.06 79 (59-104)a 0.60-1.55 Albumin g/dL 7.5 3.7 45 (35-52)a 3.5-5.1 Globulin g/dL 4.4 4 2.8 3-3.4

aCreatinine method was used ELISA. To convert values for creatinine to milligrams per decilitre, divide by 88.4. 4 | Wang et al.

TABLE 2 Origins and nucleotide sequence accession numbers of isolates used in this study

Group Name (No.) Strain No. Source Accession No. Rf. No.

Group 1 Emmonsia crescens UAMH 3008, ATCC 13704, CBS 177.60 Rodent lung, Norway AF038334 5 (19) UAMH 7365 Lung of possum, New Zealand, 1992 AF038335 5 UAMH 349 Lung of mole, USA, 1954 AF038336 5 UAMH 7268 Lung of possum, New Zealand, 1992 AF038337 5 UAMH 395 Lung of Apodemus sp., Korea, 1953 AF038338 5 UAMH 393 Lung of Clethrionomys sp., Korea, 1953 AF038339 5 UAMH 394 Lung of Clethrionomys sp., Korea, 1953 AF038340 5 UAMH 136 Skunk, Lake County, Montana, USA AF038341 5 UAMH 137 Muskrat, Lake County, Mont., AF038342 5 UAMH 129 Lung of Peromyscus maniculatus borealis, AF038343 5 Alberta, 1947 UAMH 127, CBS 475.77, ATCC 10785 Mouse lung, Alberta, 1946 AF038344 5 UAMH 128 Mouse lung, Alberta, 1946 AF038345 5 UAMH 1067 Lung of wild field mouse, Edmonton, Alberta, AF038346 5 1961 UAMH 1140 Lung of wild field mouse, Alberta, 1961 AF038347 5 UAMH 4076 Soil, Edmonton, Alberta, 1976 AF038348 5 UAMH 4077 Mouldy straw bales in a mushroom house, AF038349 5 1975 UAMH 140 Lung of Peromyscus maniculatus, Alberta, 1950 AF038350 5 UAMH 132 Lung of Peromyscus maniculatus, Alberta. AF038351 5 UAMH 126, ATCC 10784, CBS 191.55 Mouse lung, Canada, 1946 AF038319 5 Group 2 E. pasteuriana (3) SYSU 2014 Human, China, 2014 KP260922 6 NCPF 4236 Type National Collection of Pathogenic Fungi, UK HF563671 1 UAMH 9510 Unknown EF592152 a E africana (16) NCPF 4164 National Collection of Pathogenic Fungi, UK HF563670 1 MVW 0029 Human, South Africa, 2008—2012 JX398288 1 MVW 0030 Human, South Africa, 2008—2012 JX398289 1 MVW 0021 Human, South Africa, 2008—2012 JX398290 1 MVW 0013 Human, South Africa, 2008—2012 JX398291 1 MVW 0009 Human, South Africa, 2008—2012 JX398292 1 MVW 0126 Human, South Africa, 2008—2012 JX398293 1 MVW 0124 Human, South Africa, 2008—2012 JX398294 1 MVW 0078 Human, South Africa, 2008—2012 JX398295 1 MVW 0059 Human, South Africa, 2008—2012 JX398296 1 MVW 0125 Human, South Africa, 2008—2012 JX398297 1 MVW 0127 Human, South Africa, 2008—2012 JX398298 1 MVW 0123 Human, South Africa, 2008—2012 JX398299 1 SN 264 Human, South Africa, 2014 KM199782 a SN 273 Human, South Africa, 2014 KM199783 a MRL 425 Human, South Africa, 2014 KM492927 21 Emmonsia sp.(3) UAMH 10427 Unknown EF592164 a UAMH 7172 HIV+ patient, Canada, 1992 AF038322 5 NCPF 4091 National Collection of Pathogenic Fungi, UK HF563672 1 UAMH 10370 Unknown EF592151 a

(continues) Wang et al. | 5

TABLE 2 (Continued)

Group Name (No.) Strain No. Source Accession No. Rf. No.

