Mycopathologia DOI 10.1007/s11046-015-9887-0
Cutaneous Chromoblastomycosis Caused by Veronaea botryosa in a Patient with Pemphigus Vulgaris and Review of Published Reports Cheng-Yao Zhu • Yan-Ping Yang • Ping Sheng Wen Li • Wen-Ming Huang • Yi-Ming Fan
•
Received: 13 January 2015 / Accepted: 21 March 2015 Ó Springer Science+Business Media Dordrecht 2015
Abstract Chromoblastomycosis and phaeohyphomycosis represent two poles of a disease spectrum caused by melanized fungi. Veronaea botryosa belongs to a small genus of saprobic fungi that occasionally cause human infections. To date, 11 cases of V. botryosa-induced cutaneous phaeohyphomycosis have been actually reported since 1990 after exclusion of 2 duplicated cases. We report the first case to our knowledge of cutaneous chromoblastomycosis caused by V. botryosa in a patient with pemphigus vulgaris. A 61-year-old man with 5-year history of pemphigus vulgaris and long-term treatment of corticosteroids and immunosuppressive agents developed multiple nodules on the dorsum of right wrist and hand after wrist trauma. Skin biopsy showed numerous brown muriform cells and a few septate hyphae in the tissue. Veronaea botryosa was isolated from the biopsy samples and then identified based on morphologic observation and DNA sequencing. The patient underwent immediate withdrawal of cyclophosphamide and gradual decrease in prednisone. Skin lesions healed after 5-month itraconazole therapy with an interval of 1-month terbinafine and one cycle of liquid nitrogen cryotherapy. Our results demonstrate that V. botryosa
C.-Y. Zhu Y.-P. Yang P. Sheng W. Li W.-M. Huang Y.-M. Fan (&) Department of Dermatology, Affiliated Hospital of Guangdong Medical College, Zhanjiang 524001, Guangdong, China e-mail: [email protected]
could induce both chromoblastomycosis and phaeohyphomycosis. Combined use of itraconazole and cryotherapy may be preferable to treat this infection. Keywords Chromoblastomycosis Phaeohyphomycosis Veronaea botryosa Pemphigus vulgaris Pathology
Introduction Chromoblastomycosis and phaeohyphomycosis represent two poles of a disease spectrum caused by melanized fungi [1]. Clinically, chromoblastomycosis is often a local cutaneous and subcutaneous infection that usually occurs in immunocompetent hosts, while phaeohyphomycosis manifests cutaneous, subcutaneous, and systemic infections that commonly develop in immunocompromised patients. Pathologically, single or clustered, round-to-polyhedral, brown, thickwalled cells (muriform cells or sclerotic cells) are present in chromoblastomycosis, whereas melanized hyphae or yeast cells are existent in phaeohyphomycosis [1, 2]. Clinical evolution of both mycoses could principally depend on the host immune status [1], and presence of muriform cells may adapt to harsh environmental conditions [3]. Veronaea is a small genus of saprobic fungi in soil and on plant materials, belonging to the family Herpotrichiellaceae of order Chaetothyriales.
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Veronaea botryosa occasionally causes human infections [4]. Although 13 cases of V. botryosa-induced cutaneous phaeohyphomycosis have been recorded in the literature since 1990 [2, 4–15], 11 cases are actually reported excluding 2 duplicated cases [5–8]. The sclerotic cells were found in only one Japanese patient with cutaneous phaeohyphomycosis caused by V. Botryosa [9]. We herein report, to our knowledge, the first case of cutaneous chromoblastomycosis due to V. botryosa in a patient with pemphigus vulgaris (PV).
