Postgraduate Medical Journal (September 1979) 55, 593-594 Postgrad Med J: first published as 10.1136/pgmj.55.647.593 on 1 September 1979. Downloaded from

Systemic opportunistic fungal infections R. VANBREUSEGHEM C. DE VROEY M.D. D.Sci. Institute of Tropical Medicine, Nationalestraat 155, B-2000, Antwerpen, Belgium

Summary tary deficiencies. The fungus invades the dermis, The clinical manifestations of 'opportunistic' fungal subcutaneous tissues, lymph nodes and viscera and infections in compromised hosts, asthenomycoses, is usually fatal. Liautaud (1977) studied the role of differ from those caused by the same fungus in other- host defence mechanisms in 33 published and wise normal people. Examples are given on the field of personal cases. Although unable clearly to delineate dermatophytoses, aspergillosis, candidiasis and crypto- any specific immunological factors, there was coccosis. definite evidence that the factor or factors can be genetically transmitted and are linked with a high Introduction degree of inbreeding in the Algerian population. It is rather surprising that so many papers, round- Strains of Trichophyton violaceum from patients table discussions and symposia have been and still with 'maladie dermatophytique' used in inoculation Protected by copyright. are devoted to 'opportunistic fungus infections' when experiments with white mice were not more patho- this description and the term 'opportunistic fungi' genic to the mice than were dermatophytes from have been the subject of much criticism and dis- other sources. The inference is that the different agreement. During the Ciba Foundation meeting on clinical pictures were a result of abnormalities of 'Systemic Mycoses' in Ibadan, Nigeria, in 1967, it was host-susceptibility rather than fungal pathogenicity suggested that the term 'opportunistic infection' was (Courtois, 1977). useful to designate and drawattention to an important Fungi other than dermatophytes also behave group of infections, but it is unattractive in various differently in compromised hosts - the clinical mani- aspects and has not been universally accepted. festations may be atypical, the course of a normally Vanbreuseghem and Larsh in 1975 (1977) sug- chronic infection may be acute, the prognosis is gested the term 'asthenomycosis' to describe mycoses always unfavourable and treatment often unsuc- due to any species of pathogenic fungus developing cessful. as the result of the predisposing role of other The systemic mycoses which predominate in diseases, the use of therapeutic agents or other Western Europe are aspergillosis, candidiasis and unknown causes. cryptococcosis. One of the authors (R.V.) recently maintained that Aspergillosis has a wide variety of clinical mani- http://pmj.bmj.com/ all fungi are opportunistic. The clinical manifesta- festations including otomycosis, keratomycosis, tions of dermatophytic infections in compromised sinusitis, colonization of cavities in lung resulting hosts differ from those in normal patients. They may from destructive changes of tuberculosis. These be more widespread, may cause deep seated lesions, mycoses and even pulmonary aspergilloma are not e.g. Majocchi's granuloma, abscesses and even normally regarded as diseases of compromised hosts mycetoma or mycetoma-like lesions. Corticosteroid and are self-limiting. In compromised hosts, invasion therapy is a recognized predisposing factor but in may occur of surrounding tissues and consequently on October 2, 2021 by guest. many patients no such factors can be demonstrated by haematogenous spread to other organs. (Cremer, 1963; Gotz, 1962; Rook, Wilkinson and The Candida spp. and other yeasts also behave Ebling, 1968; Thorne and Fusaro, 1971; Burgoon, differently in compromised and non-compromised et al., 1974). hosts. Candidiasis ofthe vagina, mucous membranes, The importance of host factors in patients with skin and nails is commonly seen in otherwise normal chronic extensive dermatophytic infection is de- patients. Granulomatous candidiasis and invasive or scribed by Hay (1979). disseminated candidiasis are diseases of com- Hadida and Schousboe (1959) used the term promised hosts. The site of infection and the organ- 'maladie dermatophytique' to describe the unusual isms may be the same in different patients but the clinical manifestations of dermatophytic infection in host response results in a totally different clinical a group of patients with as yet unexplained heredi- presentation. The potential severity of Candida in- 0032-5473/79/0900-0593$02.00 C)© 1979 The Fellowship of Postgraduate Medicine 594 R. Vanbreuseghem and C. De Vroey Postgrad Med J: first published as 10.1136/pgmj.55.647.593 on 1 September 1979. Downloaded from fection of the mucous membranes and skin is well specific for a systemic mycosis in a compromised illustrated by Rosman (1979). Cutaneous mani- host, better analyses of reported cases indicate that festations of haematogenous spread of Candida have the clinical manifestations differ from those in non- been described by Balandran et al. (1973) and Bodey compromised patients. The differences are important and Luna (1974). Nodular lesions, located in the as they may lead to earlier diagnosis (Bodey and dermis, with an erythematous halo were observed in Luna, 1974; Schupbach et al., 1976). 