Group 3 E. parva (10) UAMH 4770 Coyote dung, Canada, 1983 AF038325 5 UAMH 134 Neotama micropus, Texas, USA, 1949 AF038326 5 UAMH 4489 Bird’s nest, Alberta, Canada, 1981 AF038327 5 UAMH 139 Weasel, Montana, USA AF038328 5 UAMH 7045 Bronchial washings, Canada, 1991 AF038329 5 UAMH 6213 Soil, Edmonton, Alberta, 1988 AF038330 5 UAMH 125 Arizona, Texas, USA, 1949 AF038331 5 UAMH 434 Soil? Italy AF038332 5 UAMH 130 Arizona, Texas, USA, 1946 AF038333 5 NCPF 4289 National Collection of Pathogenic Fungi, UK HF563673 1 Emmonsia sp.(8) UAMH 3398 Unknown EF592153 a UAMH 7101 Unknown EF592154 a UAMH 9580 Unknown EF592155 a UAMH 10539 Unknown EF592156 a UAMH 10593 Unknown EF592157 a UAMH 7101 Unknown EF592158 a UAMH 7425 Huamn, Israel, 1993 AF038323 5 UAMH 7426 Human, Israel, 1993 AF038324 5 B. dermatitidis(8) UAMH 3538, ATCC 18187, CBS 673.68 Human AF038355 5 UAMH 3604 Human, 1968 AF038356 5 UAMH 5438 Dog lung, Alberta, Canada, 1986 AF038358 5 UAMH 10246 Unknown EF592159 a UAMH 10251 Unknown EF592160 a UAMH 10592 Unknown EF592161 a UAMH 10594 Unknown EF592162 a UAMH 10245 Unknown EF592163 a Outgroup Emmonsiellopsis(2) UAMH 2304, CBS 273.77 Soil, Kansas, USA AF038320 5 UAMH 141 Soil, Boone County, USA, 1951 AF038321 5 H. capsulatum (2) UAMH 7141 Human, Clinical isolate, Alberta, Canada AF038353 5 UAMH 3536 CDC, Atlanta, USA AF038354 5 P. brasiliensis(1) UAMH 8037 Lung biopsy material, human, Alberta, Canada AF038360 5

ATCC, American Type Culture Collection, Rockville, MD, USA; CBS, Centraalbureau voor Schimmelcultures, Fungal Biodiversity Centre, Utrecht, The Netherlands; NCPF, National Collection of Pathogenic Fungi, Bristol, UK; UAMH, University of Alberta Microfungus Collection and Herbarium, Edmonton, Alberta, Canada. a(Sigler L, Peterson SW; Unpublished data).

At this point, itraconazole was added to his antifungal therapy 2 | MATERIALS AND METHODS (200 mg three times a day orally). He had an excellent response to 8 months of this therapy. The cumulative amphotericin B dose 2.1 | Mycology was 6099 mg (in PUMCH and local hospital). He was discharged on itraconazole (200 mg three times a day orally for 56 days). His Sputum and biopsy specimens were inoculated onto Sabouraud’s skin lesions, body temperature and general clinical condition all glucose 4% agar (SGA) and brain heart infusion agar (BHI) incubated normalised (Figure 4). A high-resolution CT scan conducted after at 35°C, and onto potato dextrose agar (PDA) and SGA incubated at 5 months of therapy showed that his lung lesions had diminished 25°C; plates were checked every 2 or 3 days. Light microscopic mor- in size (Figure 2B). After 10 years follow-up, he remains well and phology was observed regularly by wet mounts in lactophenol cotton free of disease and a repeat chest CT scan revealed only residual blue. For testing thermotolerance and observation of thermal dimor- linear opacifications (Figure 2C). Clinical presentation and labora- phism, strains were inoculated onto BHI and incubated at 40°C for tory parameters at different stages are compared in Table 1. 30 days. Yeast cells were transferred from BHI agar into tubes with 6 | Wang et al.

