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Cutaneous Paecilomyces lilacinus infection: Report of two novel cases
... The most common predisposing factors were solid organ (27.9%) and bone marrow transplantation (11.6%), corticosteroid therapy (9.3%), malignancies (20.9%), primary immunodeficiency (2.4%), AIDS (2.4%), diabetes mellitus (2.4%) and hepatic cirrhosis (2.4%). In eight cases (18.6%), predisposing factors for infection were unknown or not reported [4,[26][27][28][29][30][31]. ...
... Two patients suffered severe graft vs. host disease after bone marrow transplant, including one patient in whom the infection disseminated [12,32]. In two other cases, the cause of death was pneumonia, probably unrelated to the infection [36], and multiple organ failure with no documented dissemination of the infection [28]. In two cases, the cause of death was not described [13]. ...
... Amphotericin B, alone or associated with surgery, was used in 17 cases, but was unsuccessful in 15 (88.2%) cases [3,12,28,33,36,85,86]. One of the two successful cases involved a child with chronic granulomatous disease, who was cured with amphotericin B [87], and the other was a cirrhotic male, who was cured with amphotericin B and surgical debridement [35]. ...
The fungus Paecilomyces lilacinus is an emerging pathogen that causes severe human infections, including devastating oculomycosis. Usually, it shows low susceptibility to conventional antifungal drugs in vitro, and variable susceptibility to novel triazoles. A review of the published literature identified 119 reported cases of human infection by P. lilacinus between 1964 and 2004. Most were cases of oculomycosis (51.3%), followed by cutaneous and sub-cutaneous infections (35.3%), and a smaller group of miscellaneous infections (13.4%). Lens implantation is the most frequent predisposing factor for oculomycosis. Cutaneous and sub-cutaneous infections occur mainly in solid organ and bone marrow transplant recipients, although surgery and primary or acquired immunodeficiency are also relevant predisposing factors. Infections in apparently immunocompetent patients have also been reported. Surgical debridement combined with antifungal drug therapy, or the correction of predisposing factors, such as neutropenia, are usually required to obtain improvement. Treatment with traditional antifungal drugs often fails. Voriconazole has demonstrated good activity in both cutaneous and ocular infections in the few cases in which this drug has been used. The new triazoles ravuconazole and posaconazole show good in-vitro activity against P. lilacinus and could be promising therapeutic alternatives.
... 15 With regard to the skin, infections in immunocompetent persons are still very uncommon. A review of the literature has shown only six cases of cutaneous infection clearly induced by P. lilacinus, 10,[15][16][17][18][19] among which one had a previous trauma on the site of the infection, 18 and three were predisposed to minor injuries because of their jobs. [15][16][17] The patient in the present study did not have history of such diseases or predisposing factors. ...
... A review of the literature has shown only six cases of cutaneous infection clearly induced by P. lilacinus, 10,[15][16][17][18][19] among which one had a previous trauma on the site of the infection, 18 and three were predisposed to minor injuries because of their jobs. [15][16][17] The patient in the present study did not have history of such diseases or predisposing factors. The organism was demonstrated in the dermis in pure cultures from two separate biopsies. ...
Paecilomyces Sp. are saprophytic fungi, which have rarely been pathogen for human. Herein, we report a case of cutaneous infection with Paecilomyces lilacinus with unusual presentations in a healthy young woman. A biopsy provided an initial diagnosis of fungal elements in the tissue. Multiple positive fungal cultures were obtained from the biopsied tissue. Microscopic and macroscopic examination of the biopsy revealed the presence of Paecilomyces lilacinus. This case was successfully treated by prescribing oral ketoconazole (200 mg/day).
... The most frequent clinical manifestations are oculomycosis and cutaneous and subcutaneous infections [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. Less frequently, however, this fungus can also disseminate, probably due to this ability to sporulate in tissue, producing numerous conidia that spread haematogenously [1,20]. ...
... has not yet been established. Amphotericin B (AMB) is probably the most commonly used drug for treating this infection, with most of the results being negative or unknown [6,8,10,15,[21][22][23][24][25][26], in agreement with the poor in vitro response of P. lilacinus to this antifungal drug [1,27,28]. There is little data on the activity of the newer triazoles either in vitro [28,29] or in animal models [1,30], but the available data are promising. ...
