One hundred clinical isolates of Sporothrix schenckii were tested against voriconazole, itraconazole and amphotericin B using a modification of the NCCLS M27-A in vitro yeast susceptibility testing procedure. NCCLS M38-P for moulds was not used because yeast forms may have been present when the test isolates were incubated at 35 +/- 1 degrees C. The minimum inhibitory concentration (MIC) values were: voriconazole 0.5-8 (geometric mean titer 6.50) microg ml(-1) ; itraconazole 0.03-8 (geometric mean titer 1.56) microg ml(-1); and amphotericin B 0.25-2 (geometric mean titer 1.23) microg ml(-1). The minimum fungicidal concentration (MFC) values were: voriconazole 2-8 (geometric mean titer 7.67) microg ml(-1); itraconazole 0.125-8 (geometric mean titer 7.41) microg ml(-1); and amphotericin B 0.125-2 (geometric mean titer 1.53) microg ml(-1). Based upon MIC values, sensitivity to amphotericin B is strain-dependent. S. schenckii is more sensitive to itraconazole than voriconazole based upon a comparison of MIC geometric means, even though the MIC ranges were essentially the same.

ABSTRACT The in vitro activity of voriconazole was compared to those of itraconazole and amphotericin B against the mold forms of 304 isolates of three dimorphic fungi, Blastomyces dermatitidis , Coccidioides immitis , and Histoplasma capsulatum . MICs were determined by a broth microdilution adaptation of the National Committee for Clinical Laboratory Standards M27-A procedure. RPMI 1640 medium was used for tests with voriconazole and itraconazole, whereas Antibiotic Medium 3 with 2% glucose was used for amphotericin B. Minimum fungicidal concentrations (MFCs) were also determined. Amphotericin B was active against all three dimorphic fungi, with MICs at which 90% of the isolates tested are inhibited (MIC 90 s) of 0.5 to 1 μg/ml. Itraconazole had MIC 90 s of 0.06 μg/ml for H. capsulatum , 0.125 μg/ml for B. dermatitidis , and 1 μg/ml for C. immitis . The MIC 90 s of voriconazole were 0.25 μg/ml for all three fungi. Amphotericin B was fungicidal for B. dermatitidis and H. capsulatum with MFCs at which 90% of strains tested are killed (MFC 90 s) of 0.5 and 2 μg/ml, respectively. It was less active against C. immitis , with MFCs ranging from 0.5 to >16 μg/ml. Voriconazole and itraconazole were lethal for most isolates of B. dermatitidis , with MFC 50 s and MFC 90 s of 0.125 and 4 μg/ml, respectively. Both azoles were fungicidal for some isolates of H. capsulatum , with MFC 50 s of 2 and 8 μg/ml for itraconazole and voriconazole, respectively; neither had a lethal effect upon C. immitis . Our results suggest that voriconazole possesses promising activity against these important human pathogens.

ABSTRACT Changes over the last decade in overt proficiency testing (OPT) regulations have been ostensibly directed at improving laboratory performance on patient samples. However, the overt (unblinded) format of the tests and regulatory penalties associated with incorrect values allow and encourage laboratorians to take extra precautions with OPT analytes. As a result OPT may measure optimal laboratory performance instead of the intended target of typical performance attained during routine patient testing. This study addresses this issue by evaluating medical mycology OPT and comparing its fungal specimen identification error rates to those obtained in a covert (blinded) proficiency testing (CPT) program. Identifications from 188 laboratories participating in the New York State mycology OPT from 1982 to 1994 were compared with the identifications of the same fungi recovered from patient specimens in 1989 and 1994 as part of the routine procedures of 88 of these laboratories. The consistency in the identification of OPT specimens was sufficient to make accurate predictions of OPT error rates. However, while the error rates in OPT and CPT were similar for Candida albicans , significantly higher error rates were found in CPT for Candida tropicalis , Candida glabrata , and other common pathogenic fungi. These differences may, in part, be due to OPT’s use of ideal organism representatives cultured under optimum growth conditions. This difference, as well as the organism-dependent error rate differences, reflects the limitations of OPT as a means of assessing the quality of routine laboratory performance in medical mycology.