Case Report A 61-year-old male patient presented with 1-month history of an itchy nodule on the back of right wrist in April 2014. The lesion enlarged gradually and became verrucous. Three nodules occurred on the dorsum of right hand 2 weeks later. He recalled a transcutaneous trauma on the back of right wrist 2 months earlier. The patient was diagnosed as having PV in 2009 and received the combination of prednisone and cyclosporine thereafter. He was again hospitalized 4 months ago for recurrent PV with intravenous pulse therapy of methylprednisolone and cyclophosphamide and then maintained with tapering prednisone and monthly intravenous cyclophosphamide pulses. Skin examination revealed a 3.2 9 3 cm dark brown verrucous plaque with marginal ulcer and purulent exudates on the dorsum of right wrist and three erythematous to brownish, crusted nodules on the back of right hand (Fig. 1a). Brown to black hyperpigmented macules were discretely distributed over the body, without vesiculation and erosion. The present medications included prednisone (75 mg/d) and cyclophosphamide (cumulative dose 3.8 g). White blood cell count was 10.7 9 109/L with 85 % neutrophils. Serum alanine aminotransferase (ALT) was 55 U/L (reference range 5–40 U/L). Direct microscopy of exudate smears in 10 % KOH displayed no fungal elements. Skin biopsy showed mixed granulomatous inflammation and a few neutrophil microabscesses throughout the dermis. Numerous brown thick-walled sclerotic cells (muriform cells) and a few septate hyphae were seen free in the infiltrate and within multinucleated giant cells (Fig. 2a). Periodic acid–Schiff stain revealed dark red or dark brown sclerotic cells and septate hyphae (Fig. 2b). The biopsy samples were inoculated on two Sabouraud dextrose agar (SDA) slopes containing
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chloromycetin at 27 °C and yielded black velvety colonies after 2 weeks. Potato dextrose agar (PDA) subcultures at 27 °C produced velvety to woody colonies with blackish brown center and dark green periphery (Fig. 3a). Microscopic examination of slide cultures showed straight or flexuose, unbranched or occasionally branched, smooth-walled, and olivaceous to brown conidiophores. Conidia were born terminally and laterally and were smooth-walled, cylindrical to fusiform, and predominately one-septate, with rounded apices and truncated bases (Fig. 3b). The strain grew slowly at 36 °C, but not at 37 °C. The internal transcribed spacer (ITS) and D1/D2 regions of rDNA were amplified with ITS1/ITS4 and NL1/NL4, respectively. The ITS and D1/D2 sequences of our isolate displayed 99 % identity to some strains of V. botryosa (ITS: AB369905, KC205972 and KC205966; D1/D2: AB245484, AB245483 and EU041874) by 1–2 base mismatches. The strain and its ITS (586 bp) and D1/D2 (559 bp) sequences have been deposited in the China General Microbiological Culture Collection Center (Beijing; catalog number: CGMCC3.17565) and in the GenBank (accession numbers: KP187645 for ITS and KP187646 for D1/ D2). Veronaea botryosa was identified based on morphologic observation and DNA sequencing. Antifungal susceptibility testing using NeoSensitabs (Rosco, Denmark) revealed that the strain was very sensitive to voriconazole, itraconazole, ketoconazole, and terbinafine, moderately sensitive to miconazole, and resistant to amphotericin B, fluconazole, and caspofungin. The patient was initially treated with oral itraconazole (200 mg/d) and topical application of 0.1 % ethacridine solution for 1 month, followed by 1-month oral terbinafine (250 mg/d) because of continual ALT elevation. However, skin lesions were deteriorated, with a new nodule occurring on the right forearm after 6 weeks. The patient underwent one cycle of liquid nitrogen using large cotton swabs and another 4-month oral itraconazole owing to ALT reduction. During the antifungal treatment, cyclophosphamide was discontinued, prednisone was tapered to 50 mg/d, and polyene phosphatidylcholine (hepatoprotective agent) was prescribed. Skin lesions healed completely with crusts and hypopigmentation after 6-month therapy (Fig. 1b), and no relapse has been observed for 2-month follow-up.
Mycopathologia
Fig. 1 Clinical manifestations of cutaneous chromoblastomycosis caused by Veronaea botryosa before and after treatment. a A dark brown verrucous plaque with marginal ulcer and purulent exudates on the dorsum of the right wrist, and 3 crusted
nodules on the back of right hand. b Complete healing with crusts and hypopigmentation on the right forearm and back of right wrist and hand after 6-month treatment
Fig. 2 Histopathology of the skin lesion. a Numerous brown muriform cells and a few septate hyphae within and outside multinucleated giant cells (hematoxylin and eosin; original
magnification, 9400). b Numerous dark red or dark brown muriform cells and a few septate hyphae (periodic acid–Schiff stain; original magnification, 9400)
Discussion
septate hyphae in 11 cases of V. botryosa-induced phaeohyphomycosis, but yeast-like cells and sclerotic cells are also present in 3 cases and 1 case, respectively [2, 5, 9, 10]. In our patient, numerous muriform cells and a few hyphae are found in the tissue, so the diagnosis of chromoblastomycosis may be preferable to phaeohyphomycosis, suggesting that V. botryosa could cause both chromoblastomycosis and phaeohyphomycosis.
