P2408Disseminated trichosporonosis in a patient with relapsed acute myeloidleukemia

Megan Kinney, Wake Forest University School of Medicine, Winston Salem, NC,United States; Andrew Lee, MD, Wake Forest University School of Medicine,Winston Salem, NC, United States; Rita Pichardo, MD, Wake Forest UniversitySchool of Medicine, Winston Salem, NC, United States

Disseminated trichosporonosis is an emerging opportunistic fungal infectionassociated with immunocompromised patients. We describe an 18-year-old patientadmitted for relapsed acute myeloid leukemia. Six weeks into his hospital course,after receiving high-dose cytosine arabinoside and etoposide, he developed aneutropenic fever and a morbilliform eruption on his trunk, and a skin biopsyspecimen revealed sparse dermatitis. Blood cultures were negative at that time,although the patient was on prophylactic antibiotics. One week after his first skinbiopsy, the patient became hypotensive and tachypneic, requiring intubation andadmission to the ICU. At this time, purpuric nodules on the extremities wereobserved, and a skin biopsy specimen revealed a dermal invasion of fungal elements,at which point aggressive antifungal therapy was initiated. Subsequent bloodcultures and tracheal aspirates were positive for Trichosporon beigelii.Dermatologists may play a key role in the early diagnosis of disseminatedtrichosporonosis among immunocompromised patients.

AB86

cial support: None identified.

Commer

P2409Tinea pedis in an immunocompetent patient caused by Fusarium spp.

Maria Encarnacion Gimenez-Cortes, MD, Hospital Fundacion de Cieza, Cieza,Murcia, Spain; Eugenia Cutillas-Marco, MD, Hospital Fundacion de Cieza, Cieza,Murcia, Spain; Silvina Gaglio de Grecco, MD, Hospital Fundacion de Cieza, Cieza,Murcia, Spain

Background: Fusarium spp. are nondermatophyte molds that are present all over theworld. They can cause both localized or disseminated infections, commonly frompulmonar focus. Localized infections usually present as onychomycosis.

Case report: A 64-year-old man presented with a 3-month history of an exudativeplaque affecting the dorsal surface of the feet.The patient lived in a rural area in thesouth of Spain and medical history was unremarkable except for hypercholester-olemia, hyperuricemia, and trasplant of cornea. Before being referred to our clinic,he had been on treatment with prednisone and ciprofloxacin, with partial response.On physical examination, he had an erythematous plaque in his left foot with bothexudative and hyperkeratotic areas, affecting the dorsum, and interdigital skin, andspreading to the sole. He presented a yellowish opacification of hyperkeratoticmails. Lesions were scraped for culture, which was positive for Fusarium spp. After a3-week treatment with terbinafine all the skin lesion disappeared, although he wasadvised to continue the treatment because of nail infection.

Discussion: Most of the cutaneous infections caused by Fusarium spp. occur inimmunocompromised hosts, especially solid organ transplant patients or those withhematologic neoplasia. The most common cutaneous manifestation of an infectionby Fusarium spp. is onycomycosis, which is the only skin manifestation inimmunocompetent hosts. Nevertheless, a disseminated infection is possible inimmunocompromised patients. When Fusarium spp. produces an onychomycosisin an immunosupressed host, it can spread rapidly to paronychia and a disseminatedinfection, causing the death of the patient. In contrast, infections in immunocom-petent hosts spread slowly and have a good response to treatment. After clinicalexamination, confirmation of an infection by Fusarium spp. requires a positiveculture and the absence of concurrent isolation of a dermatophyte, becauseFusarium can be a contaminant.

cial support: None identified.

Commer

J AM ACAD DERMATOL

P2410Cutaneous alternariosis in renal transplant recipient

Almudena Mateu-Puchades, MD, Department of Dermatology, HospitalUniversitario Doctor Peset, Valencia, Spain; Amparo Marquina-Vila, PhD,Department of Dermatology; Hospital Universitario Doctor Peset, Valencia,Spain; Francisco Ferrando-Roca, MD, Department of Dermatology; HospitalUniversitario Doctor Peset, Valencia, Spain; Maria Neus Coll-Puigserver, MD,Department of Dermatology. Hospital Universitario Doctor Peset, Valencia, Spain

Background: Alternaria is a genus of dematiaceous fungi that is ubiquitous in theenvironment. Alternariosis is rare, but increasingly prevalent among immunosup-presed population. We report a case of cutaneous alternariosis in a renal transplantrecipient with good response to combined surgical and medical therapy.

