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ANSWER TO PHOTO QUIZ (SEE PAGE 13)
Figure 1. A, 2 3 3 -cm lesion on dorsum of the left foot of a patient with cutaneous alternariosis 6 months after kidney-pancreas transplantation. B, Histopathologic examination of a skin biopsy specimen that demonstrated subcutaneous granulomatous inflammation (hematoxylin-eosin stain; original magnification, 310). C, Alternaria species isolated from a skin biopsy specimen; septate and dark hyphae are shown (lactophenol cotton blue stain; original magnification, 340). D, Conidia of the Alternaria species that are large (7–10 3 23 –34 mm), brown, and clublike in shape with characteristic transverse and longitudinal septations (lactophenol cotton blue stain; original magnification, 3100). E, Conidiophores of the Alternaria species that are septate and zigzag in appearance (lactophenol cotton blue stain; original magnification, 380).
Diagnosis: Cutaneous Alternariosis Alternaria species are ubiquitous in the environment. Although commonly considered a saprophytic contaminant, Alternaria has been identified as a cause of cutaneous infection, sinusitis, osteomyelitis, peritonitis, ocular infections, and gran-
Reprints or correspondence: Dr. Anwer H. Siddiqui, Veterans Affairs Maryland Health Care System (BT-111), 10 North Greene Street, Baltimore, MD 21201 (
[email protected]). Clinical Infectious Diseases 2000; 30:174–5 q 2000 by the Infectious Diseases Society of America. All rights reserved. 1058-4838/2000/3001-0027$03.00
ulomatous lung disease especially in immunocompromised hosts [1–3]. The 3 pathogenic species most often implicated in humans are Alternaria alternata, Alternaria chartarum, and Alternaria tenuissima [2]. After analyzing the information presented in the photo quiz, most readers would recognize the existence of a fungal infection in this patient. Some readers, however, might have difficulty in recognizing Alternaria as the specific fungal pathogen responsible for this patient’s lesion. Our patient’s cutaneous lesion was nonspecific. However, the morphology of the fungus isolated from his lesion (figure 1C–1E) is diagnostic. The unique features of Alternaria include
CID 2000;30 (January)
Answer to Photo Quiz
rapid growth on Sabouraud dextrose agar, usually apparent within 5 days. It forms dark grayish to grayish green colonies that later turn black, often with a white rim. Biopsy of infected sites typically shows granulomatous inflammation or abscess formation (figure 1B) [2]. Microscopically, hyphae are septate and pigmented (figure 1C) [4]. Conidia are large (7–10 3 23–34 mm), brown, and clublike in shape with both transverse and longitudinal septations (figure 1D) [5]. Conidiophores are septate and of variable length, sometimes having a zigzag appearance (figure 1E) [5]. Cutaneous Alternaria infections have been successfully treated with amphotericin B, itraconazole, ketoconazole, and fluconazole. Surgical excision of the lesions is required for cure in some cases. The duration of treatment is controversial. Even if treatment is continued for at least 1 month after clinical resolution, relapses may occur [1, 2, 5]. Our patient was initially treated with itraconazole (400 mg daily) for 2 months. When the lesion failed to decrease in size,
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surgical excision was performed. After surgery, the patient was treated with amphotericin B for 6 weeks. Maria L. Romero 1 and Anwer H. Siddiqui 2 , 3 Divisions of 1 Infectious Diseases and 2 Hospital Epidemiology, University of Maryland School of Medicine, and 3 Department of Medicine, Veterans Affairs Maryland Health Care System, Baltimore, Maryland References 1. Morrison VA, Weisdorf DJ. Alternaria: a sinonasal pathogen of immunocompromised hosts. Clin Infect Dis 1993; 16:265–70. 2. Acland KM, Hay RJ, Groves R. Cutaneous infection with Alternaria alternata complicating immunosuppression: successful treatment with itraconazole. Br J Dermatol 1998; 138:354–6. 3. Iwatsu T. Cutaneous alternariosis. Arch Dermatol 1988; 124:1822–5. 4. Larone DH. Medically important fungi. Washington, DC: American Society for Microbiology Press, 1995. 5. Repiso T, Martin N, Huguet P, et al. Cutaneous alternariosis in a liver transplant patient. Clin Infect Dis 1993; 16:729–30.