Of the 11 cases of cutaneous phaeohyphomycosis caused by V. botryosa (Table 1), 5 come from China; 5 have underlying immune dysfunction; 9 exhibit multiple nodules and plaques of face, buttocks, and limbs, especially on the limbs; and 7 healed with antifungal agents or surgical excision [2, 4–6, 9–15]. Pathologic examination reveals
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Fig. 3 Morphology of the Veronaea botryosa isolate. a Colonial morphology on potato dextrose agar (PDA) at 27 °C on day 9. b Slide culture on PDA at 27 °C on day 10 revealing
sympodial conidiogenous cells with one-septate, cylindrical to fusiform conidia with round tops and truncate bases (original magnification, 9400)
Chromoblastomycosis often occurs through a previous transcutaneous trauma. The initial lesions are commonly seen in the limbs and may gradually evolve into several types of skin lesions including nodular, plaque-type, tumoral, cicatricial, and verrucous lesions. Itching might result in autoinoculation and contiguous spread, and lymphatic dissemination to remote sites could occasionally develop [1]. Both innate and adaptive immune responses are necessary for effective control of mycoses, but cell-mediated immunity is more pivotal than humoral immunity for host defense against infections caused by black fungi [3]. Our patient was susceptible to the opportunistic infections owing to 5-year history of PV and long-term regimen of corticosteroids and immunosuppressive agents. A nodule started after wrist trauma and gradually spread to contiguous sites possibly via scratch-induced autoinoculation or lymphatic dissemination. Direct microscopy, fungal culture, and pathologic examination are required to diagnose infections due to black fungi. However, ITS sequencing of rDNA is currently reliable to identify most species of the Chaetothyriales at the species level [3]. Although V. botryosa is easily recognizable by morphology, e.g., erect, unbranched conidiophores with sympodial, oneseptate conidia [2], our isolate has been subjected to sequence analysis of ITS and D1/D2 regions and ultimately identified as V. botryosa. In vitro susceptibility testing may uncover intrinsic resistance to antifungal drugs, but barely forecast therapeutic efficacy [1]. Eighteen isolates of V. botryosa displayed low minimum inhibitory concentrations (MICs) of posaconazole and itraconazole, and high
MICs for voriconazole, terbinafine, caspofungin, anidulafungin, isavuconazole, amphotericin B, and fluconazole [4]. The present strain was sensitive to voriconazole, itraconazole, ketoconazole, and terbinafine, but resistant to amphotericin B, fluconazole, and caspofungin. Antifungal therapy with surgical excision may be effective for cutaneous infections caused by V. Botryosa [2]. Of the 11 reported cases, 4 have been successfully treated with itraconazole alone or with adjuvant debridement or thermotherapy [6, 9, 11, 12], and another 3 cases have been responsive to posaconazole [2], voriconazole [13], and surgical excision [9], respectively. Combined use of chemotherapy and cryosurgery can often offer better outcomes for chromoblastomycosis, but antifungal agents should be administered at least 1 month before cryosurgery to prevent the possible infection spread [1]. Although our isolate was susceptible to itraconazole and terbinafine, the initial 1-month itraconazole and subsequent 1-month terbinafine treatment did not stop the lesional aggravation. The skin lesions healed after another 4-month itraconazole therapy and one cycle of liquid nitrogen cryotherapy. In addition, since an unsuccessful restoration of host immunity issues in worse results in black yeast infections [3], immediate withdrawal of cyclophosphamide and gradual decrease in prednisone are also critical for the successful treatment of our patient. In conclusion, our case represents the first case to our knowledge of cutaneous chromoblastomycosis caused by V. botryosa in a patient with PV. Veronaea botryosa could induce both chromoblastomycosis and phaeohyphomycosis. A combination of itraconazole and liquid nitrogen cryotherapy may be preferable to treat this infection.
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Nation
China
Libya
Philippines
Indian OceanFrance
Taiwan, China
China
USA
No
1
2
3
4
5
6
7
62/M
12/M
81/M
57/M
37/M
28/F
24/M
Age (years)/sex
3 months
6 years
3 months
11 weeks
1 year
3 years
10 years
Duration
Truck driver
Pupil
Farmer
Farmer
Machine worker
ND
Farmer
Occupation
Cardiac transplant/ ND
None/scratch
Chronic renal failure/none
Liver transplant/ ND
ND
None/ND
None/splinter prick
Underlying disease/prior trauma
Erythema, induration, intense tenderness
Verrucous nodules and plaques
Swelling plaque, papulonodules
Coalescing nodules with pus
Papules, nodules
Nodular or ulcero-nodular lesions
Verrucous nodules, cysts
Clinical features
Back of right hand
Face, upper limbs, legs, scrotum, and buttocks
Left leg and dorsal foot
Both feet and wrists
Right arm, left shin
Nasal and oral mucosa, right hand
