Case Reports

Granulomatous Dermatitis due to Malassezia sympodialis

Harsha B. Desai, MPhil, MS; Philip L. Perkins, MD; Gary W. Procop, MD, MS

N A 67-year-old man, with multiple skin lesions that some instances, with a lipid-rich hyperalimentation appeared over 2 years, had biopsies that disclosed infusion.2 Human infections by Malassezia species other granulomatous dermatitis with associated small yeasts. than M furfur have been reported, such as, for example The urinary antigen test results were negative for Malassezia pachydermatis.1,3 We report for the first time, to Histoplasma infection; cultures from the biopsies did not our knowledge, on a patient with granulomatous derma- grow any fungi or other potential pathogens. The chest titis due to Malassezia sympodialis. roentgenogram results were normal. Morphologic exami- nation revealed features of a Malassezia species. Broad- REPORT OF A CASE range fungal polymerase chain reaction and DNA se- The patient was a 67-year-old man with cutaneous lesions on quencing disclosed that the infecting fungus was Malasse- the back, chest, and neck. These lesions were biopsied over zia sympodialis, a lipid-dependent yeast. This report 2 years; the patient also had a history of multiple cutaneous supports one other case report that Malassezia species squamous cell carcinomas. Histopathologic review of these may cause granulomatous dermatitis; in the previous case, biopsies demonstrated granulomatous dermatitis (Figure 1) with small yeast forms present (Figures 2 and 3) that were of the same the etiologic agent was Malassezia pachydermatis,a size as Histoplasma capsulatum. The possibility of disseminated nonlipid-dependent species. We recommend the use of histoplasmosis was considered, but the subsequent workup lipid-supplemented culture media for specimens from included negative fungal culture results from the biopsies (ie, no patients with granulomatous dermatitis because several fungi growth), normal findings from a chest roentgenogram, and Malassezia species are dependent on lipid; the absence of a urinary antigen test result that was negative for Histoplasma. lipid supplementation in routine cultures likely explains Fungal serologic tests were not performed. The patient remained the negative culture results for this patient. This, to our otherwise asymptomatic. The slides were reexamined, given knowledge, is the first report of granulomatous dermatitis those findings. Based on the size (ie, 2 to 5 mm in diameter) and caused by M sympodialis. shape of the yeasts, and more subtle findings (ie, the presence of a collarette and broad-based buds [Figure 4]), we assigned the (Arch Pathol Lab Med. 2011;135:1085–1087) yeasts present to the genus Malassezia. Species-level identifica- tion is not possible on morphologic criteria alone. Our review of the literature revealed a single case report of granulomatous alassezia species are round to oval, often ‘‘bowling 4 M pin’’ shaped, yeasts that are routine microbiota and dermatitis caused by a Malassezia species, M pachydermatis. opportunistic pathogens of the skin of humans and MATERIALS AND METHODS domestic animals. Named for Malassez, who first de- We use broad-range polymerase chain reaction (PCR) and scribed them in 1874, these yeasts demonstrate monopolar 