Disseminated Scopulariopsis–culture is required to distinguish from other disseminated mould infections

Abstract

Disseminated fungal infections are a major cause of mortality in severely immunocompromised bone marrow transplant (BMT) patients. Scopulariopsis is a soil saprophytic mould that is typically associated with onychomycosis and only rarely associated with disseminated infection with cutaneous findings. We describe a case of fatal disseminated Scopulariopsis infection in a 56-year-old neutropenic male with chronic myelogenous leukemia status post peripheral blood stem cell transplant that was clinically and histologically indistinguishable from disseminated Aspergillus, Fusarium or zygomycosis infection. Distinguishing the above listed fungi by tissue culture is crucial because disseminated Scopulariopsis is difficult to eradicate and associated with a high mortality rate in the immunocompromised BMT patient population.

Fatal Scopulariopsis brumptii in a Pediatric Immunocompromised Host

“…Cutaneous manifestations present as erythematous macules, papules or plaques evolving into ulcers with central black eschar and peripheral erythema [1,9,10]. Granulomatous lesions with or without central necrosis can be seen [3,9].…”

“…The darkening conidia are what give the S. brumptii colonies their dark grey appearance and S. brevicaulis their more brown colonies on Sabourand's dextrose agar. Blood cultures are often negative, which is common in dry spore fungi such as Scopulariopsis [1,9].…”

“…Fusarium, and Aspergillus can start as primary cutaneous infections associated with onychomycosis similar to Scopulariopsis. Morphologically in vivo, all four species demonstrate hyaline, septated hyphae with acute angle branching and are impossible to distinguish from one another [1]. Culture can reliably differentiate between these entities based on growth rate, pigmentation and unique conidia structure [2].…”

“…In described reports, pulmonary infection is usual site of inoculation [8]. Genus Scopulariopsis contain hyaline and dematiaceous nondermatophytic filamentous molds [1], saprobes common in soil, plant debris, animal remains, and moist indoor environments [2,9]. With 40 recognized species, few are responsible for human disease [2].…”

“…Immunosuppressed individuals may manifest deep tissue and disseminated infections including pneumonia, endophthalmitis, invasive sinusitis, peritonitis, and endocarditis [2,9]. Risk factors include severe neutropenia (absolute neutrophil count <500 cells/mL for >1 week), vascular and urinary catheterization, gastrointestinal or oropharyngeal mucosal disruption by chemotherapy, broad-spectrum antibiotic use and high dose corticosteroids [1]. Clinical signs are non-specific and infection can be attributed to ongoing patient conditions including graft rejection, graft versus host disease, concurrent viral and bacterial coinfections, or be masked by high dose corticosteroids [1].…”