Felipe Francisco TuonI; Carolina PozziII; Sergio Ricardo Penteado-FilhoI; Ricardo BenvenuttiII; Fabiana Loss de Carvalho ContieriII
IDivision of Infectious and Parasitic Diseases, Hospital Universitário Evangélico de Curitiba, Curitiba, PR IIDivision of Renal Transplant, Hospital Universitário Evangélico de Curitiba, Curitiba, PR
Acremonium infection is rare and associated with immunosuppression. A case of recurrent cutaneous Acremonium infection after short term voriconazole use is described. Surgical resection was the definitive therapy. Oral voriconazole was used in the treatment of Acremonium infection, but recurrence was associated with short therapy. Prolonged antifungal therapy and surgical resection are discussed for the treatment of localized lesions.
Key-words: Voriconazole. Acremonium. Fungal infection.
Infecção por Acremonium é rara e pode estar associada com imunossupressão. Descrevemos um caso de infecção recorrente de pele por Acremonium após tratamento breve com voriconazol. Ressecção cirúrgica foi o tratamento definitivo. Terapia prolongada com antifúngicos e ressecção cirúrgica são discutidas para o tratamento de doenças fúngicas localizadas.
Palavras-chaves: Voriconazol. Acremonium. Infecção fúngica.
Acremonium is a ubiquitously fungus present in the soil and human infection is extremely uncommon1,2. Dermatophytoses, keratitis and mycetomas are the most common clinical presentation. Immunosuppressed patients show a large clinical spectrum, including pneumonia, arthritis, osteomyelitis, endocarditis, peritonitis, meningitis and sepsis1,3,4. Immunosuppressed patients can also present localized cutaneous lesions1. A case of cutaneous lesion caused by Acremonium sp with recurrence after a short course of voriconazole is described.
A 47 year-old male farmer, living in Mabore (a southern city in Brazil) was admitted to hospital due to skin lesion in the thigh on March 22, 2009. The patient has been a kidney transplant patient since November 7, 2007, using mycophenolate mofetil, tacrolimus and prednisone. The lesion, measuring 1.5cm in diameter, appeared two months before admission and presented purulent discharge (Figure 1). There was no history of trauma, the rest of the physical examination was normal and laboratorial tests were irrelevant. A skin biopsy showed a granulomatous reaction with giant cells, while Grocott stain showed phialide and phialoconidium (Figure 2). The culture was positive for Acremonium sp, though species identification was not performed.
Immunosuppressive therapy was suspended and voriconazole 200mg b.i.d. was used for 14 days. The lesion improved and drainage was suspended; however, after one month, the lesion returned and a new culture showed Acremonium sp with histological analysis showing the same aspect of the first biopsy. Surgical resection of the lesion was performed and immunosuppressive therapy was reintroduced. The lesion cured without recurrence after six months.
This case suggested that short therapy with voriconazole is inadequate for the treatment of cutaneous lesions caused by certain yeasts occurring on transplant patients. We believe that prolonged therapy should be used for transplant patients. The improvement of the lesion after two weeks of therapy demonstrated the efficacy of voriconazole against Acremonium, although no sensitivity test was performed. Nevertheless, short therapy (two weeks) was insufficient for fungus eradication from the skin. The fact that the cutaneous lesion was localized permitted a surgical resection approach.
A previous review summarized clinical experience with infections caused by species of Acremonium5. Two cases of cutaneous lesions have been published involving transplant patients. The first was described by Strabelli et al in a heart transplant patient6. This patient presented a lesion on the knee that was treated with surgery and local therapy. In another case, a subcutaneous infection in a kidney transplant patient was cured with surgical resection of the abscesses and ketoconazole7. In some instances, the particular species of Acremonium cannot be determined by morphology, as described in several reports and in this case5.
The drug of choice for treatment of Acremonium infections is amphotericin; however, the species presents low susceptibility to most antifungals, including imidazoles, fluorocytosine and amphotericin B. In vitro studies have shown that Acremonium can be susceptible to voriconazole, but resistant to other imidazoles8. Voriconazole has been used in some cases of Acremoniuminfections with success9,10. This patient received voriconazole due to renal graft and risk of renal failure.
In summary, Acremonium sp can cause skin lesions in kidney transplant patients. Voriconazole improved the lesion but recurrence occurred with short therapy. Considering the cost of new antifungal drugs, surgical resection is an adequate approach in these cases.
The authors would like to thank Marcelo Dorneles for the microbiological study.
1. Schell WA, Perfect JR. Fatal, disseminated Acremonium strictum infection in a neutropenic host. J Clin Microbiol 1996; 34:1333-1336. [ Links ]
2. Krcmery Jr V, Kunova E, Jesenska Z, Trupl J, Spanik S, Mardiak J, et al. Invasive mold infections in cancer patients: 5 years’ experience with Aspergillus, Mucor, Fusarium and Acremonium infections. Support Care Cancer 1996; 4:39-45. [ Links ]
3. Guarro J, Gams W, Pujol I, Gene J. Acremonium species: new emerging fungal opportunists-in vitro antifungal susceptibilities and review. Clin Infect Dis 1997; 25:1222-1229. [ Links ]
4. Warris A, Wesenberg F, Gaustad P, Verweij PE, Abrahamsen TG. Acremonium strictumfungaemia in a paediatric patient with acute leukaemia. Scand J Infect Dis 2000; 32:442-444. [ Links ]
5. Fincher RME, Fisher JF, Lovell RD, Newman CL, Espinel-Ingroff A, Shadomy HJ. Infection due to the fungus Acremonium (Cephalosporium). Medicine 1991; 70:398-409. [ Links ]
6. Strabelli TM, Uip DE, Amato Neto V, Bocchi EA, Higuchi ML, Stolf NA, et al. Acremoniuminfection after heart transplant. Rev Soc Bras Med Trop 1990; 23:233. [ Links ]
7. Miro O, Fernando J, Lecha V, Campistol JM. Abcesos subcutaenos por Acremonium falciforme en un transplantado renal. Med Clin (Barc) 1994; 102:316. [ Links ]
8. Wildfeuer A, Seidl HP, Paule I, Haberreiter A. In vitro activity of voriconazole against yeasts, moulds and dermatophytes in comparison with fluconazole, amphotericin B and griseofulvin. Arzneimittelforschung 1997; 47:1257-1263. [ Links ]
9. Keynan Y, Sprecher H, Weber G. Acremonium vertebral osteomyelitis: molecular diagnosis and response to voriconazole. Clin Infect Dis 2007; 45: e5-e6. [ Links ]
10. Mattei D, Mordini N, Lo NC, Gallamini A, Osenda M, Pugno F, et al. Successful treatment of Acremonium fungemia with voriconazole. Mycoses 2003; 46:511-514. [ Links ]
Dr. Felipe Francisco Tuon
Infectious and Parasitic Diseases Clinic, Hospital Universitário Evangélico de Curitiba
Alameda Augusto Stellfeld 1908/3º andar, SCIH – Bigorrilho
80730-150 Curitiba, PR, Brazil
Phone: 55 41 3240-5055; Fax: 55 41 3240-5274
Received in 08/12/2009
Accepted in 21/01/2010