L. Ajello

Imported penicilliosis marneffei in the United States: report of a second human infection

The first natural infection due to Penicillium marneffei in a human was reported in the United States in 1973. We describe a second case of penicilliosis marneffei that was diagnosed in Florida. In both instances, the patients had a history of travel in Southeast Asia where P. marneffei is endemic. The Florida patient had recurrent episodes of hemoptysis attributed to bronchitis and bronchiectasis. In spite of therapy with various antibacterial antibiotics for tuberculosis, the granulomatous lesions in the left upper lobe of the lungs persisted. The diagnosis of penicilliosis marneffei was established by isolating and identifying the dimorphic species of Penicillium, P. marneffei. The histopathologic features of the lung tissue included granulomata with central areas of necrosis and neutrophilic infiltration with many yeast-like, tissue-form cells of P. marneffei, which multiplied by a fission rather than a budding process.

CRITICAL REVIEW OF HUMAN ISOLATES OF WANGIELLA DERMATITIDIS

We studied critically 26 isolates that had been called Wangiella dermatitidis (including Kanos type culture) and were variously described in the literature as causal agents of chromoblastomycosis, chromomycosis, or phaeohyphomycosis. Only 21 ofthe 26 proved to be W. dermatitidis, on the basis of colonial and microscopic morphology, thermotolerance, decomposition of tyrosine, and exoantigen tests. Eighteen of the 21 confirmed isolates were from Japan, two from Taiwan, and one from the U.S. The remaining five isolates were identified as Exophiala jeanselmei (2), E. moniliae (2), and Fonsecaea pedrosoi (1). We also reviewed the clinical aspects of the infections, their treatment, and the histopathologic appearance of the etiologic agents in 21 cases of phaeohyphomycosis. Wangiella dermatitidis should be recognized as a dermatotropic as well as a neurotropic agent among the pathogenic dematiaceous Hyphomycetes. The high case-fatality rate (48%) caused by W. dermatitidis clearly emphasizes that this mould is an important agent of systemic phaeohyphomycosis with a marked tendency to invade the central nervous system. In the case reports, the indiscriminate use ofthe term sclerotic cells to describe the tissue forms of these fungi was not in accord with their true nature. In tissue they developed dark-walled mycelium, spherical cells, with or without buds or toruloid hyphae, either alone or in various combinations. The absence of muriform cells clearly showed that the patients had developed phaeohyphomycosis, not chromoblastomycosis. We propose that the ambiguous and inappropriate term sclerotic cells be replaced by the more appropriate term muriform cells to describe precisely the tissue form of the causal agents of chromoblastomycosis.

MEDICAL SIGNIFICANCE OF THE SO-CALLED BLACK YEASTS

Infections caused by the black yeasts (leveduras pretas) are reviewed with respect to their clinical manifestations, classification under the umbrella term, phaeohyphomycosis, and differentiation from chromoblastomycosis. Data on the prevalence of black yeasts submitted to a national reference diagnostic center are provided. Cases of phaeohyphomycosis caused by Aureobasidium pullulans, Exophiala jeanselmei, E. moniliae, E. spinifera, Phaeoannelomyces werneckii, Phaeosclera dematioirles, Sarcinomyces phaeomuriformis, and Wangiella dermatitidis are described.

Imported paracoccidioidomycosis : A public health problem in non-endemic areas

Diagnosis of paracoccidioidomycosis in an immigrant who had returned to Italy following a long sojourn in Venezuela prompted a review of imported cases of this Latin American disease in nonendemic countries. Forty-two such instances of well documented paracoccidioidomycosis were compiled. Among these, eleven individuals had arrived in nonendemic countries with active symptomatic infections, fifteen others were first suspected of having tuberculosis, and four each were considered to have blastomycosis caused by Blastomyces dermatidis and carcinomas. Three, individuals were considered to have Wegners granulomatosis or blastomycosis. Two other patients were treated for syphilis before being diagnosed as having paracocidioidomycosis. A striking feature of most of these cases was the long asymptomatic period following initial infection. The dormant periods ranged form four months to 60 years with an average duration of 14 years. The need to question patients about travel to or residency in foreign countries is emphasized, along with the necessity to include the mycoses in differential diagnoses. Three reported cases, all from Africa with no history of travel to the endemic areas of the New World, were considered to be doubtful. In one of these, Russell bodies apparently had been mistaken for the tissue-form cells of Paracoccidioides brasiliensis. A Japanese case, upon restudy of available histologic slides, revealed that the fungal cells present in various organs were those of Cryptococcus neoformans and not of P. brasiliensis.