Case report: A 60-year-old man who suffered two chronic rejections of two previousrenal transplant underwent the last renal transplant 6 months before attending ourclinic. Since then, he had been treated with prednisolone, tacrolimus, andmycofenolate mofetil. Four months after transplant, he developed a 2-cm solitary,ulcerated, violaceus nodule on his right arm. The lesion was asymptomatic and therewas no history of trauma. The nodule was completely excised and the biopsyspeciemen showed a granulomatous infiltrate in the dermis with round shapedfungus spores, and hyphae stained positive with periodic acid-Schiff. The biopsyspecimen was cultured in Sabouraud dextrose agar and Alternaria alternata wasidentified. Itraconazole 200mg bid for 4 weeks was added after surgical treatment.Tacrolimus levels were controlled along medical treatment without any complica-tions. The patient has been free of lesions after 1 year of follow-up.

Discussion: Alternaria produces a wide range of infections, from noninvasivecolonization to severe systemic involvement. Cutaneous infection is the mostcommon presentation. It usually produces a solitary lesion, but multiple lesions withsprotrichoid spread have been observed. Because Alternaria is frequently found inthe environment and on normal human skin, it could be difficult to establishwhether it is a contaminant or not. Therefore, the diagnosis requires tissue cultureand histologic evidence of dermal granuloma with hyphae. The optimal treatmentfor cutaneous alternariosis is controversial. Surgical excision, when possible, seemsto be the best therapeutical option. Alternaria species are sensitive to oralitraconazole, amphotericin B, fluconazole, micoazole, and ketoconazole, and areresistant to griseofulvin and flucytosine. Some authors recommend to combinesurgery and oral itraconazole, but doses and duration of treatment are not fullyestablished and we have to take care because simultaneous administration oftacrolimus and itraconazole may result in tacrolimus toxicity if the dosage oftacrolimus is not adjusted and serum levels monitored. Follow-up is essential,because relapse has been shown to occur frequently.

cial support: None identified.

Commer

P2411Onychomycosis therapy: Room for improvement

Aditya Gupta, MD, PhD, MBA, Mediprobe Research, London, Ontario, Canada

Effective onychomycosis therapy has historically required oral antifungal use.Despite being the criterion standard for onychomycosis, the typically moderateefficacy rates of oral therapies leave much room for improvement. These therapiesare also costly, and can pose potentially significant risk to patients. To date, only twotopical therapies have been approved for onychomycosis, one of which is notavailable in North America. The efficacy of the topical therapies is typically not ashigh as for oral antifungals, and their use is restricted to less severe cases of infection.Though some new azole antifungal medications are being developed, new researchis exploring many other avenues of onychomycosis therapy. Two novel classes ofantifungals, oxaboroles and arylguandines, are being tested. AN2690, an oxaborolenail solution, provided an efficacy of 45% to 50% after 6 months of daily application,and therefore appears to have potential in onychomycosis therapy. Other new ideasbeing explored seek to improve nail penetration using penetration enhancers,nanoemulsions, drug implants, and iontophoresis. Testing of light therapy devicesand lasers is also progressing, to determine if these modalities can sufficientlypenetrate the nail plate and provide effective treatment of onychomycosis.Aminolevulinic acid photodynamic therapy has provided high rates of efficacy insmall scale trials. A pilot trial of a new patented laser device (200 mJ; 100 msec pulseduration with 10 pulses per spot in 0.5 sec) showed that the percent of patients with75% to 100% involvement pretreatment declined from 85.7% to 14.3% at 6 monthsposttreatment. Laser and light devices not requiring drug activators are particularlyexciting because they may avoid potential drug interaction and renal/liver toxicityprovided by drug therapies, while also potentially reducing issues of patientcompliance that operate with drug regimens. There is no shortage of ideas forimproving onychomycosis therapy, with most testing being in the phase II stage ofresearch. In conjunction with molecular diagnosis techniques, it is hoped that manyof these new modalities will help provide new avenues of effective treatment foronychomycosis, while maintaining or improving the safety profile of antifungaltherapy.

cial support: None identified.

Commer

MARCH 2010