2.5% glutaraldehyde for 2 hours; sample was sent to an electron microscopy laboratory for transmission electron microscopic analysis. 5 5 5 1 22 18 19 14 Reference This study 2.2 | Phylogeny 9 299 DNA was extracted from a 20-day-old culture of the isolate (5Z489) on chocolate agar (CHL) at 37°C. PCR and sequencing analysis made use of a fungus-specific universal primer pair as previously described.4 No deposit AF038322 JX398288- AF038324 No deposit GenBank No. EU853308- AF038355 No deposit FJ214160 ITS1-M (5-GGA AGT AAA AGT CGT AAC AAG G-3) and ITS4 (5-TCC TCC GCT TAT TGA TAT GC-3) were used to amplify the rDNA internal transcribed spacer (ITS) region. The sequences used for com- parison were those of Peterson & Sigler,5 Kenyon et al.1 and Feng Italy Canada Africa South Israel Germany Geography China USA USA USA et al.6 deposited in GenBank. They are listed in Table 2. The dataset contained 74 sequences of Emmonsia species aligned using MAFFT v. 7.221.7 Alignments were also visualised and checked manually by CLUSTAL W28 and MEGA 6 1. Modeltest9 was utilised to obtain the models for ITS sequences. Phylogenetic analyses were performed using RAxML10 and MrBayes v. 3.211 (106 generations), with general HIV HIV HIV+ patient Human Rheumatoid arthritis Underlying condition Diabetes Human HIV Immunocompetent time reversible model of proportion of invariable andγ-distributed rates among sites (GTR+I+G). The outgroup used was strain UAMH 141 that was recently published as Emmonsiellopsis terrestris.12 Growth Unknown Growth Unknown Unknown 40 No growth Unknown Adiaspores Unknown 3 | RESULTS

Fungal culture of lung aspirates and skin biopsies all remained nega-

species tive. The transbronchial biopsy was not sent for fungal culture. Mould was grown on when the sputum specimen inoculated onto CHL after 19 days of incubation. The rDNA ITS domain was sequenced for routine identification. BLAST searches showed the best match with Emmonsia sp. UAMH7172 with 97% identity (565 of 582 bp without gap sites). adiaspores Small adiaspores Unknown Growth, no sporulation Restricted growth, no Growth, no sporulation 37 Growth, no adiaspores Growth, no adiaspores Growth, no sporulation Adiaspores As no close match was found, a maximum likelihood (ML) tree was constructed using Paracoccidioides, Histoplasma and Emmonsiellopsis as outgroup (Figure 6). This tree showed three main groups of emmonsia- Emmonsia and Blastomyces like species: (i) Group 1 is an Emmonsia crescens group, (ii) Group 2 Filamentous Unknown Filamentous Filamentous Filamentous Culture temperature(°C) 25 Filamentous Filamentous Filamentous Filamentous included Emergomyces pasteuriana, E. africana, our strain (5Z489) and an undescribed Emmonsia species (UAMH 7172 and UAMH 10370) and (iii) the group 3 included Blastomyces dermatitidis and Emmonsia compared with 400 μm

25 μm parva. Histoplasma, Paracoccidioides and Emmonsiellopsis were shown 100- Absent Absent Absent Absent Absent 10- Absent Adiaspore Absent as distinct clades. In group 2, a complex clade revealed emmonsia- like fungi at 42% bootstrap support (in red and dark-blue branches). Fifteen Emergomyces africana isolates from South Africa were based based based based based based based based grouped together in a well-supported clade (JX398288 to JX398299, KM199782, KM199783, KM492927) with 88% bootstrap support. Emergomyces orientalis Broad- Broad- Broad- Absent Narrow- Narrow- Narrow- Narrow- Yeast Broad- Histopathology Emmonsia pasteuriana strains UAMH 9510 (EF592151), NCPF 4236 (HF563671) and SYSU 2014 (KP260922) from Italy and China formed a well-supported clade with a bootstrap value of 85% in the ML tree. Strain UAMH 10427 (EF592164) may constitute another undescribed Emmonsia species in group 2. Group 3 had four subclades: Blastomyces isolates (subgroup 2), several emmonsia-like species (subgroup 3) and two Emmonsia parva subgroups (subgroups 1 and 4). Two unidentified Emmonsia species from humans (UAMH 7425, UAMH 7426 Species Emmonsia sp. UAMH 7426 E. parva E. parva E. crescens E. pasteuriana Emmonsia sp. UAMH 7172 E. africanus E. orientalis B. dermatitidis

