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First Reported Australian Case of Cladophilophora Arxii: Features Consistent with Possible Primary Pulmonary Chromoblastomycosis

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First Reported Australian Case of Cladophilophora Arxii: Features Consistent with Possible Primary Pulmonary Chromoblastomycosis Am. J. Trop. Med. Hyg., 92(4), 2015, pp. 791–793 doi:10.4269/ajtmh.14-0711 Copyright © 2015 by The American Society of Tropical Medicine and Hygiene Case Report: First Reported Australian Case of Cladophilophora arxii: Features Consistent with Possible Primary Pulmonary Chromoblastomycosis Anna Brischetto,* Sarah Kidd, and Rob Baird Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Northern Territory, Australia; National Mycology Reference Centre, SA Pathology at Women’s and Children’s Hospital, Adelaide, Australia; Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Northern Territory, Australia Abstract. We describe the first case of possible pulmonary chromoblastomycosis in the absence of any identified cutaneous lesions in a relatively immunosuppressed man. The causative organism was Cladophialophora arxii, which is a rare pathogen that has only been described as causing human disease two times previously. INTRODUCTION fludeoxyglucose (FDG) uptake. A decision was made to per- form a video-assisted thoracoscopic surgery (VATS) right Chromoblastomycosis, a localized chronic cutaneous and wedgeresectionofthelesionwithanintraoperativefrozensec- subcutaneous infection of the skin caused by pigmented fungi, tion in July of 2013. An intraoperative frozen section revealed is most common in the world’s tropical and subtropical 1,2 brown-pigmented cells resembling muriform cells (or medlar zones. The condition rarely occurs in Australia, although bodies), consistent with a diagnosis of chomoblastomycosis. six cases of chromoblastomycosis were seen at the Royal Histopathology examination of the resected right lung tis- Darwin Hospital, Northern Territory from 1989 to 1994.3 The sue revealed nodular areas of pneumonitis with focal areas of pathognomonic finding is the presence of brown spores or chronically inflamed fibrosis containing aggregates of brown- sclerotic bodies within granulomata or microabscesses in the pigmented fungal hyphae and fungal cells engulfed in brown- skin.1 We present the third possible case, to our knowledge, of pigmented macrophages (Figure 1). The features were consistent chromoblastomycosis involving the lung in a relatively immu- with chromoblastomycosis. nosuppressed patient. The causative organism in this patient C. arxii was grown from lung tissue and sent to the National (Cladophialophora arxii), while producing characteristic Mycology Reference Center (NMRC), SA Pathology, Adelaide histological features, is also a rarely identified and recently for identification and susceptibility testing. This fungus was slow characterized pathogen. This is only the third reporting of this growing at 35°C and eventually produced a dark, olivaceous, fungus causing disease in humans. grey felt-textured colony with dark reverse. Darkly pigmented hyphae were observed in highly branched chains of brown, smooth-walled, lemon-shaped conidia. Identification was con- CASE REPORT firmed by DNA sequencing of the internal transcribed spacer 4 – A 67-year-old man was undergoing radiographic computed (ITS) regions, with 98 99% sequence identity to other quality- tomography (CT) surveillance at the Hematology Clinic of controlled C. arxii sequences in the Centre for Biological Royal Darwin Hospital for diffuse large-cell B-cell lymphoma Sequence Analysis (CBS) and Genbank databases. The isolate is (DLCBL) in remission. He was found to have developed a stored in the NMRC culture collection, and the ITS sequence was right upper lobe irregular lesion in October of 2012. Differen- submitted to the Genbank database (accession no. KP223283). Antifungal susceptibility testing was performed using the tial diagnosis for the lesion included infective change or recur- 5 rent lymphoma. This was on a background history of diagnosis CLSI M38 A2 standard. Minimum inhibitory concentra- m with DLCBL in 2008. He was treated soon afterward 14 times tions (MICs) were as follows: amphotericin B, 2 g/mL; m m with six cycles of rituximab, cyclophosphamide, doxorubicin, 5-flucytosine, 32 g/mL; fluconazole, 64 g/mL; itraconazole, m m m vincristine, and prednisolone (R-CHOP) among other therapy. 