We studied the efficacy of voriconazole (VRC) and amphotericin B (AMB) in an immunosuppressed murine model of disseminated infection by two strains of Paecilomyces lilacinus. Mice were treated with VRC 60 mg/kg/day orally or AMB 3mg/kg/day intraperitoneally, beginning 1 day after infection and continuing for 9 days. To avoid rapid clearance of VRC, animals receiving VRC and the control group were given grapefruit juice instead of water. VRC significantly prolonged survival with respect to the group treated with AMB and the control group for both strains (P=0.005 and P<0.0001, respectively, for strain FMR 5522; and P=0.0002 and P<0.0001, respectively, for strain FMR 8252). VRC reduced the fungal load in the spleen, kidneys and liver of infected mice for both strains tested. Survival of mice challenged with strain FMR 8252 treated with AMB did not differ from that of the control group (P=0.223), being worse than that of the mice treated with VRC (P=0.0002). AMB was not able to reduce the tissue burden in any organ with respect to the control group for both strains studied.
... In the case above, the extent of infection was too great soft-tissue infection in a heart transplant recipient and its successful to allow debridement. Antifungal therapy has also been successful treatment with terbinafine, a therapeutic agent not previously deagainst paecilomyces infection [2][3][4][5]. Agents reported to be useful scribed for use against paecilomyces infection. ...
... against Paecilomyces include miconazole, griseofulvin, amphoteri-A 48-year-old man underwent heart transplantation for obstruccin B (alone or with 5-FC), ketoconazole, and itraconazole [2][3][4][5]. tive cardiomyopathy in December 1995. In March 1996 a 1.5-cm ...
... The clinical manifestation of P. lilacinum cutaneous infection can vary from small erythematous papules to plaques with central umbilication to haemorrhagic vesicle or ulceration (1,4,6,(8)(9)(10)(11). Cellulitis-like lesions or subcutaneous nodules have been also reported (8). ...
... Paecilomyces have been recognized as an emerging cause of infection in immunocompromised patients, and several outbreaks have been attributed to Paecilomyces in the past two decades (Kunstýr et al. 1997;Walsh et al. 2004). The low virulence and infection rates associated with Paecilomyces are due to aspects of the host, but fungal infections in immunocompromised individuals can have serious consequences, such as skin infections (Hecker et al. 1997), which are usually classified as hyalohyphomycoses (Houbraken et al. 2010); sinusitis (Gucalp et al. 1996); endocarditis (Haldane et al. 1974); pneumonia (Dharmasena et al. 1985); infections of the central nervous system (Kantarcioglu et al. 2003) and respiratory failure, leading to increased morbidity and mortality (Shoham and Marwaha 2010). ...
Paecilomyces variotii is a filamentous fungus that occurs worldwide in soil and decaying vegetation. Optimization of the fermentation process for exopolysaccharide (EPS) production from the fungus P. variotii, structure determination and immuno-stimulating activity of EPS were performed. Response surface methodology (RSM) coupled with central composite design (CCD) was used to optimize the physical and chemical factors required to produce EPS in submerged fermentation. Preliminary investigations to choose the three factors for the present work were made using a factorial experimental design. Glucose, ammonium nitrate (NH4NO3) and pH were used as variables for which, with constant temperature of 28 °C and agitation of 90 rpm, the optimal process parameters were determined as glucose values of 0.96%, NH4NO3 0.26% and pH 8.0. The three parameters presented significant effects. In this condition of culture, the main composition of the isolated EPS was a linear β-(1 → 6)-linked-D-glucan, as determined by Nuclear Magnetic Resonance (NMR) and methylation analysis. This polysaccharide is a very unusual as an EPS from fungi, especially a filamentous fungus such as P. variotii. Murine peritoneal macrophages cultivated with β-glucan for 6 and 48 h showed an increase in TNF-α, IL-6 and nitric oxide release with increased polysaccharide concentrations. Therefore, we conclude that the β-(1 → 6)-linked-D-glucan produced in optimised conditions of P. variotii cultivation has an immune-stimulatory activity on murine macrophages.