Fifty-nine isolates consisting of 14 genera and 33 species of ascomycetes, basidiomycetes, and zygomycetes were tested against amphotericin B, fluconazole, itraconazole and voriconazole using an in vitro modified macrobroth dilution procedure based upon the NCCLS M27-A standard method for yeasts. The triazoles voriconazole and itraconazole had similar MIC values, except for Acremonium alabamensis, A. strictum, Fusarium oxysporum, F. solani and Wangiella dermatitidis, which had substantially lower voriconazole MIC values. Voriconazole MIC values were lower than those for itraconazole for the 17 species of Trichosporon tested. Fluconazole had high MIC values, often greater than 128 microg ml-1.

Two hundred and three isolates representing 15 species of filamentous ascomycetes were evaluated against terbinafine and itraconazole using a modification of the NCCLS M27-A standard reference method for yeasts. The MIC ranges and geometric means were similar, although terbinafine tended to have the lowest values. The loculoIascomycete clade tested had consistently low MIC geometric mean values for its members, ranging from 0.03 to 0.17 microg ml-1 for terbinafine and 0.03-0.37 microg ml-1 for itraconazole.

ABSTRACT The in vitro susceptibilities of three hundred eighty-one isolates representing two classes, five orders, nine families, 30 genera, and 51 species of ascomycetous fungi to voriconazole, itraconazole, and amphotericin B were tested by using a modification of the National Committee for Clinical Laboratory Standards M27-A reference method. For those fungi of known phylogenetic relatedness, drug MICs were consistently low for isolates among all clades, except for members of the family Microascaceae. The highest MICs of all drugs tested were consistently for the Microascaceae, supporting the observation of fungal phylogeny and corresponding susceptibility to antifungal drugs. Itraconazole and voriconazole have a broad range of activity against phylogenetically similar agents of hyalohyphomycosis, phaeohyphomycosis, chromoblastomycosis, and mycetoma.

Voriconazole was compared to amphotericin B, fluconazole, and itraconazole by using an in vitro macrobroth dilution test based upon current National Committee for Clinical Laboratory Standards tentative standards against the dimorphic fungi and several opportunistic molds and yeasts. In all instances, the voriconazole MICs were lower than those of fluconazole. In most instances, the MICs were lower than the recorded MICs of amphotericin B and itraconazole.

A multicenter study was conducted to expand the generation and analysis of data that supports the proposal of a reference method for the antifungal susceptibility testing of filamentous fungi. Broth microdilution MICs of amphotericin B and itraconazole were determined in 11 centers against 30 coded duplicate pairs of Aspergillus spp., Fusarium spp., Pseudallescheria boydii, and Rhizopus arrhizus. The effect of inoculum density (approximately 10(3) and 10(4) CFU/ml), incubation time (24, 48, and 72 h), and procedure of MIC determination (conventional and colorimetric [Alamar Blue] evaluation of growth inhibition) on intra- and interlaboratory agreement was analyzed. Based on intra- (97 to 100%) and interlaboratory (94 to 95%) agreement for both drugs, the overall optimal testing conditions identified were determination of colorimetric MICs after 48 to 72 h of incubation with an inoculum density of approximately 10(4) CFU/ml. These testing conditions are proposed as guidelines for a reference broth microdilution method.

In spring 1994, an outbreak of sporotrichosis occurred at a tree nursery in Florida; 9 (14%) of 65 workers involved in production of sphagnum moss topiaries developed lymphocutaneous sporotrichosis. A cohort study of all 65 employees was conducted to identify risk factors for sporotrichosis, and an environmental investigation was done. The risk of sporotrichosis increased significantly with the duration of working with sphagnum moss (P < .05), in particular with filling topiaries (P < .05), and with having less gardening experience (P < .05). Wearing gloves was protective (P < .005). Sporothrix schenckii was cultured from patients and sphagnum moss used in topiary production. Use of restriction fragment length polymorphism revealed an identical pattern for patient isolates that was different from the patterns of environmental isolates. Physicians should be aware of sporotrichosis in patients with ulcerative skin lesions who have a history of occupational or recreational exposure to sphagnum moss.