Face, back of left hand, and forearm
Infection site
Table 1 Overview of 12 cases (including our case) of cutaneous phaeohyphomycosis caused by V. botryosa
Hyphae
Hyphae
Hyphae
Hyphae
Hyphae
Hyphae
Hyphae, thickwalled spores
Pathology
Incision, drainage; ITZ (400 mg/d) for 1 week, VOR (400 mg/d) for 10 weeks
Herbal medication [1 year; thermotherapy, local AmB injection; TBF (125 mg/d) for 6 months; ITZ (200 mg/d) for 6 months
Debridement and ITZ (200 mg/d) for 10 months
ITZ (300 mg/d) for 8 months
ITZ
ND
AmB (0.1 mg/d), nystatin (1 g/d) for 7 weeks and lesional excision without efficacy; 10 % KI for 14 months with improvement but relapse after withdrawal
Treatment
[14]/2003
[13]/2004
Cured
[12]/2003
[11]/1999
[9]/1998
[15]/1995
[5, 7]/1990
Ref/year
No effect
Cured
Cured
Cured
ND
ND
Outcome
Mycopathologia
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Taiwan, China
Japan
China
Mexico
China
8
9
10
11
12
61/M
32/F
16/F
65/F
76/M
Age (years)/sex
1 month
10 years
6 months
Farmer
ND
Student
Farmer
Farmer
[2 years
3 years
Occupation
Duration
Pemphigus vulgaris/trauma
None/pregnant aggravation
None/ear piercing
Chronic hepatitis C/ND
Diabetes mellitus/ND
Underlying disease/prior trauma
Verrucous nodules, plaque
Verrucous nodules, plaques and scars
Verrucous papules, nodule and plaques
Erythematous indurated plaque
Crusted nodules and plaques
Clinical features
Back of right wrist, right hand, and forearm
Face, trunk, and limbs
Left ear, left buttock
Back of left wrist
Right forearm and knee, left upper limb
Infection site
Hyphae, sclerotic cells
Hyphae and yeast cells
Hyphae
Hyphae, sclerotic cells
Hyphae, yeastlike cells
Pathology
ITZ (200 mg/d) for 5 months, TBF (250 mg/d) for 1 month, cryotherapy
TBF (250 mg/d) for 1 year ? ITZ (200 mg/d) for 6 months without efficacy; POS (800 mg/d)
ITZ (200 mg/d) ? thermotherapy for 6 months
Surgical excision
ITZ (200 mg/d) for 6 months, AmB for 17 days
Treatment
Cured
Cured
Cured
Cured
No effect
Outcome
M male, F female, ND not determined, AmB amphotericin B, KI potassium iodide, ITZ itraconazole, TBF terbinafine, VOR voriconazole, POS posaconazole
Nation
No
Table 1 continued
This case
[2]/2013
[6, 8]/2011
[9]/2007
[10]/2006
Ref/year
Mycopathologia
Mycopathologia Conflict of interest
None.
References 1. Queiroz-Telles F, Esterre P, Perez-Blanco M, Vitale RG, Salgado CG, Bonifaz A. Chromoblastomycosis: an overview of clinical manifestations, diagnosis and treatment. Med Mycol. 2009;47:3–15. 2. Bonifaz A, Davoudi MM, de Hoog GS, Padilla-Desgarennes C, Va´zquez-Gonza´lez D, Navarrete G, et al. Severe disseminated phaeohyphomycosis in an immunocompetent patient caused by Veronaea botryosa. Mycopathologia. 2013;175:497–503. 3. Seyedmousavi S, Netea MG, Mouton JW, Melchers WJ, Verweij PE, de Hoog GS. Black yeasts and their filamentous relatives: principles of pathogenesis and host defense. Clin Microbiol Rev. 2014;27:527–42. 4. Badali H, Yazdanparast SA, Bonifaz A, Mousavi B, de Hoog GS, Klaassen CH, et al. Veronaea botryosa: molecular identification with amplified fragment length polymorphism (AFLP) and in vitro antifungal susceptibility. Mycopathologia. 2013;175:505–13. 5. Zhang HE, Zhao BA, Yao GS, Zheng JY, Wang DL, Li RY, et al. Report of a case of phaeohyphomycosis caused by Veronaea botryosa. Chin J Dermatol. 1990;23:96–8. 6. Sang H, Zheng XE, Kong QT, Zhou WQ, He W, Lv GX, et al. A rare complication of ear piercing: a case of subcutaneous phaeohyphomycosis caused by Veronaea botryosa in China. Med Mycol. 2011;49:296–302.
7. Wang DL, Li RY, Wang XH, Zhang HE. Studies on Veronaea botryose, agent of the first human case. Acta Mycol Sin. 1991;10:159–65. 8. Xue Y, Chen H, Hu S, Lv G, Liu Z, Sun J, et al. Cutaneous phaeohyphomycosis on the auricle due to Veronaea botryosa. Eur J Dermatol. 2011;21:418–9. 9. Kondo Y, Hiruma M, Matsushita A, Matsuba S, Nishimura K, Takamori K. Cutaneous phaeohyphomycosis caused by Veronaea botryosa observed as sclerotic cells in tissue. Int J Dermatol. 2007;46:625–7. 10. Chen YT, Lin HC, Huang CC, Lo YH. Cutaneous phaeohyphomycosis caused by an itraconazole and amphoterecin B resistant strain of Veronaeae botryosa. Int J Dermatol. 2006;45:429–32. 11. Foulet F, Duvoux C, de Bie`vre C, He´zode C, Bretagne S. Cutaneous phaeohyphomycosis caused by Veronaea bothryosa in a liver transplant recipient successfully treated with itraconazole. Clin Infect Dis. 1999;29:689–90. 12. Cheng CC, Tsai YJ, Ju YM, Hu SL. Lymphocutaneous phaeohyphomycosis caused by Veronaea botryose. Dermatol Sin. 2003;21:375–83. 13. Sutton DA, Rinaldi MG, Kielhofner M. First U.S. report of subcutaneous phaeohyphomycosis caused by Veronaea botryosa in a heart transplant recipient and review of the literature. J Clin Microbiol. 2004;42:2843–6. 14. Matsushita A, Jilong L, Hiruma M, Kobayashi M, Matsumoto T, Ogawa H, et al. Subcutaneous phaeohyphomycosis caused by Veronaea botryosa in the People’s Republic of China. J Clin Microbiol. 2003;41:2219–22. 15. Ayadi A, Huerre MR, de Bievre C. Phaehyphomycosis caused by Veronea bothryosa. Lancet. 1995;346:1703–4.