... Antas et al., [202] reviewed the cases from 2006 to 2011 including cases of fungemia, keratitis, cutaneous infection, bursitis, endocarditis, rhinitis, cellulitis, onychomycosis, eumycetoma and one case associated with dog bites. However, P. lilacinum infections are rare in immunocompetent hosts with the first case described in 1977 and to date only eight other cases have been reported worldwide [203,204,205,206,207,208,209,210]. ...
The emerging filamentous fungal pathogens have been separated into two global disease entities: one with septate, hyaline hyphal tissue forms (hyalohyphomycosis), and the other with phaeoid, septate hyphal invasive forms (phaeohyphomycosis) (1–4).
Purpureocillium lilacinum, previously classified as Paecilomyces lilacinus, is a ubiquitous hyaline hyphomycete considered to be an emerging opportunistic human pathogen that is resistant to traditional antifungal agents. This case report describes what is to our knowledge the only published case of P. lilacinum recrudescence in an immunocompetent host despite initial best‐practice treatment with 10 weeks of voriconazole and surgical excision.
Hyalohyphomycosis (hyaline septate molds) is a term used to encompass a variety of less common yet medically opportunistic mycotic pathogens.1 They are non-dematiaceous molds or yeasts in which the tissue form is a colorless (hyaline) septate fungal hyphae with no pigment within the walls. This term is the counterpart to phaeohyphomycosis in which pathogens develop septate brown-walled hyphae in tissue. Hyalohyphomycosis does not represent a recognizable clinical syndrome, but in histologic tissue sections they can be misidentified as Aspergillus. Hyaline septate molds are identified by their macroscopic and microscopic morphology in culture. However, greater than 50% of hyaline molds indentified in tissue cannot be cultivated for definitive identification. The members of this group are extremely heterogeneous and include Fusarium, Penicillium, Paecilomyces, Acremonium, Scopulariopsis, and Trichoderma.
Paecilomyces species are ubiquitous saprophytic fungi that rarely cause human infections. We report herein a case of an immunocompromised patient with cutaneous hyalohyphomycosis caused by P. marquandii. The 68-year-old male suffered from diabetes mellitus, chronic obstructive lung disease, and iatrogenic Cushing syndrome due to a prolonged use of a systemic steroid for asthma. He fell down in the farm while gardening and many pustules and fluctuating ulcerative nodules with pus discharge then developed gradually on bilateral lower extremities. He had been treated as having cellulitis with intravenous antibiotics but the skin lesions progressed. Direct light microscopy of pustule scrapings in potassium hydroxide (KOH) revealed hyaline fungal hyphae. A histopathologic examination revealed dense acute and chronic inflammatory cell infiltration with abscess formation. Both periodic acid-Schiff and Gomori's methenamine-silver nitrate stains demonstrated septate hyphae and spores in the abscess. Paecilomyces marquandii was identified based on the morphological characters in culture. The cutaneous lesions were lessened gradually after the treatment with low-dose oral itraconazole (200 mg/day) for 3 months. This is the first report of a cutaneous infection caused by P. marquandii in Taiwan.
The virulence of Paecilomyces variotii, P. lilacinus and P. javanicus, the most frequent species of Paecilomyces in human infections, was compared using a murine model. The mice were immunodepressed with cyclophosphamide and inoculated intravenously with 1 × 10 7 conidia/mouse of one isolate of each of the mentioned species. No significant differences in lethality among the three species were observed (p > 0.05). In contrast, fungal recovery from tissue was higher in animals inoculated with P. variotii and P. lilacinus than with P. javanicus. Spleen and liver were the organs most affected, followed by kidneys, heart and lungs. This animal model could be useful for evaluating the efficacy of different antifungal treatments in infections caused by these fungi.
Paecilomyces lilacinus, a ubiquitous saprophytic mold found in the environment, is an emerging pathogen that causes localized to severe systemic diseases, especially in immunocompromised patients. Thus far, there are only eight reports on immunocompetent patients with cutaneous P. lilacinus in the English literature. We herein present the case of an 87-year-old immunocompetent Taiwanese man who presented with a progressive, tender, erythematous plaque mimicking cellulitis on the ventral surface of the right forearm for 2 weeks. The patient was initially diagnosed as a case of cellulitis; however, due to unresponsiveness to the treatment for 1 week, we decided to perform skin biopsy and tissue culture. Results of histopathologic analysis, tissue culture, and polymerase chain reaction assay indicated cutaneous P. lilacinus infection. Consequently, systemic antifungal treatment with oral itraconazole (200 mg/d) was initiated and the skin lesion resolved after a 4-week treatment.
