Molecular Identification of Cutaneous Alternariosis in a Renal Transplant Patient

Abstract

Cutaneous alternariosis is a rare condition, caused by an uncommon opportunistic pathogen. The most frequently affected individuals are immunosuppressed patients, e.g., organ transplant patients on immunosuppressive therapy. Clinical manifestations range from local skin lesions to disseminated disease. We present a case report of cutaneous alternariosis in a renal transplant recipient, confirmed by histological examination and molecular means. In addition, a review of the literature was performed.

Polyphasic identification of three new species in Alternaria section Infectoriae causing human cutaneous infection

“…However, in most cases its identification is limited to morphological features of the fungus growing in culture and confirmed by the analysis of the ITS barcode. Even, in some cases, only ITS analysis is carried out directly from paraffin‐embedded tissue samples without culturing . Nevertheless, as stated before, the so‐called barcode for fungi has very limited resolution to distinguish closely related species in Alternaria , usually being only able to distinguish among Alternaria species‐groups or sections .…”

“…Isolate tissue samples without culturing. 16,50 Nevertheless, as stated before, the so-called barcode for fungi has very limited resolution to distinguish closely related species in Alternaria, usually being only able to distinguish among Alternaria species-groups or sections. 17,19 Therefore, the incidence of A infectoria as causative agent of alternariosis is probably overestimated in the above-mentioned studies, since the analysis of ITS sequences only is able to confirm the relationship of the case isolate to Alternaria section Infectoriae.…”

“…[3][4][5]7,16,52 In our case, in the first patient the infection was resolved with surgical excision of the nodule and topical VRC; the second patient with multiple skin lesions was initially treated with iv LAMB but due to side effects this was switched to VRC, while multiple lesions in the third patient were improved with nursing cures without specific antifungal treatment but follow-up was not possible because she was exitus ( Table 1). It of note however that, due to hepatic impairment as side effect reported for VRC 50,53 or the significant drug-drug interaction when using ITC, 11 currently PSC has shown to be a good option to treat cutaneous alternariosis. 4,50,54 This correlates with results of in vitro antifungal testing in several studies, which show that, among azoles, PSC is the most potent drug against Alternaria species.…”

“…It of note however that, due to hepatic impairment as side effect reported for VRC 50,53 or the significant drug-drug interaction when using ITC, 11 currently PSC has shown to be a good option to treat cutaneous alternariosis. 4,50,54 This correlates with results of in vitro antifungal testing in several studies, which show that, among azoles, PSC is the most potent drug against Alternaria species. 7,55,56 In the present study, isolates of A anthropophila and A guarroi of the first two cases, respectively (Table 3), showed low MICs to this drug.…”

The Curious Case of “Case Report” of Infections Caused by Human and Animal Fungal Pathogens: An Educational Tool, an Online Archive, or a Format in Need of Retooling

“…Next, we examined whether there was any discernible pattern for the case reports that had low downloads and low or no citations (Tables 4, 5). These case reports were reported from Belgium [75], Brazil [76], China [77], India [78], Iran [79], Italy [80], Pakistan [81], Spain [76], Switzerland [82], UK [83], and USA [84][85][86][87]. The cases included four Aspergillus infections, three pathogens belonging to Mucorales order, two basidiomycetes, one each Alternaria species, Paracoccidioides species, a rare dematiaceous pathogen, and a case series on Coccidioides species.…”