Seventy yeast isolates representing species in the genera Candida and Torulopsis but excluding Candida albicans were examined in three laboratories for production of pseudohyphae in Dalmau cultures. The microscopic morphology of the isolates was scrutinized by four individuals experienced in yeast identification and three inexperienced persons, all of whom were blinded as to the putative identification of the yeasts. For 49 (70%) of the 70 isolates, the seven observers recorded comparable scores for morphology, but 5 (7%) of the isolates showed extreme variation in recorded morphologies, from true hyphae formed to no pseudohyphae formed. Isolates of Candida parapsilosis and Torulopsis glabrata consistently did and did not form pseudohyphae, respectively: however, other Candida and Torulopsis spp. did not always express their expected morphologies. In 48 (19%) of 252 readings (seven observers), 36 isolates of Candida spp. were scored as forming no pseudohyphae, and in 22 (9.2%) of 238 readings, 34 isolates of Torulopsis spp. were recorded as forming true hyphae or pseudohyphae. These results show that pseudohypha formation is not a reliable characteristic for identification of yeasts at the genus level; we suggest that the merger of Torulopsis spp. into the genus Candida should be finally accepted.

Case ReportsRecurrent Allergic Fungal Sinusitis Sequentially Caused by Exserohilum and Bipolaris Mohamad M. El-Zaatari, MD, ABMM Lester Pasarell, and MPH, BS (MT) Michael R. McGinnisPhD, ABMM Mohamad M. El-Zaatari Address correspondence to Dr. El-Zaatari, Hennepin County Medical Center, OB/GYN Department #823, 701 Park Avenue South, Minneapolis, MN 55415 USA. From the University of Texas Medical Branch, Clinical Microbiology and Immunology Division, Galveston Search for more papers by this author , Lester Pasarell Address reprint requests to Lester Pasarell, Supervisor, Medical Mycology Research Center, Center for Tropical Diseases, Departments of Pathology, The University of Texas Medical Branch, Galveston, Texas 77555-0609 USA. From the University of Texas Medical Branch, Clinical Microbiology and Immunology Division, Galveston From the Center for Tropical Diseases, Medical Mycology Research Center, Departments of Pathology, Galveston Search for more papers by this author , and Michael R. McGinnis From the University of Texas Medical Branch, Clinical Microbiology and Immunology Division, Galveston From the Center for Tropical Diseases, Medical Mycology Research Center, Departments of Pathology, Galveston Search for more papers by this author Published Online:1 Sep 1996https://doi.org/10.5144/0256-4947.1996.564SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionAllergic fungal sinusitis is one of four distinct forms of fungal disease involving the paranasal sinuses.1 The disease is typically caused by a species of Aspergillus,2 as well as numerous other genera and species of both dematiaceous and nondematiaceous fungi.3–9 At the University of Texas Medical Branch, between 1989 and 1991, we treated six cases of fungal sinusitis that were caused by Bipolaris spicifera, Exserohilum rostratum, Curvularia verruculosa and Pseudallescheria boydii. Our experience, as well as that published in the literature, suggests that allergic fungal sinusitis is being recognized more frequently. The isolation of two different known etiologic agents of allergic fungal sinusitis from the same patient is noteworthy.CASE REPORTSCase 1A 16-year-old white female was referred to the University of Texas Medical Branch at Galveston (UTMB) clinics in May 1987 for treatment. She had a history of chronic right pansinusitis dating from October 1986. In June 1987, she underwent a right maxillary sinus obliteration with abdominal fat and rectus fascia homograft to the medial sinus wall. She was given intranasal corticosteroids. No tissue was sent to the mycology laboratory for culture. The pathology report described inflammatory polyps with eosinophils. Eighteen months later, in January 1990, the patient complained of nasal blockage and drainage from her right naris. On physical examination, she had two polyps in the middle right meatus with purulent secretions. She was treated with intranasal corticosteroids for five months with no improvement. Computerized tomography (CT) examination of her sinuses revealed extensive soft tissue filling the right sphenoid and posterior ethmoid cavities. In May 1990, the patient underwent a right Caldwell-Luc procedure and right posterior ethmoidectomy and sphenoidectomy. A thick material of “peanut butter” consistency and extensive polyposis were seen. Noninvasive, Fontana-Masson stain was positive, and fungal elements were present with an eosinophilic exudate “allergic mucin.” The presence of melanin in the fungi indicated that the fungus was one of the black molds. Evaluation of the contents in potassium hydroxide (KOH) revealed abundant hyaline septate hyphae. Cultures on mold inhibitory agar grew Exserohilum rostratum. Reexamination of the previous nasosinus excisions from the same patient revealed noninvasive