First Reported Case of a Clinically Nonresponsive-to-Itraconazole Alternaria alternata Isolated from a Skin Infection of a Nonimmunocompromised Patient from Romania

Abstract

Background: Alternaria alternata is a melanic fungus capable of causing a wide variety of infections, some of which have lethal potential. It is a ubiquitous fungus and a well-known plant pathogen. Cutaneous infections with Alternaria alternata most often occur in the extremities of patients who perform conventional agriculture, thus being exposed to occupational hazards leading to the disruption of the skin barrier. Methods: This paper presents the first case report from Romania of an itraconazole nonresponsive cutaneous alternariosis in a patient without any type of immunosuppression. Results: After an initial misdiagnosis regarding the etiology of the patient’s skin infection, two successive punch biopsies, followed by mycologic examination, lead to the final diagnosis of cutaneous alternariosis. Treatment guided by antifungal susceptibility testing has been instituted, leading to the gradual healing of the patient’s skin ulcerations. Conclusions: The ability of Alternaria alternata to infect immunocompetent human hosts and to develop resistance to antifungal drugs highlight the importance of correctly diagnosing the etiology of skin ulcerations and instituting appropriate treatment guided by antifungal susceptibility testing whenever the suspicion of a fungal skin infection is plausible.

Cutaneous Alternariosis in Immunosuppressed Patients Treated with Photodynamic Therapy and Oral Antifungals, a Synergistic Strategy

“…Cutaneous alternariosis is caused by the dematiaceous fungus Alternaria , which is frequently isolated in opportunistic deep cutaneous mycoses [ 5 ]. Alternaria is widely distributed and can be found in plants, water, soil water, or objects, among others [ 2 ]. The most frequent transmission mechanism in cutaneous infections is direct inoculation during or after a traumatism, commonly causing phaeohyphomycosis.…”

“…Nevertheless, the use of these treatments in OTRs requires close monitoring due to their interaction with calcineurin inhibitors, as well as other adverse reactions such as hepatotoxicity. A combination of surgery plus different antifungals is commonly needed to achieve cure rates around 90% due to adverse events to the antifungal drugs or lack of response to them [ 5 ], which is emerging as a concern even in immunocompetent patients [ 2 ].…”

“…This melanized mold can lead to a diverse range of clinical conditions, varying from localized manifestations in specific organs to more widespread systemic infections [ 1 ]. Alternaria infects mainly immunocompromised hosts; although there have been occasional instances of infections in individuals with healthy immune systems [ 2 , 3 ], these cases seldom progress to invasive diseases [ 4 ].…”

“…1 Thirty minutes of incubation followed by two hours of exposure to sunlight, once every 10 days. 2 Incubation time starting at 1 hour and progressively increasing to 3 hours, and subsequent illumination with Aktilite ® CL 128 increasing fluence from 37 to 74 J/cm 2 , once a week. 3 Three hours of incubation followed by illumination with Aktilite ® CL 128 (fluence 37 J/cm 2 ), twice weekly.…”