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Cutaneous Chromoblastomycosis Caused by Veronaea botryosa in a Patient with Pemphigus Vulgaris and Review of Published Reports Cheng-Yao Zhu • Yan-Ping Yang • Ping Sheng Wen Li • Wen-Ming Huang • Yi-Ming Fan
•
Received: 13 January 2015 / Accepted: 21 March 2015 Ó Springer Science+Business Media Dordrecht 2015
Abstract Chromoblastomycosis and phaeohyphomycosis represent two poles of a disease spectrum caused by melanized fungi. Veronaea botryosa belongs to a small genus of saprobic fungi that occasionally cause human infections. To date, 11 cases of V. botryosa-induced cutaneous phaeohyphomycosis have been actually reported since 1990 after exclusion of 2 duplicated cases. We report the first case to our knowledge of cutaneous chromoblastomycosis caused by V. botryosa in a patient with pemphigus vulgaris. A 61-year-old man with 5-year history of pemphigus vulgaris and long-term treatment of corticosteroids and immunosuppressive agents developed multiple nodules on the dorsum of right wrist and hand after wrist trauma. Skin biopsy showed numerous brown muriform cells and a few septate hyphae in the tissue. Veronaea botryosa was isolated from the biopsy samples and then identified based on morphologic observation and DNA sequencing. The patient underwent immediate withdrawal of cyclophosphamide and gradual decrease in prednisone. Skin lesions healed after 5-month itraconazole therapy with an interval of 1-month terbinafine and one cycle of liquid nitrogen cryotherapy. Our results demonstrate that V. botryosa
C.-Y. Zhu Y.-P. Yang P. Sheng W. Li W.-M. Huang Y.-M. Fan (&) Department of Dermatology, Affiliated Hospital of Guangdong Medical College, Zhanjiang 524001, Guangdong, China e-mail: [email protected]
could induce both chromoblastomycosis and phaeohyphomycosis. Combined use of itraconazole and cryotherapy may be preferable to treat this infection. Keywords Chromoblastomycosis Phaeohyphomycosis Veronaea botryosa Pemphigus vulgaris Pathology
Introduction Chromoblastomycosis and phaeohyphomycosis represent two poles of a disease spectrum caused by melanized fungi [1]. Clinically, chromoblastomycosis is often a local cutaneous and subcutaneous infection that usually occurs in immunocompetent hosts, while phaeohyphomycosis manifests cutaneous, subcutaneous, and systemic infections that commonly develop in immunocompromised patients. Pathologically, single or clustered, round-to-polyhedral, brown, thickwalled cells (muriform cells or sclerotic cells) are present in chromoblastomycosis, whereas melanized hyphae or yeast cells are existent in phaeohyphomycosis [1, 2]. Clinical evolution of both mycoses could principally depend on the host immune status [1], and presence of muriform cells may adapt to harsh environmental conditions [3]. Veronaea is a small genus of saprobic fungi in soil and on plant materials, belonging to the family Herpotrichiellaceae of order Chaetothyriales.
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Veronaea botryosa occasionally causes human infections [4]. Although 13 cases of V. botryosa-induced cutaneous phaeohyphomycosis have been recorded in the literature since 1990 [2, 4–15], 11 cases are actually reported excluding 2 duplicated cases [5–8]. The sclerotic cells were found in only one Japanese patient with cutaneous phaeohyphomycosis caused by V. Botryosa [9]. We herein report, to our knowledge, the first case of cutaneous chromoblastomycosis due to V. botryosa in a patient with pemphigus vulgaris (PV).