fungal hyphae positive for melanin with the Fontana-Masson stain, and located in a dense mucus with an eosinophilic exudate. After surgery, her symptoms receded, but eight months later she continued to have a purulent right nasal discharge. In May 1991, the patient experienced right nasal congestion, and upon examination, had right posterior nasal crusting and right nasal passage obstruction. She was treated with decongestants, intranasal steroids, and periodic crust removal in clinic. A CT scan revealed soft tissue filling of the right sphenoid sinus. In August 1991, she underwent right sphenoidectomy, and nasal antral window was performed. Histologic examination of the sinus contents revealed the same findings as before, except that culture of the material obtained grew Bipolaris spicifera. Results of in vitro antifungal susceptibility studies are shown in Table 1. The patient received antifungal chemotherapeutic agent(s) under the supervision of a local physician. She remained well with no signs of recurrence during a 15-month period of follow-up. A CT scan of her sinuses obtained in July 1992 showed marked improvement in the right sinuses except for minimal mucoperiosteal thickening without bone destruction. Her last clinic visit was August 1992, at which time there were no symptoms and cultures were negative.Table 1. In vitro susceptibility to antifungal agents of Bipolaris and Exserohilum.*Case 2A 35-year-old white female, with an eight-year history of frontal headaches, purulent nasal discharge, and obstruction which progressed to chronic sinusitis, underwent an intranasal polypectomy by a local doctor in September 1987 without improvement. A CT scan revealed opacification of all sinuses and soft tissue masses in the paranasal sinuses. In March 1988, she underwent endoscopic sinus surgery with bilateral intranasal ethmoidectomies, sphenoidectomies, maxillary osteotomies, and intranasal polypectomies. Dark-brown cheesy material was found within the nasal sinuses. The nasosinus content contained branching septate hyphae, but no cultures were done. She was treated with systemic and topical corticosteroids after the surgery. Her condition improved during the next year, but in March 1990, she developed frontal headaches with nasal obstruction and expulsion of chunks of mucoid material from her naris. On inspection, extensive nasal polyps were found in both nares, with purulent material from the left middle meatus. She had no symptomatic relief from antibiotics and systemic and intranasal steroids. A CT scan revealed that the maxillary, ethmoid, and frontal sinuses contained bilateral polyps. She underwent bilateral intranasal polypectomy and bilateral maxillary sinuscopy with removal of cheesy, “peanut-butter”–like balls. Histopathologic findings were as previous (Figure 1), and the diagnosis of noninvasive fungal allergic sinusitis was made. KOH preparation was not performed, and culture of the maxillary material grew E. rostratum as well as Staphylococcus aureus and Hemophilus influenzae. One month after her last surgical treatment, she required a revision endoscopic nasal surgery with bilateral anterior ethmoidectomies, enlargement of the nasal frontal recess, and left Caldwell-Luc procedure. Histopathologic findings were similar to the findings in the previous two specimens. No culture was requested. The patient refused to take steroids and other types of medical treatment, including antifungal chemotherapy. Her disease remained clinically stable over an 18-month period. A follow-up CT scan showed recurrence of soft-tissue abnormalities within the paranasal sinuses. The patient underwent revision, functional endoscopic surgery, enlargement of maxillary sinus ostia, and bilateral nasal polypectomy in October 1991. Histopathologic findings were the same as the previous examinations (Figure 2). KOH preparation revealed golden-colored septate hyphae, and the culture of the sinus contents grew B. spicifera. Skin tests were positive (very large reaction more than 10 x 10 mm) by the prick method (1:20 wt/vol) for Alternaria, Helminthosporium, Russian Thistle, and UTMB grass mix, but negative for Aspergillus.Figure 1. Fungal elements of Exserohilum rostratum in tissue from nasal sinus, case 2 (Fontana-Masson melanin stain, 630x).Download FigureFigure 2. Fungal elements of Bipolaris spicifera in tissue from nasal sinus, case 2 (Gomori's methenamine silver stain, 630x).Download FigureAfter two years of follow-up there was no improvement in her condition. She continues to have frontal headaches and nasal congestion with facial fullness and pressure. She was maintained on topical steroids. Her last CT scan showed bilateral pansinusitis with mucosal thickening in all areas. Her physical examination revealed bilateral nasal polyposis. A revision functional endoscopic sinus surgery with nasal polypectomy was performed on December 30, 1993. Histopathologic findings were the same as before, but no tissue was sent for culture.DISCUSSIONPhaeohyphomycosis is an umbrella term which refers to a broad spectrum of infections