1 DNA sequencing in our laboratory for the characterization of budding The base of the bud is commonly described as fungi for research purposes. Additionally, we have extensive broad, and, although not always discernible, a collarette experience with the microdissection of infected, formalin-fixed, composed of residual cell wall material may be seen at the paraffin-embedded tissues for the molecular detection of base of the bud.2 These yeasts are commonly seen in the mycobacteria. We, therefore, combined these methods to further keratin layer of the epidermis of skin biopsies and, in most characterize the yeasts present in the foci of granulomatous instances, are simply commensal skin microbiota. dermatitis. Foci of the granulomatous inflammation that con- Malassezia furfur is the most commonly recognized tained the most yeast cells were mapped to the corresponding Malassezia species in humans.2 It is a cause of tinea sites on the paraffin blocks. The blocks were cleaned with alcohol and microdissected using a sterile, disposable punch biopsy tool versicolor and fungemia, the latter of which is usually (4-mm Miltex punch, Kai Medical, Honolulu, Hawaii). The associated with an intravenous catheter infection and, in dissected tissue was deparaffinized, resuspended in 360 mLof MagNA Pure bacteria lysis buffer (Roche Diagnostics, Mann- Accepted for publication December 13, 2010. heim, Germany) with approximately 100-mg glass beads (Sigma- From the Department of Pathology and Laboratory Medicine, Aldrich Chemie, Munich, Germany), and spun in a vortex mixer Cleveland Clinic, Cleveland, Ohio (Ms Desai and Dr Procop); and the for 15 minutes. This was followed by proteinase K (Roche) Department of Pathology, Munson Medical Center, Traverse City, digestion at 65 C overnight and DNA extraction using the Michigan (Dr Perkins). u The authors have no relevant financial interest in the products or NucliSENS easyMAG automated system (bioMe´rieux, Durham, companies described in this article. North Carolina) with the generic protocol and a 25-mL elution Presented in part at the 110th General Meeting of the American volume. Society for Microbiology, San Diego, California, May 26, 2010. Broad-range fungal PCR was accomplished using a PCR that Reprints: Gary W. Procop, MD, MS, Department of Pathology and targeted the portion of the 28S ribosomal RNA gene, as Laboratory Medicine, Cleveland Clinic, 9500 Euclid Ave, L11, Cleve- previously described.5 The Rotor-Gene 3000 (Qiagen, Valencia, land, OH 44195 (e-mail: [email protected]). California) was used for PCR and gel electrophoresis (2% Arch Pathol Lab Med—Vol 135, September 2011 Granulomatous Dermatitis due to Malassezia—Desai et al 1085 Figure 1. Nonnecrotizing granulomas fill the dermis in this skin biopsy (hematoxylin-eosin, original magnification 3100). Figure 2. Yeast forms were apparent within the vacuoles present within the granulomas (arrow) (hematoxylin-eosin, original magnifi- cation 31000). Figure 3. The yeasts were round to oval, and some demonstrated monopolar buds (Gomori methenamine silver, original magnification 3500). Figure 4. The base of the bud was broad (arrow), and some demonstrated evidence of a collarette associated with the base of the bud (Gomori methenamine silver, 31000 magnification).