Case Report A 61-year-old male patient presented with 1-month history of an itchy nodule on the back of right wrist in April 2014. The lesion enlarged gradually and became verrucous. Three nodules occurred on the dorsum of right hand 2 weeks later. He recalled a transcutaneous trauma on the back of right wrist 2 months earlier. The patient was diagnosed as having PV in 2009 and received the combination of prednisone and cyclosporine thereafter. He was again hospitalized 4 months ago for recurrent PV with intravenous pulse therapy of methylprednisolone and cyclophosphamide and then maintained with tapering prednisone and monthly intravenous cyclophosphamide pulses. Skin examination revealed a 3.2 9 3 cm dark brown verrucous plaque with marginal ulcer and purulent exudates on the dorsum of right wrist and three erythematous to brownish, crusted nodules on the back of right hand (Fig. 1a). Brown to black hyperpigmented macules were discretely distributed over the body, without vesiculation and erosion. The present medications included prednisone (75 mg/d) and cyclophosphamide (cumulative dose 3.8 g). White blood cell count was 10.7 9 109/L with 85 % neutrophils. Serum alanine aminotransferase (ALT) was 55 U/L (reference range 5–40 U/L). Direct microscopy of exudate smears in 10 % KOH displayed no fungal elements. Skin biopsy showed mixed granulomatous inflammation and a few neutrophil microabscesses throughout the dermis. Numerous brown thick-walled sclerotic cells (muriform cells) and a few septate hyphae were seen free in the infiltrate and within multinucleated giant cells (Fig. 2a). Periodic acid–Schiff stain revealed dark red or dark brown sclerotic cells and septate hyphae (Fig. 2b). The biopsy samples were inoculated on two Sabouraud dextrose agar (SDA) slopes containing
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chloromycetin at 27 °C and yielded black velvety colonies after 2 weeks. Potato dextrose agar (PDA) subcultures at 27 °C produced velvety to woody colonies with blackish brown center and dark green periphery (Fig. 3a). Microscopic examination of slide cultures showed straight or flexuose, unbranched or occasionally branched, smooth-walled, and olivaceous to brown conidiophores. Conidia were born terminally and laterally and were smooth-walled, cylindrical to fusiform, and predominately one-septate, with rounded apices and truncated bases (Fig. 3b). The strain grew slowly at 36 °C, but not at 37 °C. The internal transcribed spacer (ITS) and D1/D2 regions of rDNA were amplified with ITS1/ITS4 and NL1/NL4, respectively. The ITS and D1/D2 sequences of our isolate displayed 99 % identity to some strains of V. botryosa (ITS: AB369905, KC205972 and KC205966; D1/D2: AB245484, AB245483 and EU041874) by 1–2 base mismatches. The strain and its ITS (586 bp) and D1/D2 (559 bp) sequences have been deposited in the China General Microbiological Culture Collection Center (Beijing; catalog number: CGMCC3.17565) and in the GenBank (accession numbers: KP187645 for ITS and KP187646 for D1/ D2). Veronaea botryosa was identified based on morphologic observation and DNA sequencing. Antifungal susceptibility testing using NeoSensitabs (Rosco, Denmark) revealed that the strain was very sensitive to voriconazole, itraconazole, ketoconazole, and terbinafine, moderately sensitive to miconazole, and resistant to amphotericin B, fluconazole, and caspofungin. The patient was initially treated with oral itraconazole (200 mg/d) and topical application of 0.1 % ethacridine solution for 1 month, followed by 1-month oral terbinafine (250 mg/d) because of continual ALT elevation. However, skin lesions were deteriorated, with a new nodule occurring on the right forearm after 6 weeks. The patient underwent one cycle of liquid nitrogen using large cotton swabs and another 4-month oral itraconazole owing to ALT reduction. During the antifungal treatment, cyclophosphamide was discontinued, prednisone was tapered to 50 mg/d, and polyene phosphatidylcholine (hepatoprotective agent) was prescribed. Skin lesions healed completely with crusts and hypopigmentation after 6-month therapy (Fig. 1b), and no relapse has been observed for 2-month follow-up.
Mycopathologia
Fig. 1 Clinical manifestations of cutaneous chromoblastomycosis caused by Veronaea botryosa before and after treatment. a A dark brown verrucous plaque with marginal ulcer and purulent exudates on the dorsum of the right wrist, and 3 crusted
nodules on the back of right hand. b Complete healing with crusts and hypopigmentation on the right forearm and back of right wrist and hand after 6-month treatment
Fig. 2 Histopathology of the skin lesion. a Numerous brown muriform cells and a few septate hyphae within and outside multinucleated giant cells (hematoxylin and eosin; original
magnification, 9400). b Numerous dark red or dark brown muriform cells and a few septate hyphae (periodic acid–Schiff stain; original magnification, 9400)
Discussion
septate hyphae in 11 cases of V. botryosa-induced phaeohyphomycosis, but yeast-like cells and sclerotic cells are also present in 3 cases and 1 case, respectively [2, 5, 9, 10]. In our patient, numerous muriform cells and a few hyphae are found in the tissue, so the diagnosis of chromoblastomycosis may be preferable to phaeohyphomycosis, suggesting that V. botryosa could cause both chromoblastomycosis and phaeohyphomycosis.