caused by dematiaceous fungi.10 During the past several years, there has been an increase in the frequency of cases of phaeohyphomycosis caused by the members of the genera Bipolaris and Exserohilum.11 Allergic phaeohyphomycosis caused by dematiaceous fungi, such as Alternaria, Bipolaris, Cladosporium, Curvularia, and Exserohilum species, are capable of localized colonization, and infection of the paranasal sinuses in both immunocompetent3–9,11–21 and immunocompromised hosts.21–24 Intracranial extension of the dematiaceous fungi in patients with allergic fungal sinusitis has been reported in the literature,4,13,19,20 which illustrates how dangerous these fungi can become.Allergic fungal sinusitis is one of four types of fungal disease of the paranasal sinuses.1,13,18 It is associated with allergies or asthma and is characterized by chronic colonization of the lumen with massive mucus and eosinophilic leukocyte exudation with no tissue invasion. Not all allergic fungal sinusitis are associated with Aspergillus species, and the isolation of the etiologic agent in culture is necessary to distinguish the various fungal agents. Allergic non-Aspergillus sinusitis or allergic Bipolaris sinusitis are terms used recently for allergic fungal sinusitis caused by fungi other than Aspergillus species. We support the use of the term allergic phaeohyphomycosis when referring to patients with histologic and culture-proven dematiaceous fungal agents causing this disease.Humans undergo intimate and continued exposure to fungal elements via the inhalation of airborne fungal propagules and the ingestion of food contaminated by molds and yeast. Nonallergic individuals would expel the inhaled fungus without consequence.1,18 Noninvasive allergic fungal sinusitis is an example of a disease due solely to a hypersensitive response to the colonization of an inhaled fungus. Concurrent mixed infections at the same time and from different sites in the same patient caused by more than one genus of dematiaceous fungus have been reported in both healthy6 and immunocompromised patients.24 Adams and co-workers4 reported a 10-year-old boy with chronic allergic fungal sinusitis from which E. rostratum was isolated from his left sinuses, and after a relapse with recurrence of his symptoms, three months later, Alternaria species was isolated from the same site from material obtained from surgical treatment.Our two cases demonstrate the clinical features associated with chronic allergic fungal sinusitis.1,2 The isolation of two dematiaceous fungi, B. spicifera and E. rostratum, from the same patient and the same site after a relapse is an interesting and unusual finding. This raises the possibility of a new exposure to B. spicifera during the long remission period, or possibly the reactivation of a persistent infection rather than reinfection with flare-up of a dormant species following steroid therapy. We suspect reinfection occurred by a second fungus for a number of reasons: 1) both E. rostratum and B. spicifera are easy to grow in the laboratory, 2) there is no documentation of these fungi being antagonistic towards each other, 3) the same laboratory using the same media and techniques handled the specimens, and 4) the patients were seen at different times, and if the cultures were mixed, the conidia of these two fungi are so distinctive,11 a single conidium of either fungus could be recognized as belong to the appropriate taxon. Isolation of these fungi, together with the histopathologic visualization in tissue of dematiaceous hyphae, confirmed the diagnosis of allergic fungal sinusitis. Although two different genera of fungi were isolated from material cultured from the sinuses, the two fungi cannot be differentiated in the tissue by histological stains. There is enough antigenic differentiation between the two so that if an immunological stain is prepared, they could be separated, except for the Bipolaris species, which cannot be differentiated from the Curvularia species.25The use of antifungal agents is controversial, as invasion does not typically occur in this condition. A proportion of patients with allergic fungal sinusitis will be “cured” with only surgical debridement of the sinus, as in the four patients we saw who are not reported here. Another group will manifest recurrent and chronic disease within months (more than three months) or will have recurrence after a long period, as in our two reported patients. Amphotericin B is usually considered the antifungal drug of choice for infections with the dematiaceous fungi. Recently, however, the imidazole derivatives ketoconazole, fluconazole, and itraconazole have been increasing in popularity as useful agents. Itraconazole is especially useful in infections caused by the black fungi. Correlation between in vitro susceptibility results and clinical outcome needs evaluation. Even when we acknowledge that there is no correlation of in vivo and in vitro susceptibility testing, which is dependent on the method used, it is still useful in predicting what type of therapy could be used in a patient, as many other studies suggest.26 Case 1 showed that antifungal agents were helpful in curing this patient with chronic, recurrent, allergic sinusitis. After a long period of follow-up, the patient showed clinical improvement and negative cultures. In Case 2, topical and systemic steroids after surgical debridement without antifungal agent(s) did not help the patient over a two-year follow-up.ARTICLE REFERENCES:1. Goldstein MF. "Allergic fungal sinusitis: an underdiagnosed problem" . Hosp Pract (Office Ed). 