The incidence of systemic fungal infections increased during the last two decades. Rare fungi, such as Mucor, Fusarium and Paecilomyces, are emerging as causes of systemic fungal infections in immunocompromised hosts. There are reports of cutaneous infections, endophthalmitis, keratitis, sinusitis, neumopathy and fungemia in immunocompromised and immunocompetent adult patients. We report a 5 years old neutropenic patient with acute myeloid leukemia treated with multiple courses of chemotherapy, with a fungemia caused by Paecilomyces lilacinus (PL). His initial clinical course was characterized by fever, skin lesions, respiratory distress and shock. Blood and bone marrow cultures were positive. The patient was treated with amphotericin B and itraconazole with a good clinical response (Rev Méd Chile 2003; 131: 77-80).
Purpureocillium lilacinum is a saprophytic fungus found in soil and decaying organic matter, but has been reported as an emerging pathogen in immunocompromised patients and following surgical procedures. Infections caused by this mold are often difficult to treat because of its intrinsic resistance to conventional antifungal agents and variable susceptibility to novel triazoles. In immunocompetent subjects, infections caused by P. lilacinum are unusual and mainly involve the skin. We describe herein a case of cutaneous hyalohyphomycosis due to this fungus in an immunocompetent girl without any predisposing risk factors and review the previously reported cases in immunocompetent hosts.
Paecilomyces lilacinus is an emerging pathogen in immunocompromised patients. We report here a case of cutaneous hyphomycosis in a 63-year-old heart transplant recipient caused by the simultaneous presence of 2 molds: Paecilomyces lilacinus and Alternaria alternata. The infection was successfully treated with local voriconazole followed by oral terbinafine.
Paecilomyces lilacinus is an emerging fungal pathogen that is highly resistant to many antifungal drugs. Skin and subcutaneous soft tissue infections caused by this organism are very unusual. Most cases occur in patients with impaired host defenses or following surgical procedures. There has been only one previous report of a histologically confirmed cutaneous infection due to Paecilomyces lilacinus in a patient without predisposing factors. Described here is the second histopathologically proven case of Paecilomyces lilacinus cutaneous infection in a healthy patient without any apparent portal of entry. Prolonged antifungal chemotherapy with itraconazole led to resolution of the skin lesion. This case of sporadic cutaneous infection due to Paecilomyces lilacinus is believed to be the first reported in Europe and the first histopathologically proven case successfully treated with itraconazole.
A 72‐year‐old Caucasian man presented with tender, hyperkeratotic, violaceous,
ill‐defined, scattered plaques associated with minimal pitting edema of the right upper extremity. He had been discharged 3 days earlier from an outlying community hospital after a 33‐day admission for exacerbation of chronic obstructive lung disease requiring large doses of systemic corticosteroids. A right subclavian central venous line for intravenous access was placed after he developed a gastrointestinal bleed and myocardial infarction. The clinical differential diagnosis of the eruption on the right upper extremity at the time he presented to our service included cellulitis, deep venous thrombosis, and brachial plexus neuropathy. Brachial plexus neuropathy was ruled out with normal electromyography, nerve conduction studies, and cervical spine radiographs. Deep venous thrombosis was never completely eliminated, because the patient refused a venogram and the venous Doppler exam was nondiagnostic. Treatment for a presumed bacterial cellulitis was initiated with Nafcillin intravenously. As there was clinical disease progression without appreciable improvement by day nine ( Fig. 1 and 2 ), a skin biopsy was performed and topical Nystatin powder was added for possible yeast etiology. Bacterial cultures were negative; however, fungal cultures on Sabouraud’s agar were positive for Paecilomyces lilacunis after 15 days. Histologic sections demonstrated skin with an essentially normal epidermis. Within the dermis, there was an extensive, mixed, granulomatous inflammatory infiltrate with abundant multinucleated giant cells. Necrosis was not abundant. Occasional 8–12 μm yeast‐like organisms were apparent within the cytoplasm of multinucleated cells and in an extracellular location, together with occasional hyphal forms with irregular branching. Periodic acid–Schiff (PAS) with diastase and Gomori methenamine silver accentuated the staining and confirmed the fungal nature of the organisms ( Fig. 3 ). The histologic differential included various other fungi. Cryptococcus is usually smaller, endospores characteristic of coccidiomycosis were not present, and a thick capsule usually seen in blastomycosis was not observed in these organisms. The diagnosis of Paecilomyces lilacunis was established, and itraconazole 200 mg orally twice a day was instituted. Clinical improvement as measured by decreased edema, increased range of motion, and resolution of cutaneous lesions was dramatic during the first week. Itraconazole was decreased to 200 mg a day and the patient continued to improve. He was discharged to home. He has followed up in our clinic every month with complete resolution to date 7 months after discharge.