TABLE 3 Characteristics of and HF563672=NCPF 4091 respectively), previously identified as Wang et al. | 7

Emmonsia parva, were in distinct lineages. Our emmonsia-like fun- identity), suggesting that it constitutes a separate, novel species, which gus 5Z489 was clustered with two unidentified taxa (UAMH 7172, is described below. Characteristics of the novel species compared with AF038322 and UAMH 10370, EF592151) at 60% bootstrap support known Emmonsia and Blastomyces species are listed in Table 3. (Figure 6). The distance between 5Z489 and its closest relatives in Emergomyces orientalis P. Wang, Y.C. Xu & Fan, H.W., sp. nov. this tree (UAMH 7172 and UAMH 10370) was large (565/582, 97% Mycobank MB 813518 Figure 5A-H.

(A) (B)

(E) (F)

(G) (H)

FIGURE 5 A, Initial culture from sputum on SDA after 20-30 days showing white to beige, felty satellite colonies; B, Detail of initial culture on CHL agar; C, D, Yeast-like colonies after 50 days of incubation at 37°C in BHI agar. E-F, Microscopy of slide culture on PDA at 28°C. G, Light microscopy of yeast-like cells after 50 days of incubation at 37°C in BHI broth; H, TEM microscopy of yeast-like cells 8 | Wang et al.

FIGURE 6 Phylogeny of Emergomyces and related genera based on rDNA ITS sequences generated by maximum likelihood (ML) with GTR+I+G; bootstrap values >80% are indicated with the branches. Red dots indicate strains from human hosts

Holotype CBS 124587 (metabolically inactive specimen under liq- transferred to CHL (Figure 5C) and BHI (Figure 5D) at 37°C, yeast colo- uid nitrogen), from sputum of a 64-year-old male with type-2 diabetes nies were yielded after 20 days of incubation. On day 20, they reached mellitus, Shanxi, China, 2005, Peng Wang; living strain from the same 2-6 mm in diameter and had a creamy texture. When incubated on batch CBS 124587=Peng 5Z489=CGMCC 2.4011. Sequences of PDA for 2 months at 28°C, the colony appeared white, waxy, in the D1/D2 LSU domain and ITS region have GenBank accession numbers centre with coiled hyphae (Figure 5B). Colony at 37°C turned from EU853308 and EU853309 respectively. white to beige when young, turning brown with age (Figure 5C,D).

