Fungal Necrotizing Cellulitis
Phycomyces and Aspergillus species may cause a gangrenous cellulitis in compromised hosts. The hallmark of these infections is the invasion of blood vessels by hyphae, followed by thrombosis and subsequent necrosis extending to all soft tissue compartments. Spores from these fungi are ubiquitous.
The Phycomyces species are characterized by broad-based nonseptate hyphae. Rhizopus, Mucor, and Absidia are the major pathogenic genera within the family Mucoraceae. Serious rhinocerebral, pulmonary, or disseminated infections have been found in patients with diabetes, lymphoma, or leukemia. Phycomycotic gangrenous cellulitis usually occurs in patients with severe burns or diabetes. The characteristic dermal lesion is a black, anesthetic ulcer or an area of necrosis with a purple edematous margin. There is no gas or exudate, and the infection may progress rapidly.
Aspergillus species are characterized histologically by branching septate hyphae. These fungi can cause serious pulmonary or disseminated infections in compromised hosts. Aspergillus gangrenous cellulitis may be primary or from a disseminated infection. The dermal lesion is an indurated plaque that leads to a necrotic ulcer. Gas and exudate are not present.
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Ocular aspergillosis - Case report
Patrícia Ioschpe GusI; Marcia Cristina BayerII; Guilherme Herrmann MatosIII; Cristiane Von Werne BaesIV; Maria Fernanda Melo MartinsIV; Júlio Vargas NetoIV; Thor Gunnar OnstenV
IProfessora da Disciplina de Sistema Visual da Faculdade de Medicina na Universidade Luterana do Brasil - ULBRA, Doutora em Oftalmologia IIAcadêmica do 10º semestre da Faculdade de Medicina da Universidade Luterana do Brasil IIIAcadêmico do 8º semestre da Faculdade de Medicina da Universidade Luterana do Brasil IVAcadêmica(o) do 7º semestre da Faculdade de Medicina da Universidade Luterana do Brasil VProfessor da Disciplina de Hetamologia da Faculdade de Medicina na Universidade Luterana do Brasil - ULBRA
Presence of fungus in the conjunctiva is a constant threat to the eyes, because these microorganisms, defined as opportunistic, may provoke severe ocular infections, in situations as low organic resistance, use of immunosuppressants, antibiotics and epithelial alteration. Our goal here is to report a case of ocular aspergillosis in an immunosupressed patient where paroxysmal nocturnal hemoglobinuria was diagnosed. A 51-year-old immunosupressed, thrombocytopenic patient was hospitalized with a diagnosis of paroxysmal nocturnal hemoglobinuria. On examination, she had a visual acuity of 20/40 in the right eye (RE) and light perception in the left (LE). She presented hyposphagma, bilateral conjunctival edema on biomicroscopy and had some multiple and circumscribed conjunctival abscesses in both eyes; clear cornea in both eyes. Fundoscopy of the RE did show any particularity, in the LE there was a smear hemorrhage. Computed tomograph showed a fat periocular infiltration. Magnetic resonance lead to the same finding, compatible with orbital cellulitis. Hemoculture showed Aspergillus growth and direct smears of conjunctival material was negative. There was great improvement while treating her with amphotericin B, but there was complete remission after using 5% natamicyn eye drops. Orbital infections caused by Aspergillus are uncommon, usually appearing in immunosuppressed patients. Frequently they progress insidiously, and can be confounded with other orbital processes. Immunological impairment can inhibit the expression of local and systemic symptoms, resulting in diagnostic confusion. The diagnosis is established by laboratory tests, but culture can be negative in spite of the classical presentation, making the beginning of treatment difficult. In these cases management starts according to the symptoms.
Keywords: Aspergillosis; Eye infections, fungal/microbiology; Eye infections; Opportunistic infections; Case report; Adult; Female
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Cryptococcal myositis and vasculitis: an unusual necrotizing soft tissue infection.
Gave AA, Torres R, Kaplan L.
Department of Surgery, Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale University School of Medicine, New Haven, Connecticut, USA.
Cryptococcus neoformans var. neoformans is an opportunistic yeast that typically infects immunocompromised patients.