Right upper extremity demonstrating violaceous hue, edema, and scale taken after 9 days of Nafcillin. Note progression of disease to involve the left upper extremity
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Closer view of right upper extremity showing tremendous scale. There is suture where the biopsy was performed
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Gomori methenamine silver stain reveals multiple 8–12 μm organisms. Original magnification, 400×
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New opportunistic fungal infections cause significant morbidity and death in patients who are severely immunocompromised. Cutaneous lesions may be the first clinical manifestation and give the clue to early diagnosis.
The purpose of this study was to describe the clinical and histologic manifestations of Paecilomyces lilacinus infection in patients who are severely immunosuppressed.
Within a 3-month period, we observed 5 patients with allogenic bone marrow transplantation and 4 patients with aplasia after chemotherapy for hematologic malignancies who developed skin eruptions caused by invasive P lilacinus.
The skin lesions began in 7 cases during or shortly after recovery of pancytopenia. Most of the skin lesions were located on the lower extremities. The cutaneous manifestations were highly variable including erythematous macules, nodules, pustules, vesicular lesions, and necrotic crusts. In 3 biopsy specimens, histologic examination revealed hyphae in periodic acid-Schiff-stained sections. In all patients P lilacinus was isolated from skin tissue samples. P lilacinus was identified from all lesions either by skin biopsy or needle aspiration from clinically evident lesions. In 3 additional cases, the patient's hands were colonized without skin lesions. The source of the epidemic outbreak was finally traced down to several contaminated lots of a topical moisturizing agent. Two patients died; one patient had septic lesions in the eye and kidney as the result of P lilacinus.
Clinical and histologic findings of P lilacinus infection with cutaneous manifestations in patients who are severely immunosuppressed are summarized. P lilacinus is resistant to all systemic antimycotics available, and in general, recovery of immunosuppression is necessary to eradicate the mold. Contaminated topical dermatologic agents should be included in the differential diagnosis as a source for severe epidemic cutaneous manifestations of fungal infection in patients who are severely immunosuppressed. This fact implies that additional safety guidelines are necessary for topical dermatologic agents used for patients who are severely immunosuppressed.
Paecilomyces lilacinus is a rare fungal pathogen in humans. We report a case of fungemia caused by P. lilacinus in a non-neutropenic adult, 120 days after bone marrow transplant. The patient's primary risk factor was the presence of an indwelling vascular catheter. Her initial clinical course was characterized by fever, chills, and rigors. Blood cultures from the central line and peripheral veins were positive, as was a peripheral specimen drawn after removal of the catheter. Two initial peripheral specimens were positive for P. lilacinus only by blind subculture and/or sustained incubation. She developed peripheral pulmonary nodules following the fungemia, thus raising the possibility of disseminated disease, but definitive diagnosis was confounded by Pseudomonas bacteremia. The nodules cleared and she recovered following removal of the central line and treatment with amphotericin B and 5-fluorocytosine, despite in vitro resistance to these antifungal drugs. This case underscores the increasing importance of P. lilacinus as a human pathogen capable of producing disease in immunocompetent, as well as in immunocompromised hosts. Also of note is that blood culture systems may require extended incubation or subcultures in order to detect fungi.
Moulds belonging to the genus Paecilomyces are rare opportunistic pathogens. About 100 cases have been reported in immunocompromised hosts or in relation to surgical procedures. We describe here a cutaneous infection due to P. lilacinus in a renal transplant patient, which responded to voriconazole treatment.