13% of patients with acute leukaemia and proved The symptomatology of asthenomycoses is dif- disseminated candidiasis. The lesions were similar in ferent from that caused by the same fungi in other- appearance to those seen in allergic drug rashes. wise normal patients. Cryptococcus neoformans may be responsible for acute, subacute and chronic infections in both com- References promised and non-compromised hosts. The clinical BALANDRAN, L., ROTHSCHILD, H., PUGH, N. & SEABURY, J. presentations may be the same in both host groups (1973) A cutaneous manifestation of systemic candidiasis. but the frequency of infection is commoner in Annals of Internal Medicine, 78, 400. BODEY, G.P. & LUNA, M. (1974) Skin lesions associated with compromised patients. desseminated candidiasis. Journal of the American Medical The commonest clinical manifestation is meningi- Association, 229, 1466. tis, the portal of entry being the respiratory tract. BURGOON, C.F., BLANK, F., JOHNSON, W.C. & GRAPPEL, S.F. Pulmonary symptoms are usually transitory and (1974) Mycetoma formation in Trichophyton rubrum infec- tions. British Journal of Dermatology, 90, 115. unrecognized. Butler et al. (1964) studied 40 cases of BUTLER, W.T., ALLING, D.W., SPICKARD, A. & UTZ, J.P. cryptococcal meningitis of which only 20 had a (1964) Diagnostic and prognostic value of clinical and recognizable underlying disease. They did not com- laboratory findings in cryptococcal meningitis: A follow-up ment on differences between the 2 categories but study of forty patients. New England Journal of Medicine, 270, 59. generally the evolution of disease is more acute in COURTOIS, P.H. (1977) Les dermatophyties semi-profondes compromised hosts. et profondes: aperqu de la litterature et experimentationsProtected by copyright. Primary cutaneous cryptococcosis is a very rare personnelles. Thesis, Institute of Tropical Medicine, event. Lasagni, Riboldi and Berti (1978) reported a Antwerp, Belgium. CREMER, G. (1963) A special granulomatous form of mycosis patient with apparently primary cutaneous crypto- on the lower legs caused by Trichophyton rubrum Castellani. coccosis of about 20 years' duration and without Dermatologica, 107, 28. systemic involvement. Multiple skin lesions usually DAMAN, L.A., HASHIMOTO, K., KAPLAN, R.J. & TRENT, W.G. indicated disseminated disease (Sarosi, Silberfarb (1977) Disseminated histoplasmosis in an immunosup- pressed patient. Southern Medical Journal, 70, 355. and Tosh, 1971). Schupbach et al. (1976) believe that GOTZ, H. (1962) Die Pilzkrankheiten der Haut durch Dermato- cutaneous manifestations of disseminated crypto- phyten, p. 190. Springer Verlag, Berlin. coccosis are commoner than currently appreciated. HADIDA, E. & SCHOUSBOE, A. (1959) Aspects de la maladie In 5 patients the skin lesions were the first indication dermatophytique. Algerie Medicale, 63, 303. HAY, R.J. (1979) Failure oftreatment in chronic dermatophyte of underlying cryptococcosis in immunosuppressed infections. Postgraduate Medical Journal, 55, 608. patients. The lesions on the extremities initially LASAGNI, A., RIBOLDI, A. & BERTI, E. (1978) A case of resembled cellulitis followed by herpes-type vesicu- cryptococcosis of the skin. In: Proceedings of the Inter- lations and ulceration. The initial diagnosis of national Cilag-Chemie Symposium, Flims, Switzerland, bacterial cellulitis was disproved by observing yeast January, 24-26. Ed. Ch. Diefenbach, Mykosen, Supple- mentum 1/78. http://pmj.bmj.com/ cells in direct films and by culturing C. neoformans. LIAUTAUD, B. (1977) Mecanisme de defense au cours des Increased awareness of cutaneous involvement dermatophvtoses. These de Doctorat en Sciences Medicales. should result in some cases of disseminated crypto- Universit6 d'Alger, Algeria. ROOK, A., WILKINSON, D.S. & EBLING, F.J.G. (1968) Text- coccosis being diagnosed earlier. book of Dermatology, p. 851. Blackwell Scientific Publica- Histoplasma capsulatum, usually regarded as a tions, Oxford. 'primary pathogen', produces atypical infections in ROSMAN, N. (1979) Chronic mucocutaneous candidiasis. compromised hosts. Daman et al. (1977) reported a Postgraduate Medical Journal, 55, 61 1. SAROSI, G.A., SILBERFARB, P.H. & TOSH, F.E. (1971) third case of disseminated histoplasmosis associated Cutaneous cryptococcosis: a sentinel of disseminated on October 2, 2021 by guest. with immunosuppressive therapy which presented as disease. Archives of Dermatology, 104, 103. an erysipelas-like eruption and panniculitis. H. SCHUPBACH, C.W., WHEELER, C.E., BRIGGAMAN, R.A., capsulatum was demonstrated in biopsies. WARNER, N.A. & KANOF, E.P. (1976) Cutaneous mani- festations of disseminated cryptococcosis. Archives of Other mycoses apparently only occurring in com- Dermatology, 112, 1834. promised hosts include those caused by Mucor, THORNE, G. & FUSARO, R. (1971) Subcutaneous Trichophyton Alternaria and Geotrichum. rubrutm abscesses. Dermatologia, 142, 167. VANBREUSEGHEM, R. & LARSH, H.W. (1977) Conclusions to the round-table on the global problems due to opportu- Conclusion nistic fungi. In: Recent Advances in Medical and Veterinary Although it is generally accepted that there are no Mycology (Ed. by Iwati, K.), p. 253. University of Tokyo symptoms, X-rays or laboratory findings which are Press.