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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 282-284

A case report of white grain eumycetoma caused by Scedosporium apiospermum in a tertiary care hospital of the Eastern India


1 Department of Microbiology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
2 Department of Microbiology, National Medical College, Kolkata, West Bengal, India
3 Department of Microbiology, Sagar Dutta Medical College, Kolkata, West Bengal, India

Date of Web Publication16-Dec-2015

Correspondence Address:
Kalidas Rit
70B T. C. Mukherjee Street, Rishra Post, Hooghly - 712 248, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.171925

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  Abstract 

Scedosporium apiospermum and its asexual state Pseudallecheria boydiiare increasingly recognized as an opportunistic pathogen. Here, we describe a white grain eumycetoma of left foot of a 48-year-old female caused by S. apiospermum. Treatment with oral voriconazole was successful.

Keywords: Eumycetoma, Scedosporium apiospermum, voriconazole


How to cite this article:
Rit K, Saha R, Chakrabarty P, Chakraborty B. A case report of white grain eumycetoma caused by Scedosporium apiospermum in a tertiary care hospital of the Eastern India. Arch Med Health Sci 2015;3:282-4

How to cite this URL:
Rit K, Saha R, Chakrabarty P, Chakraborty B. A case report of white grain eumycetoma caused by Scedosporium apiospermum in a tertiary care hospital of the Eastern India. Arch Med Health Sci [serial online] 2015 [cited 2020 Feb 20];3:282-4. Available from: http://www.amhsjournal.org/text.asp?2015/3/2/282/171925


  Introduction Top


The asexual state of the ascomycete Scedosporium apiospermum and its sexual state Pseudallescheria apiospermum (previously known as Pseudallescheria boydii) is frequently isolated from soil, manure, and decaying vegetation. [1] It commonly causes systemic disease in immunocompromised individuals and eumycetoma in immununocompetent patients. [2] Eumycetoma is a chronic granulomatous infection most commonly affecting muscles, bones, cartilage and joints of lower extremities particularly the foot. It has a classical triad of soft tissue swelling, draining sinus tracts, and expulsion of grains. [3] Here, we describe a white grain eumycetoma caused by S. apiospermum in an immunocompetent individual that was successfully cured with oral voriconazole therapy.


  Case Report Top


A 48-year-old woman from rural Bengal presented with a 1-year 8 months history of progressive pain and swelling of the left foot [Figure 1]. There was a history of injury left foot while doing agricultural work. Plain X-ray of affected foot showed widening of joint spaces with periosteal reaction, bone destruction, erosive changes, and demineralization [Figure 2]. The patient was non-diabetic and normotensive. Routine blood examination revealed no abnormality. Her blood sample was nonreactive to HIV1 and HIV2 antibodies. Expressed material from discharging sinus tract examined under a microscope after mixing with 10% potassium hydroxide revealed whitish grain containing broad septate hyphae. Hematoxilin and eosin stain demonstrated a granulomatous response on dermice and subcutaneous tissue containing localized abscesses with spherical white grain eumycetoma [Figure 3]. Culture of a sample of a biopsy on Sabouraud glucose agar revealed fungal growth identified as S. apiospermum. Lactophenol cotton blue preparation of fungal colony when examined under a microscope revealed branching septate hyphae having ovoid conidia with thick walls at the end of the conidiophores.
Figure 1: Eumycotic lesions involving the left foot

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Figure 2: X-ray appearance of affected foot

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Figure 3: Histopathological appearance of collected biopsy specimen

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The patient was initially treated with oral itraconazole therapy (200 mg/day) for 1½ years but there was no improvement of her disease condition. The patient was not willing to accept any surgical intervention. Therapy with oral voriconazole at a dose of 200 mg twice daily was started, and she showed clinical improvement. Therapy was continued for 1-year and 2 months. At follow-up, 3 years later, her clinical signs had been completely resolved [Figure 4].
Figure 4: Photograph showing healed lesions

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  Discussion Top


S. apiospermum causes infection in both immunocompetent and immunocompromised individuals. This fungus is commonly associated with eumycetoma but disseminated, and invasive infections with this fungus are seen primarily in immunocompromised hosts. Here, the patient was immunocompetent, and the diagnosis was confirmed by both microscopically and positive culture of causative pathogen. Scedosporiosis is reported infrequently. Eumycetoma due to S. apiospermum is more common in the USA and uncommon in the Indian subcontinent. There are very few reports of infections caused by this pathogen from India. [4] Mycetoma because of actinomycetes is common in Southern India, and mycetoma due to the fungal cause is more common in Northern India. There are only occasional reported cases of white grain eumycetoma around India. Singh and Venugopal reported cases of white grain eumycetoma around the Indian subcontinent. [5],[6] Maiti et al. reported few cases of eumycetoma due to S. apiospermum in this part of the country. [7],[8]