Of the 11 cases of cutaneous phaeohyphomycosis caused by V. botryosa (Table 1), 5 come from China; 5 have underlying immune dysfunction; 9 exhibit multiple nodules and plaques of face, buttocks, and limbs, especially on the limbs; and 7 healed with antifungal agents or surgical excision [2, 4–6, 9–15]. Pathologic examination reveals
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Fig. 3 Morphology of the Veronaea botryosa isolate. a Colonial morphology on potato dextrose agar (PDA) at 27 °C on day 9. b Slide culture on PDA at 27 °C on day 10 revealing
sympodial conidiogenous cells with one-septate, cylindrical to fusiform conidia with round tops and truncate bases (original magnification, 9400)
Chromoblastomycosis often occurs through a previous transcutaneous trauma. The initial lesions are commonly seen in the limbs and may gradually evolve into several types of skin lesions including nodular, plaque-type, tumoral, cicatricial, and verrucous lesions. Itching might result in autoinoculation and contiguous spread, and lymphatic dissemination to remote sites could occasionally develop [1]. Both innate and adaptive immune responses are necessary for effective control of mycoses, but cell-mediated immunity is more pivotal than humoral immunity for host defense against infections caused by black fungi [3]. Our patient was susceptible to the opportunistic infections owing to 5-year history of PV and long-term regimen of corticosteroids and immunosuppressive agents. A nodule started after wrist trauma and gradually spread to contiguous sites possibly via scratch-induced autoinoculation or lymphatic dissemination. Direct microscopy, fungal culture, and pathologic examination are required to diagnose infections due to black fungi. However, ITS sequencing of rDNA is currently reliable to identify most species of the Chaetothyriales at the species level [3]. Although V. botryosa is easily recognizable by morphology, e.g., erect, unbranched conidiophores with sympodial, oneseptate conidia [2], our isolate has been subjected to sequence analysis of ITS and D1/D2 regions and ultimately identified as V. botryosa. In vitro susceptibility testing may uncover intrinsic resistance to antifungal drugs, but barely forecast therapeutic efficacy [1]. Eighteen isolates of V. botryosa displayed low minimum inhibitory concentrations (MICs) of posaconazole and itraconazole, and high
MICs for voriconazole, terbinafine, caspofungin, anidulafungin, isavuconazole, amphotericin B, and fluconazole [4]. The present strain was sensitive to voriconazole, itraconazole, ketoconazole, and terbinafine, but resistant to amphotericin B, fluconazole, and caspofungin. Antifungal therapy with surgical excision may be effective for cutaneous infections caused by V. Botryosa [2]. Of the 11 reported cases, 4 have been successfully treated with itraconazole alone or with adjuvant debridement or thermotherapy [6, 9, 11, 12], and another 3 cases have been responsive to posaconazole [2], voriconazole [13], and surgical excision [9], respectively. Combined use of chemotherapy and cryosurgery can often offer better outcomes for chromoblastomycosis, but antifungal agents should be administered at least 1 month before cryosurgery to prevent the possible infection spread [1]. Although our isolate was susceptible to itraconazole and terbinafine, the initial 1-month itraconazole and subsequent 1-month terbinafine treatment did not stop the lesional aggravation. The skin lesions healed after another 4-month itraconazole therapy and one cycle of liquid nitrogen cryotherapy. In addition, since an unsuccessful restoration of host immunity issues in worse results in black yeast infections [3], immediate withdrawal of cyclophosphamide and gradual decrease in prednisone are also critical for the successful treatment of our patient. In conclusion, our case represents the first case to our knowledge of cutaneous chromoblastomycosis caused by V. botryosa in a patient with PV. Veronaea botryosa could induce both chromoblastomycosis and phaeohyphomycosis. A combination of itraconazole and liquid nitrogen cryotherapy may be preferable to treat this infection.