1992; 27: 73–4, 79–84, 87–8, 91–2. Google Scholar2. Katzenstein ALA, Sale SR, Greenberger PA. "Allergic Aspergillus sinusitis: a newly recognized form of sinusitis" . J Allergy Clin Immunol. 1983; 72: 89–93. Google Scholar3. Brummund W, Kurup VP, Harris GJ, et al. "Allergic sino-orbital mycosis: a clinical and immunologic study" . JAMA. 1986; 256: 3249–53. Google Scholar4. Adam RD, Paquin ML, Petersen EA, et al. "Phaeohyphomycosis caused by the fungal genera Bipolaris and Exserohilum. A report of 9 cases and review of the literature" . Med. 1986; 65: 203–17. Google Scholar5. Rinaldi MG, Phillips P, Schwartz JG, et al. "Human Curvularia infections. Report of five cases and review of the literature" . Diag Microbiol Infect Dis. 1987; 6: 27–39. Google Scholar6. Washburn RG, Kennedy DW, Begley MG, et al. "Chronic fungal sinusitis in apparently normal hosts" . Med. 1988; 67: 231–47. Google Scholar7. Robson JMB, Hogan PG, Benn RAV, Gatenby PA. "Allergic fungal sinusitis presenting as a paranasal sinus tumor" . Aust N Z J Med. 1989; 19: 351–3. Google Scholar8. Zieske LA, Kopke RD, Hamill R. "Dematiaceous fungal sinusitis" . Otolaryngol Head Neck Surg. 1991; 105: 567–77. Google Scholar9. Pingree TF, Holt GR, Otto RA, Rinaldi MG. "Bipolaris-caused fungal sinusitis" . Otolaryngol Head Neck Surg. 1992; 106: 302–5. Google Scholar10. El-Zaatari MM, McGinnis MR. Phaeohyphomycosis. In: Murphy JW, Friedman H, Bendinelli M, eds. Fungal infections and immune responses. New York: Plenum Press, 1993;379–91. Google Scholar11. McGinnis MR, Rinaldi MG, Winn RE. "Emerging agents of Phaeohyphomycosis: pathogenic species of Bipolaris and Exserohilum" . J Clin Microbiol. 1986; 24: 250–9. Google Scholar12. Manning SC, Schaefer SD, Close LG, Vuitch F. "Culture-positive allergic fungal sinusitis" . Arch Otolaryngol Head Neck Surg. 1991; 117: 174–8. Google Scholar13. McGinnis MR, Campbell G, Gourley WK, Lucia HL. "Phaeohyphomycosis caused by Bipolaris spicifera: an informative case" . Eur J Epidemiol. 1992; 8: 383–6. Google Scholar14. Friedman GC, Hartwick RWJ, Ro JY, et al. "Allergic fungal sinusitis. Report of three cases associated with dematiaceous fungi" . Am J Clin Pathol. 1991; 96: 368–72. Google Scholar15. Bartynski JM, McCaffrey TV, Frigas E. "Allergic fungal sinusitis secondary to dematiaceous fungi—Curvularia lunata and Alternaria" . Otolaryngol Head Neck Surg. 1990; 103: 32–9. Google Scholar16. Corey JP, Romberger CF, Shaw GY. "Fungal diseases of the sinuses" . Otolaryngol Head Neck Surg. 1990; 103: 1012–5. Google Scholar17. Travis WD, Kwon-Chung KJ, Kleiner DE, et al. "Unusual aspects of allergic bronchopulmonary fungal disease: report of two cases due to Curvularia organisms associated with allergic fungal sinusitis" . Human Pathol. 1991; 22: 1240–8. Google Scholar18. Gourley DS, Whisman BA, Jorgensen NL, et al. "Allergic Bipolaris sinusitis: clinical and immunopathologic characteristics" . J Allergy Clin Immunol. 1990; 85: 583–91. Google Scholar19. Aviv JE, Lawson W, Bottone EJ, et al. "Multiple intracranial mucoceles associated with phaeohyphomycosis of the paranasal sinuses" . Arch Otolaryngol Head Neck Surg. 1990; 116: 1210–3. Google Scholar20. Ismail Y, Johnson RH, Wells MV, et al. "Invasive sinusitis with intracranial extension caused by Curvularia lunata" . Arch Intern Med. 1993; 153: 1604–6. Google Scholar21. Morgan MA, Wilson WR, Neel HB, Roberts GD. "Fungal sinusitis in healthy and immunocompromised individuals" . Am J Clin Pathol. 1984; 82: 597–601. Google Scholar22. Anaissie E, Bodey GP, Kantarjian H, et al. "New spectrum of f ungal infections in patients with cancer" . Rev Infect Dis. 1989; 11: 369–78. Google Scholar23. Morrison VA, Weisdorf DJ. "Alternaria: a sinonasal pathogen of immunocompromised hosts" . Clin Infect Dis. 1993; 16: 265–70. Google Scholar24. Loveless MO, Winn RE, Campbell M, Jones SR. "Mixed invasive infection with Alternaria species and Curvularia species" . Am J Clin Pathol. 1981; 76: 491–3. Google Scholar25. Pasarell L, McGinnis MR, Standaed PG. "Differentiation of medically important isolates of Bipolaris and Exserohilum with exoantigens" . J Clin Microbiol. 1990; 28: 1655–57. Google Scholar26. Rex JH, Cooper CR, Merz WG, et al. "Detection of Amphotericin B-resistant Candida isolates in a broth-based system" . Antimicrob Agents Chemother. 1995; 39: 906–09. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 16, Issue 5September 1996 Metrics History Received25 July 1995Accepted1 April 1996Published online1 September 1996 InformationCopyright © 1996, Annals of Saudi MedicinePDF download