0.12 g/mL; voriconazole, 0.06 g/mL; posaconazole, 0.03 g/ m m Relevant past medical history included Hodgkin’s lymphoma mL; caspofungin, 2 g/mL; anidulafungin, 2 g/mL; and m in 1971 (treated with radiotherapy and splenectomy) and metal micafungin, 2 g/mL. Although there are no interpretive aortic valve replacement for aortic regurgitation in 2006. He breakpoints currently accepted for any drug against this was asymptomatic from the lesion apart from some mild wors- species, the triazole drug MICs would generally be considered ening of shortness of breath on exertion. low and indicative of in vitro sensitivity. Over 4 months, the nodular density increased in size from No cutaneous lesions of chromoblastomycosis were found 17 + 11 to 17 + 14 mm. He underwent a bronchoscopy with after careful examination. The patient was initially treated negative mycobacterial, Nocardia, fungal, and bacterial cul- with oral fluconazole at 400 mg daily. This was ceased after tures and negative human immunodeficiency virus (HIV) test- 2 weeks because of raised liver enzymes, with a peak alanine ing. A CT-guided biopsy was attempted but unsuccessful, and a transaminase (ALT) of 143IU/L. It was decided by the infec- Positron emission tomography (PET) scan showed no avid tiousdiseasesteamtomonitorthepatientratherthantreatwith an antifungal, because the lesion appeared to have been completely excised, and there were issues with azole side effects. The patient was reviewed regularly in the infectious diseases outpatient clinic. A repeat CT scan performed 4 months post- *Address correspondence to Anna Brischetto, Department of Infec- tious Diseases, Royal Darwin Hospital, 105 Rocklands Drive, Tiwi, surgery showed no recurrence of the pulmonary lesion. He was Northern Territory, Australia, 0810. E-mail: [email protected] feeling fit and well, with a return of his exercise tolerance. 791 792 BRISCHETTO AND OTHERS Figure 1. (A) Right lung microscopy showing nodular areas of pneumonitis. There are focal areas of chronically inflamed fibrosis containing aggregates of brown pigmented fungal hyphae and fungal cells (arrow), which are sometimes engulfed in brown-pigmented macrophages. (B) Periodic acid-Schiff stain of right lung tissue showing fungal cells and hyphae (arrow) within areas of pneumonitis. (C) Lactophenol cotton blue stain from plate culture of the fungus showing erect, partially apically branched, elongated conidiophores producing acropetal chains of smooth-walled conidia of C. arxii. The conidia are limoniform to fusiform (2.0–4.0 mm in size). He was last reviewed 1-year post-removal of the lesion, and he also relatively immunosuppressed, having received chemother- had a normal chest X-ray and remained asymptomatic. apy for DLCBL a few years previously. This relative immuno- suppression may account for the unusual presentation of a primary pulmonary presentation of chromoblastomycosis. The DISCUSSION only other reported case of chromoblastomycosis involving the lung was in a 40-year-old male in Kenya with associated Chromoblastomycosis refers to cutaneous or subcutaneous cutaneous lesions on the legs. The causative organism was lesions caused by melanized fungi. Pathognomonic of this Cladosporium trichoides.12 condition is the presence of muriform cells on histology, The causative agent in our case was C. arxii, which is a rare, which are round, brown sclerotic cells seen on direct micros- recently identified dematiaceous fungus. It was first identified copy.1,2,6 The conditions under which these bodies form and as a new member of the genus Cladophialophora in 1991.13 how they do it is not completely understood.7 The most com- The clinical case described an otherwise well 22-year-old mon causative agents are Fonsecaea pedrosoi, which is gener- woman with a 5-cm granulomatous pulmonary lesion. This ally seen in humid environments, and Cladophialophora was surgically excised and incorrectly identified as sarcoido- carrionii, which is the most common causative agent seen in sis. Two years later, recurrent lesions were found on the tra- Australia.3 It is usually seen in otherwise healthy individuals, chea and intra-abdominally. These grew the new species of and extradermal spread is extremely rare. Cases have been Cladophialophora C. arxii. Muriform bodies, similar to those described in the cornea,8 liver,9 lymph nodes,10 and recently, described in our case, were found on histological examination lung11 but usually, they are in the presence of skin lesions. of all of the lesions. After surgical excision of the lesions, the Phaeohyphomycosis refers to clinical syndromes caused by patient was treated with 6 weeks of flucytosine and itraconazole melanized fungi that are not classified as eumycetoma or andthencontinuedonitraconazolealonefor12months.She chromoblastomycosis.7 Eumycetoma is characterized by the was free of symptoms at 2 years post-therapy. To the best of presence of grains or sclerotia on histopathological examina- our knowledge, the only other case of C. arxii infection in tion, and chromoblastomycosis must have the presence of the humans was a case of femoral osteomyelitis in a patient with pathognomonic muriform cells. Phaeohyphomycosis, there- chronic granulomatous disease.14 fore, shows dark fungal hyphae on histopathological examina- Both surgical and medical treatments of chromoblas- tion without the presence of muriform cells
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