Clinical Mycology: Some Interesting Cases

V.Crespo Erchiga & E. Gomez Moyano.

Department of Dermatology. Regional  Hospital Carlos Haya, Málaga , Spain

We present five cases of cutaneous mycosis, who attended  our Hospital in recent years, and that I believe could be interesting from a clinical point of view, and by its etiology, differential diagnosis and treatment as well.

The first case was a 46 year old male, showing a facial oedema and a papulo-pustular eruption for ten months. At first he had been diagnosed as seborrhoeic dermatitis and since then treated with systemic and topical corticosteroids.

The clinical differential diagnosis could be discussed among the following diseases: discoid lupus, acne rosacea, atypical atopic dermatitis, seborrhoeic dermatitis and atypical ringworm (Tinea incognito).

We carried out a direct microscopy with KOH+Ink and cultures in Sabouraud media. The first one showed abundant typical hyaline hyphae, and in culture M.gypseum was isolated. This is a geophilic dermatophyte which generally produces inflammatory lesions. The patient, living in the country, acquired the infection through contact with contaminated soils. He was treated with oral terbinafine, 250 mg/day for two months and topical sertaconazole cream, achieving a complete clinical and mycological cure.

The second case was a 26 year old man from Paraguay (South America) who was also infected with the human inmunodeficiency virus. Eight months earlier,

during a trip to his own country, he had undergone surgery for an abscess just

in the same place where, at present, a cutaneous ulcer has appeared. He had

no fever or other systemic symptoms, nor any other cutaneous or mucous lesions.

From a purely clinical point of view, a differential diagnosis was discussed among: Cutaneous Leishmaniasis, Chancriform Pyodermitis (Covisa and Bejarano), Cutaneous Histoplasmosis, Syphilis maligna praecox and Lupus vorax (cutaneous tuberculosis).

We performed a skin biopsy, which showed abundant budding, yeast-like intrahistiocytic structures, stained in black with silver methenamine and in red with PAS stain. In cultures both in Blood Agar and Saboutraud Glucose Agar (SGA), Histoplasma capsulatum var capsulatum was isolated and identified. There is a high risk of laboratory-acquired infection with this fungus that should be managed under strict safety measures (Bio safety level 2). The patient was treated with oral Itraconazole : 200 mg twice a day for 12 weeks. Although he was clinically healed at the end of the first three months, he went on with a secondary prophylaxis with Itraconazole subAcaps (low dose) 100 mg/day for one year.

Case number three was a 30 years old man, coming from Northern Africa. He showed very irregular itching skin lesions that had been present for 9 months, beginning in the groins, further progressing slowly to the buttocks. The patient had been using different corticosteroid creams (betametasone propionate, clobetasol,,) without any control. The differential diagnosis suggested either a bacterial, viral or fungal infection, a perforating skin disorder, or even a psoriasis.

In this case, we made a Direct Microscopy in calcofluor white, which was positive, and cultures in Sabouraud agar, isolating T.rubrum var raubitschekii. This is a “primitive” variant of T.rubrum, usually found in some Western African countries. The treatment was the same as in case one, with the same good results.

The fourth case was a female patient, 43 years old, coming from Cuba, and showing OSDL of both toenails since at least five years before, and mild lesions of Tinea pedis interdigitalis. Neither systemic nor topical previous treatment had been undertaken. Under the clinical suspicion of Tinea unguium/Onychomycosis, we performed Direct microscopy with KOH+Ink and cultures in Sabouraud media, with and without cycloheximide.

By direct microscopy, non-dermatophyte, pigmented and irregular hyphae were seen. Cultures showed no growth on Sabouraud Agar with cycloheximide, while floccose gray-black fast growing colonies, filling the plate in a week, developed on Sabouraud glucose agar medium. The fungus was identified as Neoscytalidium dimidiatum, a no-Dermatophyte mould agent of onychomycosis and tinea pedis in tropical countries. Neoscytalidium onychomycosis seem to be resistant to most available systemic antifungal drugs. We prescribed in this case chemical nail avulsion with 40% urea ointment followed by amorolfine nail laquer twice a week.The patient did not return to the Hospital.

The last case was a male patient, fifty five years old, who suffered from long-lasting proliferative, warty cutaneous lesions covering the right leg, from the knee to the ankle, suggesting either aTuberculosis verrucosa cutis or a Mycosis fungoides (Alibert-Bazin) (T-cell lymphoma), a Pyodermitis vegetans (Hallopeau) or a subcutaneous mycosis like Chromoblastomycosis.

We performed a skin biopsy where some Medlar´s bodies were seen. These structures are a rather characteristic histological finding of a specific subcutaneous mycosis: the Chromoblastomycosis.

In cultures in Sabouraud glucose Agar Fonsecaea pedrosoi was isolated. This is the main causal agent of this mycosis, which can be also produced by other dematiaceous moulds (Phialophora verrucosa or Cladosporium carrionii).

The patient had been treated previously with different antifungal drugs, including itraconazol, without any result. We prescribed Posaconazole, 400 mg/twice a day and the patient showed a significant improvement after 6 months, and was completely healed after one year.