The objectives of this study were to determine, in neonates of <1250 g birthweight (N = 57), the initial time of skin colonization by Malassezia furfur, rate of colonization by Candida spp., and whether skin colonization by these yeasts was predictive of central line colonization or fungaemia. By age two weeks, 51% of neonates were culture-positive for M. furfur on umbilical or groin skin. During hospitalization, positive skin cultures for M. furfur or Candida spp. were obtained in 70% and 37% of neonates, respectively. Risk factors associated with positive skin cultures were mechanical ventilation and three or more episodes of suspected sepsis. Eight of the 52 infants with central venous catheters, had positive blood cultures withdrawn from the lines; five (62%) of these had positive skin surveillance cultures. Although positive skin cultures for M. furfur, Candida spp., or both were commonly observed in this population, they were not predictive of positive central line cultures or systemic illness.

MICs of fluconazole and amphotericin B were determined independently for 100 coded yeast isolates by each of six laboratories to determine reproducibility of results by using a colorimetric oxidation-reduction-based broth microdilution test. In addition, each site tested five quality control isolates on at least four different occasions during the study. Results agreed within a three-dilution range (mode +/- 1 log2 dilution) for 96.2% of fluconazole tests and 92.7% of amphotericin B tests. Agreement among tests with the quality control isolates was 99.4% with fluconazole and 98.6% with amphotericin B. These results indicate that the colorimetric microdilution method is reproducible among laboratories.

