Phaeohyphomycosis due to Alternaria species in transplant recipients

Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
Transplant Infectious Disease (Impact Factor: 2.06). 12/2009; 12(3):242-50. DOI: 10.1111/j.1399-3062.2009.00482.x
Source: PubMed


R.D. Boyce, P.J. Deziel, C.C. Otley, M.P. Wilhelm, A.J. Eid, N.L. Wengenack, R.R. Razonable. Phaeohyphomycosis due to Alternaria species in transplant recipients. Transpl Infect Dis 2010: 12: 242–250. All rights reserved
Abstract: Alternaria species are members of a heterogenous group of dematiaceous fungi that rarely cause opportunistic infections in transplant recipients. During a 20-year period from 1989 to 2008, 8 solid organ transplant recipients (63% males; median age, 48 years) developed Alternaria species infections at the Mayo Clinic. All patients were highly immunocompromised as evidenced by their receipt of multiple transplants, treatment of acute and chronic allograft rejection, and occurrence of other opportunistic infections. All patients presented with non-tender erythematous or violaceous skin papules, nodules, or pustules in exposed areas of the extremities. No case of visceral dissemination was observed. Itraconazole was the most common drug used for treatment, although voriconazole, posaconazole, and caspofungin could potentially be useful based on our limited clinical data and in vitro antifungal susceptibility testing. One patient was treated with voriconazole, while another patient who was refractory to itraconazole had rapid resolution of lesions after the addition of caspofungin. Attempts at antifungal therapy alone were unsuccessful; all patients eventually required surgical excision of lesions. In conclusion, Alternaria species are rare but increasingly recognized opportunistic infections among highly immunocompromised transplant recipients. Wide excisional surgery combined with prolonged systemic antifungal therapy and reduction in immunosuppressive regimens provided the best chance of cure. Although itraconazole remains the most common drug for treatment, this case series highlights the potential clinical utility of caspofungin, voriconazole, and posaconazole as alternative regimens.

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    • "However, there is no formal consensus which specific agent to use and the ideal duration of therapy because clinical trials are lacking (Ben-Ami et al., 2009; Naggie and Perfect, 2009; Revankar, 2006). Surgery is probably the best treatment of well delineated lesions (Boyce et al., 2009; Farina et al., 2007; Ogawa et al., 2009), but even when excision is complete, additional medical treatment is advocated to avoid local sporotrichoid dissemination and to treat concomitant subclinical lesions (Boyce et al., 2009; Farina et al., 2007). In selected patients, cure can be achieved with medical treatment alone, as demonstrated in the second case in which one of the lesions healed without excision (Farina et al., 2007; Naggie and Perfect, 2009). "
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