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Nation
China
Libya
Philippines
Indian OceanFrance
Taiwan, China
China
USA
No
1
2
3
4
5
6
7
62/M
12/M
81/M
57/M
37/M
28/F
24/M
Age (years)/sex
3 months
6 years
3 months
11 weeks
1 year
3 years
10 years
Duration
Truck driver
Pupil
Farmer
Farmer
Machine worker
ND
Farmer
Occupation
Cardiac transplant/ ND
None/scratch
Chronic renal failure/none
Liver transplant/ ND
ND
None/ND
None/splinter prick
Underlying disease/prior trauma
Erythema, induration, intense tenderness
Verrucous nodules and plaques
Swelling plaque, papulonodules
Coalescing nodules with pus
Papules, nodules
Nodular or ulcero-nodular lesions
Verrucous nodules, cysts
Clinical features
Back of right hand
Face, upper limbs, legs, scrotum, and buttocks
Left leg and dorsal foot
Both feet and wrists
Right arm, left shin
Nasal and oral mucosa, right hand
Face, back of left hand, and forearm
Infection site
Table 1 Overview of 12 cases (including our case) of cutaneous phaeohyphomycosis caused by V. botryosa
Hyphae
Hyphae
Hyphae
Hyphae
Hyphae
Hyphae
Hyphae, thickwalled spores
Pathology
Incision, drainage; ITZ (400 mg/d) for 1 week, VOR (400 mg/d) for 10 weeks
Herbal medication [1 year; thermotherapy, local AmB injection; TBF (125 mg/d) for 6 months; ITZ (200 mg/d) for 6 months
Debridement and ITZ (200 mg/d) for 10 months
ITZ (300 mg/d) for 8 months
ITZ
ND
AmB (0.1 mg/d), nystatin (1 g/d) for 7 weeks and lesional excision without efficacy; 10 % KI for 14 months with improvement but relapse after withdrawal
Treatment
[14]/2003
[13]/2004
Cured
[12]/2003
[11]/1999
[9]/1998
[15]/1995
[5, 7]/1990
Ref/year
No effect
Cured
Cured
Cured
ND
ND
Outcome
Mycopathologia
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123
Taiwan, China
Japan
China
Mexico
China
8
9
10
11
12
61/M
32/F
16/F
65/F
76/M
Age (years)/sex
1 month
10 years
6 months
Farmer
ND
Student
Farmer
Farmer
[2 years
3 years
Occupation
Duration
Pemphigus vulgaris/trauma
None/pregnant aggravation
None/ear piercing
Chronic hepatitis C/ND
Diabetes mellitus/ND
Underlying disease/prior trauma
Verrucous nodules, plaque
Verrucous nodules, plaques and scars
Verrucous papules, nodule and plaques
Erythematous indurated plaque
Crusted nodules and plaques
Clinical features
Back of right wrist, right hand, and forearm
Face, trunk, and limbs
Left ear, left buttock
Back of left wrist
Right forearm and knee, left upper limb
Infection site
Hyphae, sclerotic cells
Hyphae and yeast cells
Hyphae
Hyphae, sclerotic cells
Hyphae, yeastlike cells
Pathology
ITZ (200 mg/d) for 5 months, TBF (250 mg/d) for 1 month, cryotherapy
TBF (250 mg/d) for 1 year ? ITZ (200 mg/d) for 6 months without efficacy; POS (800 mg/d)
ITZ (200 mg/d) ? thermotherapy for 6 months
Surgical excision
ITZ (200 mg/d) for 6 months, AmB for 17 days
Treatment
Cured
Cured
Cured
Cured
No effect
Outcome
M male, F female, ND not determined, AmB amphotericin B, KI potassium iodide, ITZ itraconazole, TBF terbinafine, VOR voriconazole, POS posaconazole
Nation
No
Table 1 continued
This case
[2]/2013
[6, 8]/2011
[9]/2007
[10]/2006
Ref/year
Mycopathologia
Mycopathologia Conflict of interest
None.
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7. Wang DL, Li RY, Wang XH, Zhang HE. Studies on Veronaea botryose, agent of the first human case. Acta Mycol Sin. 1991;10:159–65. 8. Xue Y, Chen H, Hu S, Lv G, Liu Z, Sun J, et al. Cutaneous phaeohyphomycosis on the auricle due to Veronaea botryosa. Eur J Dermatol. 2011;21:418–9. 9. Kondo Y, Hiruma M, Matsushita A, Matsuba S, Nishimura K, Takamori K. Cutaneous phaeohyphomycosis caused by Veronaea botryosa observed as sclerotic cells in tissue. Int J Dermatol. 2007;46:625–7. 10. Chen YT, Lin HC, Huang CC, Lo YH. Cutaneous phaeohyphomycosis caused by an itraconazole and amphoterecin B resistant strain of Veronaeae botryosa. Int J Dermatol. 2006;45:429–32. 11. Foulet F, Duvoux C, de Bie`vre C, He´zode C, Bretagne S. Cutaneous phaeohyphomycosis caused by Veronaea bothryosa in a liver transplant recipient successfully treated with itraconazole. Clin Infect Dis. 1999;29:689–90. 12. Cheng CC, Tsai YJ, Ju YM, Hu SL. Lymphocutaneous phaeohyphomycosis caused by Veronaea botryose. Dermatol Sin. 2003;21:375–83. 13. Sutton DA, Rinaldi MG, Kielhofner M. First U.S. report of subcutaneous phaeohyphomycosis caused by Veronaea botryosa in a heart transplant recipient and review of the literature. J Clin Microbiol. 2004;42:2843–6. 14. Matsushita A, Jilong L, Hiruma M, Kobayashi M, Matsumoto T, Ogawa H, et al. Subcutaneous phaeohyphomycosis caused by Veronaea botryosa in the People’s Republic of China. J Clin Microbiol. 2003;41:2219–22. 15. Ayadi A, Huerre MR, de Bievre C. Phaehyphomycosis caused by Veronea bothryosa. Lancet. 1995;346:1703–4.
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