Two cases of human fungal infections caused by members of the genus Phialemonium, a genus proposed by Gams and McGinnis (1983) for fungi intermediate between the genera Acremonium and Phialophora, are presented. The first case was a phaeohyphomycotic cyst on the foot of a renal transplant recipient. The fungus was detected by direct examination and histopathology and was recovered by several procedures over 4 months. It was flat, glabrous, and white becoming yellow with the production of a diffusible yellow pigment; it had conidiophores that were mostly solitary and lateral and terminal phialides and adelophialides with distinct collarettes producing cylindrical to curved conidia. The isolate resembled both Phialemonium dimorphosporum and Phialemonium curvatum, although its characteristics were more consistent with those of the latter. The second case was peritonitis in a renal transplant recipient. The fungus was white-to-cream colored and yeast like, but later became black with a green diffusible pigment, and produced obovoid conidia; it was easily identified as Phialemonium obovatum. Difficulties encountered in the identification and taxonomy of members of this genus highlight the need for standardized conditions, e.g., potato dextrose agar culture incubated at 24 to 25 degrees C for morphologic comparisons, to control significant variations due to culture conditions.

One thousand four hundred forty-seven clinical and environmental isolates of molds, yeasts, aerobic actinomycetes, and algae belonging to 164 genera (382 taxa) maintained on potato dextrose agar at -70 degrees C for periods ranging from 6 months to 13 years were subcultured and then incubated at 25 degrees C to determine their viabilities. Thirty-three isolates, Alternaria alternata (n = 1), Apophysomyces elegans (n = 1), Bipolaris spicifera (n = 1), Blastomyces dermatitidis (n = 4), Cokeromyces recurvatus (n = 1), Coremiella cubispora (n = 1), Cryptococcus ater (n = 1), Curvularia sp. (n = 1), Exserohilum monoceras (n = 1), Exserohilum pedicillatum (n = 1), Exserohilum rostratum (n = 1), Filobasidium floriforme (n = 1), Madurella mycetomatis (n = 1), Oedocephalum spp. (n = 2), Penicillium marneffei (n = 1), Pseudomicrodochium spp. (n = 4), Saksenaea vasiformis (n = 1), Sporothrix sp. (n = 1), and Mycelia Sterilia (n = 8), did not grow after repeated attempts at subculturing. Neither time in storage nor taxonomic classification was associated with a lack of viability. Storage at low temperature for either short or long periods of time is an excellent method for maintaining most medically important fungi.

One year after receiving a liver transplant and 2 months after treatment with high doses of steroids and monoclonal anti-CD3 for an episode of rejection, a 38-year-old woman developed a skin papule above the left medial malleolus. The papule, which at first had an annular shape, evolved into a pustule, ulcerated, drained, and assumed a crusted verrucous appearance. Multiple satellite papules appeared around the lesion, which was incompletely excised and thought to represent squamous cell carcinoma. Review of the histologic slides revealed pseudoepitheliomatous hyperplasia with multiple epidermal and dermal abscesses, pigmented hyphae, and yeast-like forms. Culture of material obtained at reexcision yielded a dematiaceous fungus that was identified as Exophiala pisciphila. No evidence of dissemination was found. This represents a unique report of human infection with this fungus, a well-recognized pathogen of fish. Except for the absence of sclerotic bodies, the clinicopathologic features resembled those of chromoblastomycosis rather than those of the subcutaneous cystic form of phaeohyphomycosis often associated with species of Exophiala.