Pulmonary Phaeohyphomycosis in a Pa...

Pulmonary Phaeohyphomycosis in a Patient with Hemoptysis

Phaeohyphomycosis is usually a chronic, slowly progressive infection caused at a variety of closely related "black" or dematiaceous fungi which are plant in plants and soil. The infection is usually initiated through traumatic implantation into the skin. Generally, the organisms remain localized to the site of inoculation, nevertheless rarely hematogenous spread to distant organs (eg CNS) come abouts [1-6] Alternatively, the infection may be acquired on inhalation of the conidia with hematogenous spread to distant organs. [7]

Phaeohyphomycosis of the lung readyed in a patient with unrelenting hemoptysis and no identifiable source of cutaneous infection. To our knowledge, this is the first published report of an unequivocally documented case of isolated pulmonary infection causing hemoptysis to be paid to Exophiala dermatitidis, and it is the first infection owing to this fungus which was luckily treated.

CASE REPORT

A 79-year-old white woman (an unmarried retired schoolteacher) had a history of renewed hemoptysis. A bronchoscopy in 1979 failed to demonstrate any cause of bleeding. refinements of the secretions taken at bronchoscopy were negative for pathogenic microorganisms. Based about the history, findings on bronchoscopy and x-ray films, she was reflection to have and was treated for bronchiectasis involving the lingula of the lung She continued to have occasional episodes of hemoptysis. Past medical history was otherwise not significant. Prior to admission, she had had progressive weakness and weight los for six month and had a cough with hemoptysis for sum of two units weeks.

On examination, at the time of admission forward Nov 7, 1985, temperature w 370[degrees]C and respiratory rate, 28 by minute. She was intermittently expectorating ensanguined sputum. The remainder of the physical examination was unremarkable. The chest was clear to auscultation, and there was no significant lymphadenopathy or hepatosplenomegaly.

The chest x-ray film had an inflitrate in the left lower lobe and lingula and apical pleural thickening (Fig 1) and showed no major change from previous roentgenograms. in succession admission, hemoglobin value was 11 g/dl with normal indices; white family cell count was 11,600/cu mm with a normal differential; starch-sugar value was 110 mg/dl; and albumin even was 3.7 g/dl. Immunoglobulin flats were normal. The initial Mantoux standard was 14 mm, but couple subsequent tests had no induration.

onward the night of admission, she had a syncopal episode with documented hypotension and questionable seizure activity. At bronchoscopy there was profuse bleeding from the left lung probably originating in the lingula. She was meditation to have tuberculosis and was treated with isoniazid, ethambutol, rifampin, and multiple kin transfusions. However, two weeks later, a dematiaceous fungus grew from the specimen obtained at bronchoscopy This was identified as Exophiala dermatitidis upon the basis of morphology (Fig 2) and physiologic characteristics by way of both the Clinical Mycology Section at the National Institute of Allergy and Infectious Diseases and the Illinois Department of Public Health Laboratory. The antituberculosis medications were stopped. A repeat bronchoscopy was done upon Nov 26, 1986, and following cultures from the lavage of the lingula again grew E dermatitidis. Direct microscopic examination of the lavage showed a moderate number of septate hyphae (Fig 3) She had a CT scan of the head and a lumbar perforate but both were unremarkable. She was treated with amphotericin B (40 mg IV three times a week for three month with a total dose of 1536 g) and 5-fluocytosine (15 g po qid for three months) The patient improved and had resolution of her cough and hemoptysis. She gained weight and solidity and resumed normal activities. Sputum specimens from September of 1986 and 1987 were negative for fungi. As of June 1988 she has had no return of hemoptysis or of symptoms suggestive of pulmonary infection.

DISCUSSION

Phaeohyphomycoses are cutaneous and systemic infections characterized by means of darkly pigmented, septate hyphae current in the tissue. [8] They are caused by dint of a heterogeneous group of imperfect black (dematiaceous) fungi which contain a cytoplasmic melanin-like pigment that appears to have etiologic significance at decreasing susceptibility of these organisms to antifungal agents. [9] Taxonomic characterization of these fungi is controversial, in the way that the names given to these fungi are extremely variable and still changing as taxonomic criteria improve. about commonly recognized species included in this assign places to are Exophiala dermatiditis (synonymous with Wangiella dermatiditis), Cladosporium, Curvularia, and Drechslera species.

Phaeohymphomycosis involving infections of the paranasal sinuses, mucous and mucocutaneous membranes, subcutaneous tissues, and the central nervous regularity including brain abscesses, meningitis, and mycotic aneurysm have been reported. Reports of dematiaceous fungi of the respiratory a whole include the incidental finding of Cladosporium cladosporoides cultur at autopsy from a previously existing lung cavity and the isolation of various species from nasal septa and/or colonization of maxillary sinuses. [10-15] These were all isolated infections, and hence, were probably acquired from inhalation of the fungi.