3.1 | Colony characters 3.2 | Microscopy

After 20 days, on SDA (Figure 5A) at 28°C showing mycelial colonies The mycelial phase at 28°C showed hyaline hyphae which were brown with velvety texture (~1 cm in diameter). Colony reverse was 2-3 μm in diameter, after several months of incubation bearing buff to yellow. When isolates from SDA (Figure 5A) at 28°C were ellipsoidal to pear-shaped or gourd-shaped aleurioconidia, 2-5 μm Wang et al. | 9 in diameter at right angles (Figure 5E-F). At 37°C, presence of thin- With the description of Emmonsia (Emergomyces) pasteuriana in walled, globose budding cells of 4-10 μm in diameter, but occasionally 1998,14,15 a systemic human disease entity similar to blastomycosis up to 25 μm were found. Budding cells had narrow bases (Figure 5G). was uncovered, that is, disseminated infection with secondary cutane- No adiaspores were evident at any stage. No growth was observed on ous lesions and small yeast cells in tissue. Previously, Emmonsia spe- BHI agar at 40°C. Transmission electron microscopy (TEM) analysis of cies were mainly associated with asymptomatic colonisation of rodent yeast-like cells is shown in Figure 5H. lungs, and were noted only exceptionally in human adiaspiromycosis, a lung infection characterised by large resting spores in tissue.16 This paradigm has been shattered with reports of cases of disseminated in- 3.3 | Histopathology fection caused by dimorphic fungi from a wide array of countries17 and Percutaneous lung puncture biopsy specimen revealed chronic led to the introduction of several unknown novel species and their re- granulomatous inflammation with associated plasma cell infiltration. lations. (Dukik K, Muñoz J, Jiang Y et al; Unpublished data) introduced Transbronchial lung biopsy showed numerous ellipsoidal fungal cells the novel genus Emergomyces for Emmonsia pasteuriana and its close with surrounding necroinflammatory changes. Haematoxylin-eosin relatives, all with narrow-based budding cells at 37°C. In this study, (HE), periodic acid-Schiff (PAS) (Figure 3) and Gomori’s methenamine we describe the first case of infection of another agent disseminated silver (GMS) stains were positive. Mucicarmine stain was negative. No mycosis among the thermally dimorphic Onygenales, Emergomyces adiaspores were seen. A skin biopsy showed chronic granulomas and orientalis. some fungal cells. The taxonomy of dimorphic systemic fungi belonging to the Ajellomycetaceae, that includes the genera Blastomyces, Emergomyces, Emmonsia, Histoplasma and Paracoccidioides, is complex and requires 4 | DISCUSSION revision. For example, studies have demonstrated a close phylogenetic relationship between Emmonsia and Blastomyces, leading some to sug- Previously, Emmonsia species were mainly associated with asympto- gest that consideration should be given to placing them both in the matic colonisation of rodent lungs, and were noted only occasionally in same genus.5 Our phylogenetic study based on ITS sequence analysis human adiaspiromycosis (“emmonsiosis”), a lung infection characterised showed that our isolate belongs to a new species close to E. pasteur- by large resting spores in tissue.2 This paradigm has been shattered with iana. Group 1 comprises a single member and is known from rodent the description of cases of disseminated infection caused by dimorphic pulmonary adiaspiromycosis.18,19 This species is unable to convert to a emmonsia-like fungi from a wide array of countries14 and with small, yeast phase and thus is unlikely to be able to disseminate in humans.17 narrow-based budding cells at 37°C, for which the genus Emergomyces Emergomyces orientalis is located in group 2 with E. pasteuriana and has been erected. (Dukik K, Muñoz J, Jiang Y et al; Unpublished data) with several clusters of strains labelled as “Emmonsia sp.” and which We describe the first case of infection of Emergomyces orientalis with apparently represent undescribed species. Group 3 not only contains a species clustering in the Emmonsia clade as Emergomyces orientalis, a Blastomyces dermatitidis, which is able to convert to yeast cells and to further agent of disseminated cutaneous infection. disseminate at 37°C but also contains Emmonsia parva with adiaspores Emergomyces orientalis is easily distinguished from Emmonsia at this temperature. Emergomyces orientalis shows closest affinities to crescens and E. parva by absence of adiaspores in vivo and in vitro. The isolate UAMH 7172 obtained from biopsy of skin lesions in a HIV- size of the yeast cells of E. orientalis (4-10 μm) was similar to those infected individual from Saskatchewan, Canada in 19925 and UAMH of Blastomyces dermatitidis. Emergomyces pasteurianus has both small 10370 from a blood cultures from a diabetic male with a renal trans- cells which are oval to pyriform (2-4 μm) and large thick-walled cells plant and presenting with a pneumonic process, Saskatchewan, Canada (8-15 μm), all with narrow-based budding, mostly unipolar.14 At room in 2003.20 Full genome sequencing of isolates from all the emergomy- temperature, the mycelial phase of E. orientalis revealed delayed pro- ces- and blastomyces-like species will be required to provide greater duction of aleurioconidia at the end of terminal conidiophores, which resolution of phylogenetic relationships, and to clarify taxonomic were similar to conidia of B. dermatitidis. boundaries between these species. Emergomyces africana infections are mostly observed in patients with concomitant HIV infection,1 but the only source of immune REFERENCES compromise we could identify in our patient was diabetes. No source 1. Kenyon C, Bonorchis K, Corcoran C et al. 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