Scedosporium apiospermum Skin Infection in an Immunocompromised Patient
Brent Spencer, MD; Daniel Bennett, MD
Division of Dermatology, Scott & White Memorial Hospital, Texas A&M Health Science Center College of Medicine, Temple, TX
INTRODUCTION
Scedosporium apiospermum are ubiquitous
filamentous fungi known to cause an array of
infections. Treatment of these infections is difficult
due to resistance to many antifungal agents. We report
a case of skin infection secondary to Scedosporium
apiospermum in a patient on chronic corticosteroid
therapy. The patient was treated with wide surgical
excision and voriconazole, and no evidence of
recurrence has been noted 7 months since initial
presentation.
CASE PRESENTATION
A 72 year-old white male presented to our hospital
consultation service with a two month history of a
growing nodule on his right forearm. His past medical
history was significant for a two-year history of sacral
plasmacytoma treated with radiation therapy and
systemic corticosteroids. The patient lived in West
Texas and was an avid rose gardener.
PHYSICAL EXAM
Examination of the right dorsal forearm revealed
a 2.5 cm hemorrhagic, purulent, crusted plaque
with a slight rim of erythema (Figure 1). No other
lesions were noted, and the patient did not have
lymphadenopathy.
Figure 1
Produced by the Scott & White Graphic Services Department
HISTOPATHOLOGY
Biopsy performed from the right forearm revealed
atypical squamous epithelium and extensive acute
inflammation with abscess formation in the dermis
(Figure 2). Distinct grains were not visualized. GMS
staining revealed branching septate fungal hyphae
within the abscess (Figure 3).
Figure 2
Hematoxylin and Eosin Stain of Biopsy (100X)
Figure 3
Gomori Methenamine Silver Stain of Biopsy (400X)
CULTURE
Tissue culture from the right forearm was positive for
4+ Scedosporium apiospermum.
TREATMENT COURSE
• The patient was placed on voriconazole 200 mg
twice daily for a total of one month. This was ini-
tiated one week prior to surgical therapy.
• The lesion was excised with 1 cm margins, and
the remaining defect was closed with a split-thick-
ness skin graft.
• Repeat histopathology from the excision showed
similar findings to initial biopsy. Along with ab-
scess formation, sinus tracts were noted on this
specimen (Figure 4). PAS staining revealed sev-
eral fungal hyphae. (Figure 5)
• Four months after initial presentation, the area on
the arm was well-healed with no evidence of re-
current infection (Figure 6).
• The patient remained clear of infection at 7 month
follow-up.
Figure 4
Hematoxylin and Eosin Stain of Excision Specimen
(40X)
Figure 5 DISCUSSION
Periodic Acid-Schiff Stain of Excision Specimen
(400X) • Scedosporium apiospermum is the asexual anamorph of Pseudallescheria
boydii. These ubiquitous filamentous fungi are present in soil, sewage,
and polluted waters. These fungi can cause a range of infections, most
commonly affecting the skin and the lungs. The most common cutaneous
manifestation of this infection is the mycetoma. In recent years, there have
been increasing reports of localized cutaneous infection without the typical
features of mycetoma. These infections with S. apiospermum have been
associated with immunosuppression.
• Our case demonstrates S. apiospermum skin infection in a patient with
immunosuppression secondary to chronic corticosteroid therapy. Upon
further questioning, our patient reported a history of trauma to the right
arm from a rose thorn. Traumatic inoculation is a predisposing factor to
development of infection with S. apiospermum.
• Mycetomas are characterized by the clinical triad of swollen tissues, draining
sinuses, and extrusion of grains. Our case demonstrated sinus tracts but
failed to demonstrate any grains on histopathologic examination. This
unusual presentation without grains has been previously reported. Localized
skin infection without grain production is much rarer than mycetoma.
Figure 6
Several authors have hypothesized that localized skin infection without
grain production is associated with immunosuppression, while typical
mycetomas are associated with an immunocompetent state. Therefore, this
particular case may be better described as a localized cutaneous infection
secondary to S. apiospermum rather than a mycetoma.
• Treatment of infections with S. apiospermum is challenging due to the
resistance of the organism to many antifungal medications. Surgery is
recommended for most cases of eumycetoma. Furthermore, antifungal
therapy is recommended before both before and after surgery. In-vitro data
has shown susceptibility of S. apiospermum to voriconazole, itraconazole,
and miconazole. The most potent in vitro activity was observed for
voriconazole. Because of the rarity of this infection, the optimal dose and
duration of antifungal therapy are not standardized. In our case, the patient
had an excellent clinical response after 4 weeks of voriconazole combined
with surgical excision.
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