We describe a renal transplant recipient with cutaneous hyalohyphomycosis due to Paecilomyces lilacinus and highlight the increasing importance of such opportunistic fungal infections in immunosuppressed patients.
A 59-year-old woman presented to us with an eight-month history of Paecilomyces lilacinus soft tissue infection. She was treated with a six-month course of oral itraconazole. The lesion resolved fully without the need for adjunctive surgery. Susceptibility testing confirmed susceptibility to itraconazole. This is the second case of confirmed P. lilacinus soft tissue infection in an immunocompetent host treated with oral itraconazole alone.
Zusammenfassung. Eine 59-jährige Frau stellte sich vor mit einer bereits 8 Monaten bestehenden Hautinfektion, verursacht durch Paecilomyces lilacinus. Sie wurde 6 Monate lang mit Itraconazol oral behandelt. Die Läsion heilte vollständig ab, ohne dass chirurgisch interveniert werden musste. Die Empfindlichkeitsprüfung bestätigte die Itraconazol-Sensibilität des Erregers. Es ist dies der zweite Fall einer Paecilomyces lilacinus-Weichteilinfektion bei einem immunkompetenten Wirt, die allein durch orale Itraconazolbehandlung kuriert werden konnte.
Paecilomyces lilacinus was the causal agent of a case of subcutaneous infection in a patient with liver cirrhosis. Surgical treatment in combination with systemic amphotericin B therapy led to complete recovery. Retrospectively performed microdilution testing revealed dose dependent in vitro susceptibility of the isolate to voriconazole (MIC = 2 g/ml) and terbinafine (MIC = 1 microg/ml).
A cat was presented for a 2-year history of a recurrent, soft-tissue swelling of the left metacarpal region. The mass was excised and submitted for aerobic and anaerobic bacterial culture, fungal culture, and histopathological examination. Cultures revealed the organism Paecilomyces lilacinus, and histopathological examination showed a nodular mycotic granuloma. Itraconazole (10 mg/kg body weight, per os [PO], q 24 hours) was administered and continued for a total of 60 days, with a swelling of the upper lip occurring 3 months after the initial presentation. Subsequent surgical excisions and debridements along with treatment with itraconazole (20 mg/kg body weight, PO, q 24 hours) for a total of 4 months were curative.
Cutaneous infection with Paecilomyces lilacinus is encountered worldwide, with most infections occurring either iatrogenically or in immunocompromised hosts. We report three cases of cutaneous hyalohyphomycosis caused by P. lilacinus, one of which occurred in an immunocompetent individual. In addition, we review the 17 cases previously reported in the literature. Although this infection can be difficult to treat, most cases are not fatal. Most cases responded well to systemic azole antifungal agents, either alone or in association with surgical excision of the lesion. Paecilomyces species are saprophytic fungi found in soil and decaying organic matter. Infection in humans is rare, but when it occurs treatment is often difficult. We report three cases of cutaneous hyalohyphomycosis caused by P. lilacinus and review the 17 previously reported cases in which the clinical history and response to therapy were described.
The incidence of systemic fungal infections increased during the last two decades. Rare fungi, such as Mucor, Fusarium and Paecilomyces, are emerging as causes of systemic fungal infections in immunocompromised hosts. There are reports of cutaneous infections, endophthalmitis, keratitis, sinusitis, neuropathy and fungemia in immunocompromised and immunocompetent adult patients. We report a 5 years old neutropenic patient with acute myeloid leukemia treated with multiple courses of chemotherapy, with a fungemia caused by Paecilomyces lilacinus (PL). His initial clinical course was characterized by fever, skin lesions, respiratory distress and shock. Blood and bone marrow cultures were positive. The patient was treated with amphotericin B and itraconazole with a good clinical response.
