Cutaneous alternariosis in a renal transplant recipient: A case report and literature review

Abstract

Organ transplant recipients under immunosuppressive therapy have a highly increased risk of acquiring unusual opportunistic infections. Diagnosis of the etiology of infection may be difficult in clinical manifestations, which need further histological and biological investigations. We recently treated a male renal transplant recipient with a cutaneous phaeohyphomycosis due to Alternaria species. The diagnosis was based on microscopy and culture of the skin lesions. Treatment with oral itraconazole for 5 weeks was ineffective, then clinical improvement was achieved by combination of amphotericin B wet-packing and systemic antifungal therapy with oral voriconazole. Alternaria species are ubiquitous plant-inhabiting saprobes, which are increasingly associated with opportunistic phaeohyphomycosis in immunocompromised individuals. To the best of our knowledge, this is the second case report noting sporotrichoid pattern as the manifestation of cutaneous alternariosis. In this context, we reviewed recent renal-transplant-related cutaneous alternariosis reported in the English-language literature during 1995 to 2011 to summarize its clinical features and outcomes, and to guide clinicians in the care of kidney transplant patients with cutaneous alternariosis.

Clinical spectrum of phaeohyphomycosis in solid organ transplant recipients

“…Although it has been published that phaeohyphomycosis is more frequent in kidney transplant recipients,1, 4, 6, 7, 8, 10 we did not find a statistical difference between kidney and heart transplants in our series. This finding may be owing to the limited number of patients.…”

“…The incidence of phaeohyphomycosis in OTR is approximately 9%, and disease usually occurs in the first few years after transplant 1, 2, 8. Phaeohyphomycosis developed in all of our patients within the first 2 years after transplant.…”

“…The incidence of phaeohyphomycosis seems to be increasing as a result of increasing numbers of OTRs and scientific advances made in immunosuppressant medications 4, 5, 6, 8. Regarding the specific immunosuppressant drug, it seems that calcineurin inhibitors such as tacrolimus are more associated with greater susceptibility to fungal infections, which later can become recurrent 1, 4, 5, 7.…”

“…Despite that there are more than 100 species of fungi associated with this disease, there is still no correlation between the etiologic agent and morphology of lesions 3, 7, 8…”

“…The increase in the number of organ transplant recipients (OTRs), in conjunction with improvement in their long-term treatment, has led to an increase in the incidence of phaeohyphomycosis 1, 3, 4, 5, 6, 7. Phaeohyphomycosis has a wide range of clinical presentations, which are associated with the immune status of the host 1, 2, 3, 4, 5, 6, 7, 8, 9, 10. We describe 7 cases of phaeohyphomycosis in OTRs, which clearly demonstrate that the clinical presentations can have profound variations and that treating this infection in this specific patient population can be challenging.…”