Before the advent of newer antifungal more effective against S. apiospermum, the most successful approach to control of eumycetoma was surgical, mostly amputation. However, the procedure of amputation is disfiguring and also traumatic to the patient and may compromise day to day activity. There are also chances of recurrence of mycetoma on the amputation stump. The correct diagnosis of white grain eumycetoma is important because S. apiospermum is resistant to a variety of commonly used antifungal agents. S. apiospermum is usually not amenable to ketoconazole therapy and frequently resistant to itraconazole in vitro. However newer azoles like voriconazole have shown some promise. [9] Voriconazole showed higher in vitro activity against S. apiospermum with lower minimum inhibitory concentration value in comparison to other available antifungal agents. [10] Voriconazole has been used in a few cases of white grain eumycetoma with success. [10],[11] Moreover, although expensive, it should be considered as a first line antifungal agent for the treatment of eumycetoma caused by S. apiospermum. [12],[13] The dose requirement and optimum duration of therapy should be individualized.


  Acknowledgment Top


Dr. P. K. Maiti, MD, Prof. and Head Department of Microbiology, Institute of Post Graduate Medical Education and Research. 244 AJC Bose Road, Kolkata - 700 020.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rippon JW. Pseudallescheriasis. In: Wonsiewicz M, editor. Medical Mycology: The Pathogenic Fungi and the Pathogenic Actinomycetes. 3 rd ed. Philadelphia: W.B. Saunders; 1988. p. 651-3.  Back to cited text no. 1
    
2.
Pistono PG, Rapetti I, Stacchini E, Guasco C. Clinical case of mycetoma caused by Scedosporium apiospermum. G Batteriol Virol Immunol 1989;82:88-91.  Back to cited text no. 2
    
3.
Cortez KJ, Roilides E, Quiroz-Telles F, Meletiadis J, Antachopoulos C, Knudsen T, et al. Infections caused by Scedosporium spp. Clin Microbiol Rev 2008;21:157-97.  Back to cited text no. 3
    
4.
Thammayya A, Sanyal M. Monosporium apiospermum causing mycetoma pedis in India. Indian J Med Res 1973; 61:1289-91.  Back to cited text no. 4
    
5.
Singh H. Mycetoma in India. Indian J Surg 1979;41:577-97.  Back to cited text no. 5
    
6.
Venugopal PV, Venugopal TV. Pale grain eumycetomas in Madras. Australas J Dermatol 1995;36:149-51.  Back to cited text no. 6
    
7.
Maiti PK, Ray A, Bandyopadhyay S. Epidemiological aspects of mycetoma from a retrospective study of 264 cases in West Bengal. Trop Med Int Health 2002;7:788-92.  Back to cited text no. 7
    
8.
Maiti PK, Chakraborty B, Ghosh S, De A. Does the benefit of salvage amputation always outweigh disability in drug-failure mycetoma? a tale of two cases. Indian J Dermatol 2015;60:74-6.  Back to cited text no. 8
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9.
Muñoz P, Marín M, Tornero P, Martín Rabadán P, Rodríguez-Creixéms M, Bouza E. Successful outcome of Scedosporium apiospermum disseminated infection treated with voriconazole in a patient receiving corticosteroid therapy. Clin Infect Dis 2000;31:1499-501.  Back to cited text no. 9
    
10.
Johnson EM, Szekely A, Warnock DW. In-vitro activity of voriconazole, itraconazole and amphotericin B against filamentous fungi. J Antimicrob Chemother 1998; 42:741-5.  Back to cited text no. 10
    
11.
Porte L, Khatibi S, Hajj LE, Cassaing S, Berry A, Massip P, et al. Scedosporium apiospermum mycetoma with bone involvement successfully treated with voriconazole. Trans R Soc Trop Med Hyg 2006;100:891-4.  Back to cited text no. 11
    
12.
Bosma F, Voss A, van Hamersvelt HW, de Sévaux RG, Biert J, Kullberg BJ, et al. Two cases of subcutaneous Scedosporium apiospermum infection treated with voriconazole. Clin Microbiol Infect 2003;9:750-3.  Back to cited text no. 12
    
13.
Gosbell IB, Toumasatos V, Yong J, Kuo RS, Ellis DH, Perrie RC. Cure of orthopaedic infection with Scedosporium prolificans, using voriconazole plus terbinafine, without the need for radical surgery. Mycoses 2003;46:233-6.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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