A 74-year-old woman presented in April, 2003, with cutaneous lesions of the face by Paecilomyces lilacinus infection. The patient had received predonisolone and azathioprine for 20 months for treatment of autoimmune hemolytic anemia. The lesion first developed on the right lateral eyelid 1.5 years earlier, and gradually enlarged. Physical examination revealed a dark reddish or brownish plaque and scattered papules and abscesses around the plaque on right lateral and lower eyelids, and the cheek. She noted mild tenderness on pressure. Cultures obtained from pus and biopsy specimen showed moulds, and those were identified as Paecilomyces lilacinus. Griseofulvin, 500 mg per day, was not effective for the lesion, so itraconazole, 200-300 mg per day, was administered orally for 11 weeks. Since culture from pus still yielded P. lilacinus despite clinical effectiveness, itraconazole pulse therapy (400 mg daily, 7 days a month) was started. The lesion cleared after three cycles of the pulse therapy.
Fungal infections of the skin, hair and nails are among the most common skin diseases. The increased incidence of these infections in recent years has been attributed to the large number of immunocompromised patients, life-style changes (greater attendance at gymnasiums, public baths, etc.), the use of chemotherapeutic agents, and the greater presence of elderly people in the general population. Superficial fungal infections were also the most frequent and troublesome dermatological condition occurring among US forces during the war in Vietnam.
A 56-year-old male who was 12 months status post liver transplant presented with a 2-month history of painful, erythematous nodules over the right knee. Several biopsies yielded a mold initially phenotypically identified as a Penicillium species, but molecular sequence analysis ultimately determined the identity as Paecilomyces lilacinus. Several courses of oral voriconazole were required for resolution of the infection. A review of the literature revealed that Paecilomyces species are an infrequent cause of disease in transplant patients, with skin and soft tissue infections being the most common presentation. It is important to accurately identify these infections, and polymerase chain reaction assay using universal fungal primers offers a rapid and precise diagnostic approach. Treatment of Paecilomyces infections may require multiple courses of antifungal therapy, often with surgical debridement. We suggest that voriconazole may be a useful treatment alternative to the more traditional therapy with amphotericin B-based agents.
• A 20-year-old woman had erythematous scaly plaques persistent for 15 years on the left cheek. Cultures from scales and biopsy specimens on Sabouraud's glucose agar repeatedly yielded floccose lilac colonies, and those on a Czapek's solution agar plate developed deep purplish red pigment, which is characteristic of Paecilomyces lilacinus. The PAS stain of the tissue section showed ovoid, divergent, or club-shaped fungal elements among the inflammatory cells or in giant cells. Two months after the patient and a control subject were inoculated with the isolates, P lilacinus could be reisolated from the patient only. Oral administration of griseofulvin significantly reduced erythema and papules. This is the first report, to our knowledge, of deep cutaneous mycosis caused by P lilacinus.
(Arch Dermatol 113:1687-1690, 1977)
• Paecilomyces lilacinus, a saprophytic soil fungus, is an uncommon human pathogen. An immunocompromised patient developed a deep cellulitis due to P lilacinus. The infection responded poorly to intravenous amphotericin B but eventually resolved after combination therapy with amphotericin B and flucytosine (5-fluorocytosine). Previous in vitro studies have suggested that miconazole is the most active antifungal agent against P lilacinus.
(Arch Dermatol 1986;122:1169-1170)
A salvaged eye in a case of mycotic endophthalmitis is reported. The case was one of eleven in the United States resulting from Luminex lens implants contaminated with amphotericin B resistant Paecilomyces lilacinus, and one of two eyes salvaged in this series of cases. The fungus, recognized 28 days after the lens was inserted, was in the anterior chamber, on the psuedophakos, and in the vitreous. The therapeutic procedures included removal of the pseudophakos, radical vitrectomy and iridectomy, and the intraocular and combined topical and systemic use of antimycotic compounds, including miconazole and thiabendazole.
We report an immunosuppressed host with an unusual fungal infection which resolved during intravenous therapy with a new antifungal agent. This agent, miconazole, appears to have minimal side effects and a broad antifungal spectrum, and it deserves consideration for treatment of susceptible organisms.
An 8-year-old boy who had chronic granulomatous disease developed a soft tissue infection of the right heel after riding on
a motor scooter. Infection was insidious, and minor heel pain and fevers occurred only on the day interferon-γ was injected.
Soft tissue biopsy showed hyphal elements, and Paecilomyces varioti grew in culture. The infection was treated with amphotericin B for 7 weeks (total dose, 40 mg/kg) followed by 1 year of therapy
with itraconazole (100 mg twice daily). Complete cure was achieved during the follow-up period of 10 months.