A case report and review of the pertinent English-language literature are presented.
Necrotizing vasculitis associated with cryptococcal invasion was identified in 1986. Until now, only 24 cases of cryptococcal cellulitis have been reported, including one case of cryptococcal necrotizing fasciitis and one case of necrotizing vasculitis. We report an unusual case of occult disseminated cryptococcosis presenting as necrotizing cellulitis, fasciitis, and myositis.
Cryptococcal soft tissue infection serves as a marker of disseminated cryptococcosis in immunocompromised hosts. Owing to its rarity as a cause of soft tissue infections, diagnosis is difficult and mortality is high.
Review PMID: 15684802 [PubMed - indexed for MEDLINE]
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Cryptococcal cellulitis in a patient on prednisone monotherapy for myasthenia gravis.
Lafleur L, Beaty S, Colome-Grimmer MI, LaForte RA, Dotson AD.
Louisiana State University Medical Center, New Orleans, USA.
The development of cutaneous cryptococcosis is extremely rare in the human immunodeficiency virus-negative population. The cutaneous manifestations vary greatly, with the rarest presenting as cellulitis. We report a unique case of a 64-year-old woman who had been on prednisone monotherapy for the treatment of myasthenia gravis and subsequently developed cryptococcal cellulitis. This case provides an opportunity to discuss the importance of including cryptococcal cellulitis in the differential diagnosis of cellulitis in a patient on low-dose prednisone who is not responding to empiric antibiotic therapy. Early recognition is crucial as cutaneous manifestations are usually the first sign of disseminated cryptococcosis.
PMID: 15499758 [PubMed - indexed for MEDLINE]
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Ringworm causing childhood preseptal cellulitis.
Rajalekshmi PS, Evans SL, Morton CE, Williams RE, Ng CS.
Department of Ophthalmology, H. M. Stanley Hospital, St. Asaph, United Kingdom.
A 4-year-old girl had redness and swelling of the left upper eyelid of 1 week's duration. She had been treated with topical fusidic add and oral flucloxacillin without resolution. Ophthalmic examination showed a diffuse, erythematous, tender lesion affecting the entire upper eyelid. There was a central area of skin ulceration with marked bleeding and discharge. Also found were small vesicles under the left eyebrow. The child's mother had noticed a scaly rash on her own forearm. Examination under anesthesia was carried out to assess the globe and to obtain samples for microbiology investigation. Microbiology scrapings showed fungal hyphae of the Dermatophyte group. Treatment with Griseofulvin was commenced, and complete resolution of the lesion occurred. To our knowledge there is only one similar case reported in the literature describing ring-worm as a cause of preseptal cellulitis. This case highlights the importance of considering alternative diagnoses when standard antibiotic treatment has failed.
Case ReportsPMID: 12918565 [PubMed - indexed for MEDLINE]
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Inflammatory tinea pedis/manuum masquerading as bacterial cellulitis.
Sweeney SM, Wiss K, Mallory SB.
Department of Medicine, Division of Dermatology, University of Massachusetts Medical School, Worchester 01605, USA. email@example.com
Tinea pedis and tinea manuum in children are more common than previously recognized. Clinical presentations of dermatophyte infections may vary in children and may be difficult to diagnose.
To show the necessity of potassium hydroxide preparations and/or fungal cultures in assessing suspicious cases of cellulitis in children who may have dermatophyte infections.
We describe 4 children with inflammatory tinea pedis or tinea manuum who were initially misdiagnosed as having bacterial cellulitis.
A potassium hydroxide examination was performed on 3 patients. Fungal cultures were performed on 2 patients.
Inflammatory/bullous dermatophyte infections were detected by potassium hydroxide examination in all 4 patients and all 4 children successfully responded to topical antifungal therapy. CONCLUSIONS: These cases demonstrate that inflammatory tinnea pedis/manuum can masquerade as cellulitis in children. Early potassium hydroxide examination can allow appropriate antifungal treatment to be initiated before fungal culture results are finalized.
PMID: 12413346 [PubMed - indexed for MEDLINE]