Agarose E-gel, Invitrogen, Carlsbad, California) was performed fungemia in patients with an intravenous access catheter, to determine whether amplification of the target had occurred. particularly those receiving lipid-containing hyperalimen- The amplified product was purified using the QIAquick PCR tation.2 Cultures for M furfur are complicated by a growth purification kit (Qiagen) and was submitted to the DNA requirement of the fungus for long-chain fatty acids; in the sequencing core facility for traditional dye-terminator sequenc- laboratory, this requirement may be met through the use ing (Cleveland Clinic Genomic Core Facility, Lemar Research 2 Institute, Cleveland, Ohio). The DNA sequence was manually of a sterile olive oil overlay of the agar media. Unlike M examined for quality and compared against GenBank (National furfur, Malassezia pachydermatis and certain other Malasse- Center for Biotechnology Information, Bethesda, Maryland; zia species are not lipid dependent and will grow in the http://blast.ncbi.nlm.nih.gov/Blast; accessed July 28, 2010) absence of long-chain fatty acid supplementation. Malas- genetic database, using the Basic Local Alignment Search Tool sezia pachydermatis, which is most commonly associated (BLAST). This comparison demonstrated a 100% sequence with canines, has been reported to cause skin infections in homology with M sympodialis, with 2% difference between M both human and domestic animals.3,4 In addition, M sympodialis and the next Malassezia species in the sequence pachydermatis was reported as the cause of granulomatous database. dermatitis in a human; that report suggests that Malassezia species are capable of producing granulomatous skin PATHOLOGIC FINDINGS disease.4 Malassezia species are commensal microbiota of the skin Malassezia sympodialis, like M furfur, is an obligatory of humans and animals but are known to cause disease, lipophilic Malassezia species.6 The cells of M sympodialis such as tinea (pityriasis) versicolor and pityrosporum are ovoid to globose, 1.5 to 2.5 mm by 2.5 to 6.0 mm, with a folliculitis. Malassezia furfur is a well-known cause of distinct collarette.6 Repetitive or sympodial budding may disease in humans.2 It causes tinea versicolor and be observed.6 The buds have been described as having a 1086 Arch Pathol Lab Med—Vol 135, September 2011 Granulomatous Dermatitis due to Malassezia—Desai et al narrow base, although a broader base was appreciated in sympodialis. Finally, this case demonstrates that, although this case.7 Malassezia sympodialis has been reported as the technical challenges still exist, molecular methods are most frequent skin-colonizing yeast in both patients with useful in characterizing fungi present in formalin-fixed, atopic eczema, as well as healthy individuals.8 It has also paraffin-embedded tissues. been associated with folliculitis and catheter-related References 9,10 infections. In animals, it has caused otitis externa in 1. Macon MJ, Powel DA. Human infections due to Malassezia spp. Clin 7,11 cats and is a known commensal of swine. In addition Microbiol Rev.1992;5(2):101–119. to M furfur and M sympodialis, there are other lipid- 2. Warren NG, Hazen KC. Candida, Cryptococcus and other yeasts of medical dependent Malassezia species, such as Malassezia dermati- importance. In: Murrry PR, Baron EJ, Pfaller MA, Tenover FC, Yolken RH, eds. Manual of Clinical Microbiology. 7th ed. Washington, DC: American Society For tis, Malassezia nana, and Malassezia equi, which require Microbiology; 1999;95:1184–1199. nucleic acid analysis for reliable differentiation.12 3. Levin NA. Beyond spaghetti and meatballs: skin diseases associated with The morphologic features present, such as a small size, a the Malassezia yeasts. Dermatol Nurs. 2009;21(1):7–13,51. 4. Fan YM, Huang WM, Li SF, Wu GF, Lai K, Chen RY. Granulomatous skin broad-based bud, and evidence of a collarette, support the infection caused by Malassezia pachydermatis in a dog owner. Arch Dermatol. molecular identification of Malassezia species. Although 2006;142(9):1181–1184. M pachydermatis has been associated with granulomatous 5. Sandhu GS, Kline BC, Stockman L, Roberts GD. Molecular probes for dermatitis, it is likely that the Malassezia species causing diagnosis of fungal infections. J Clin Microbiol. 1995;33(11):2913–2919. 6. Gue´ho E, Midgley G, Guillot J. The genus Malassezia with description of disease in this patient was a lipid-dependent species four new species. Antonie Van Leeuwenhoek. 1996;69(4):337–355. because the culture results from the biopsies remained 7. Crespo MJ, Abarca ML, Caban˜es FJ. Otitis externa associated with negative (ie, M pachydermatis would have grown in routine Malassezia sympodialis in two cats. J Clin Microbiol. 2000;38(3):1263–1266. 8. Schmid-Grendelmeier P, Scheynius A, Crameri R. The role of sensitization fungal cultures without lipid supplementation, whereas to Malassezia sympodialis in atopic eczema. Chem Immunol Allergy. 2006;91: lipid-dependent species would not have grown). 98–109. The sequence-based identification of a lipid-dependent 9. Ishinkin N, Zasshi G. A case of central venous catheter-related infection with Malassezia species, M sympodialis, is consistent with the Malassezia sympodialis. Nippon Ishinkin Gakkai Zasshi. 2001;42(4):220–222. 10. Akaza N, Akamatsu H, Sasaki Y, et al. Malassezia folliculitis is caused by failure to grow this fungus in routine culture. This report, cutaneous resident Malassezia species. Med Mycol. 2009;47(6):618–624. in conjunction with the previous report of granulomatous 11. Nardoni S, Merildi V, Frangioni S, et al. Isolation and characterization of dermatitis caused by M pachydermatis, suggests that Malassezia spp. in healthy swine of different breeds. Vet Microbiol. 2010;141(1– Malassezia species are possible etiologic agents in patients 2):155–158. 12. Caban˜es FJ, Herna´ndez JJ, Castella´ G. Molecular analysis of Malassezia with this disease. To our knowledge, this is the first report sympodialis–related strains from domestic animals. J Clin Microbiol. 2005;43(1): of a patient with granulomatous dermatitidis due to M 277–283.

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