Chronic granulomatous disease (CGD) is a rare inherited disorder in which neutrophils do not appropriately generate cytotoxic superoxide anion, the respiratory burst, in response to invading bacteria or fungi as a part of normal host defence. We report the case of a child with CGD who had two abdominal wall abscesses caused by Paecilomyces lilacinus, an organism not previously known to cause infections in patients with CGD. The abdominal wall is a location that is rarely associated with Paecilomyces infections. Parenteral amphotericin B eradicated the infection in an immunocompromised child whereas this regimen has heretofore largely been unsuccessful in the treatment of this infection. Paecilomyces species and other fungi from immunocompromised hosts and thought to be laboratory contaminants, need to be carefully investigated for they may become pathogens in this clinical setting.
A case of hyalohyphomycosis caused by Paecilomyces lilacinus is described in a renal transplant patient. Infection was localized on the left forearm. Two separate cultures of the lesions yielded the same organism. Histological sections disclosed hyaline elements in the tissue. The infection responded well to therapy with oral griseofulvin (500 mg daily) and the patient was cured within 45 days. Forty-six cases of human infection due to Paecilomyces species have been reported previously in the literature, most of them occurring in conjunction with prosthesis implants or immunosuppression. The antifungal sensitivity of Paecilomyces varies widely among the species but the general trend is for Paecilomyces variotii isolates to be almost universally sensitive to amphotericin B and 5-fluorocytosine, while P. lilacinus and Paecilomyces marquandii isolates are resistant to these antifungals but sensitive to the imidazoles.
Systemic infections caused by saprophytic fungi are being diagnosed more frequently. We describe the second reported instance of Paecilomyces lilacinus causing infection in an immunocompromised host. The diagnosis and treatment of this unusual pathogen are discussed.
Paecilomyces lilacinus was isolated on two separate occasions from the left antrum of a patient with chronic maxillary sinusitis. The clinical presentation and characteristics of the fungus and the sinus debris histopathology are discussed.
A healthy 58-year-old woman had a small nodular, tender, erythematous lesion on the tip of her left third toe for 2 months. The lesion was diagnosed as an abscess and was lanced. A few days later, in spite of antibiotic treatment given after a strain of Staphylococcus epidermidis was found in the wound, the clinical picture worsened: the whole toe became edematous and bluish in color. A second tender nodule, 2 cm in diameter, appeared on the back of the foot, followed by another nodule on the anterior surface of the left leg 2 weeks later. The patient was afebrile. The erythrocyte sedimentation rate was slightly elevated; the leukocyte count was high, with neutrophilia and low CD8 lymphocyte count (15%; normal range 19-39%). Physical examination revealed diffuse erythema and edema of the back of the left foot extending to the whole third toe, which was bluish with a small erosion on its back. There was a scab on the tip of the toe and under the nail (Fig. 1). Two reddish-purple, dome-shaped, rather tough nodules, 3 cm and 1 cm in diameter, respectively, were present on the back of the foot and on the anterior surface of the middle of the leg. Both were surrounded by a ring of erythematous and edematous skin (Fig. 2). Enlarged, tender lymph nodes, adherent to the deep tissues, were palpable in the left inguinocrural region. The overlying skin was erythematous. A biopsy taken from the nodule on the foot revealed the presence in the dermis of a microgranulomatous infiltrate containing eosinophils with a tendency to form microabscesses. Numerous newly formed blood vessels with hyperplasia of the endothelium and thickened walls were also present. No fungi or mycobacteria were apparent in preparations stained with the PAS and Ziehl-Neelsen methods (Fig. 3A, B). The exudate obtained from the nodule was cultured in various culture media (Sabouraud, blood-agar, selective media for mycobactaria). On Sabouraud agar a velvety white colony developed after 10 days (Fig. 4). Microscopic preparations of the colony revealed brush-like conidiophores ending in phialides carrying chains of conidia (Fig. 5) with a typical aspect of the genus Paecilomyces and very similar to Penicillium sp.
Sporotrichosis-like lesions caused by a Paecilomyces genus fungus
- Leigheb
Saprophytic molds as agents of cutaneous and subcutaneous infection in the immunocompromised host
- Weitzmann