An outbreak and review of cave-associated histoplasmosis capsulati

Three male college students from Florida developed acute onsets of fever, chills, shortness of breath, and cough within one day of each other, and all were eventually hospitalized for four to 29 days. All chest x-ray films showed diffuse reticulonodularities in both lung fields. Laboratory studies confirmed the diagnosis of histoplasmosis. The three students had been spelunking (cave exploring) 6 to 7 days before their onset of symptoms. One of four soil samples collected in the caves was positive for Histoplasma capsulatum by the indirect mouse inoculation procedure. Of three investigators who entered the implicated caves, two developed acute febrile illness within 15-21 days. One investigator was hospitalized for 18 days with a confirmed diagnosis of histoplasmosis. Investigation identified an additional case (the person had entered the caves 6 months before this episode), but was not reported to health authorities. Spelunkers should be aware of the potential risk of histoplasmosis and how to avoid infection. Physicians should be cognizant of cave-associated histoplasmosis, inquire about spelunking in persons who develop febrile respiratory illnesses with diffuse nodularities on chest x-ray films, and report such cases to their health department. A review of 42 reported outbreaks of cave-associated histoplasmosis and the approach to environmental control of infected caves are included.

Wangiella dermatitidis endocarditis in an intravenous drug user

Wangiella dermatitidis is an infrequently encountered dematiacious fungus that usually causes localized infections of the skin and subcutaneous tissues. This report presents the first well-documented case of natural valve infection caused by this organism as it occurred in intravenous drug abuser. His course has been complicated by relapsing infection of two aortic prostheses and dissemination to the vertebral spine. Treatment with a combination of amphotericin B, rifampin, and ketoconazole has arrested the progression of his infection. The microbiologic features and existing clinical information regarding this fungus are reviewed and in vitro susceptibility data for the present isolate are presented.

Phaeohyphomycosis caused by Exophiala moniliae

We studied two cases of phaeohyphomycosis that occurred in Japan. Histopathologic examination of biopsy material showed the presence of dematiaceous catenulate fungal cells and mycelium characteristic of phaeohyphomycosis. In detailed mycologic study of the two cultures isolated from the patients we found that both formed conidiogenous cells with proximal swellings with long, neck-like extensions bearing distinct annellations and clusters of conidia at their apices. The isolates were identified as Exophiala moniliae de Hoog. These two Japanese cases are the second and third known cases of phaeohyphomycosis caused by E. moniliae and the first recorded in that country.

Fungal melanonychia: ungual phaeohyphomycosis caused by Wangiella dermatitidis

A 51‐year‐old female Japanese patient developed black pigmentation affecting both big toe‐nails. Direct potassium hydroxide examination of the nail tissue demonstrated clusters of spherical dematiaceous cells, toruloid hyphae, and septate hyphae. Wangiella dermatitidis was repeatedly isolated from the affected toe‐nail lesions. This case represents the first documented case of ungula phaeohyphomycosis, ‘fungal melanonychia,’ caused by the dematiaceous fungus W. dermatitidis. The patient was successfully treated with a topical solution of bifonazole.

Systemic zygomycosis caused by Apophysomyces elegans.

A case of systemic zygomycosis caused by Apophysomyces elegans in a 56-year-old man is described. The left kidney and the bladder showed presence of broad, nonseptate-to-infrequently septate hyphae in both the bladder lesion and in the septic kidney. Surgical debridement and treatment with amphotericin B cured the infection. No underlying immune defect was ever demonstrated, and the patient was not hyperglycemic or acidotic at any time. This zygomycetous fungus closely resembles Absidia corymbifera, but is distinguished by its distinctive morphological features.

Current Taxonomic Concepts Pertaining to the Dermatophytes and Related Fungi

During the past four decades, there has been a considerable increase in studies about mycotic infections in both humans and animals. Although nearly every medical specialty now includes a discussion of mycotic disease in its scientific programs and publications, only dermatologists really have shared the mycologists interest in mycotic diseases until three decades ago. Superficial cutaneous mycotic infections primarily involve the keratinized tissues of the epidermis, pilosebaceous follicles, and nails. Their etiologic agents constitute a group of microorganisms categorized as causing dermatophytosis, candididiasis, tinea nigra, tinea versicolor, and piedra. Since they have a predilection for the skin and its appendages, gross hairs and scrapings of keratinized tissue are readily obtained for direct microscopic examinations and culture studies. Dermatophytosis has been known for a long time, and the dermatophytes were among tbe first pathogenic microorganisms to bave been recognized and named. In his historical review of the dermatophytes, Ajello marked 11 milestones that contributed major scientific developments and breakthroughs in this field. He stated that the development of our knowledge of tbe dermatophytes parallels that of medical mycology in general. The taxonomy and nomenclature of the dermatophytes had remained most unsatisfactory and confusing for a long period of time until the discovery of sexual reproduction among the dermatophytes and related fungi. This led to general agreement on the taxonomic and genetic status of this highly specialized group of pathogenic fungi. In this review, major emphasis is placed on directing the reader to appropriate