Diagnosis at first sight
Skin nodules in a liver transplant recipient
Nódulos cutáneos en trasplantado hepático
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"etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nódulos cutáneos en trasplantado hepático" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 713 "Ancho" => 950 "Tamanyo" => 83621 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dark cotton-like colonies in Sabouraud-dextrose agar medium after 10 days of incubation at 86<span class="elsevierStyleHsp" style=""></span>°F.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical description</span><p id="par0005" class="elsevierStylePara elsevierViewall">Thirty-eight-year-old male from Guinea who lived in Brazil for four (4) years and has been living in Spain since the year 2004. He had a prior history of Chagas disease accompanied by mild sensory polyneuropathy that was treated with benznidazole. Back in May 2010 he underwent one orthotopic liver transplant at our center due to hepatitis B virus-related cirrhosis and hepatocarcinoma. The post-transplant period occurred without any complications.</p><p id="par0010" class="elsevierStylePara elsevierViewall">On the +60th day, the patient had an asymptomatic infection due to cytomegalovirus that was treated with valganciclovir for two (2) weeks. Ten (10) days later, the presence of two (2) painless, violet, nonsuppurative skin nodes (one in each thigh) of approximately 2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>cm was confirmed. The patient had no recollection of prior trauma. He was on immunosuppressive treatment with tacrolimus and steroids. He had not received any antifungal drugs at that time or previously. The skin biopsy was suggestive of panniculitis with presence of hyphae on the anatomopathological study. Both nodes were removed, and after (5) days of incubation at 86<span class="elsevierStyleHsp" style=""></span>°F the culture on Sabouraud-dextrose agar medium showed dark cotton-like colonies that were black on the back (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The microscopic study showed dark septate hyphae, conidiogenous cells with collarets, and slightly curved cylindrical conidia (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Progression</span><p id="par0015" class="elsevierStylePara elsevierViewall">The nucleotide sequence with ITS-1 and ITS-4 primers revealed a 98 per cent sequence similarity with Phaeoacremonium fuscum using the GenBank BLAST database. Then, the Mycology Unit of the National Microbiology Center of Madrid, Spain confirmed the identification of Phaeoacremonium fuscum with the following sensitivity using the EUCAST methodology<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a>: minimum inhibitory concentration (MIC): amphrotericin B 0.12<span class="elsevierStyleHsp" style=""></span>mg/l; itraconazole >8<span class="elsevierStyleHsp" style=""></span>mg/l; voriconazole 2<span class="elsevierStyleHsp" style=""></span>mg/l, posaconazole >8<span class="elsevierStyleHsp" style=""></span>mg/l; terbinafine 1<span class="elsevierStyleHsp" style=""></span>mg/l; and caspofungin >16<span class="elsevierStyleHsp" style=""></span>mg/l.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The thoracoabdominal CT scan conducted revealed normal findings. The patient has remained asymptomatic ever since and no new lesions have appeared.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Final comment</span><p id="par0025" class="elsevierStylePara elsevierViewall">The Phaeoacremonium species that was described by Crous et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> includes over 20 different species of filamentous fungi. It can be found in the environment and it has been isolated in human beings and woody plants such as endophytes or disease causal agents. Few species have proven to be human pathogens only.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> On the morphological level, the Phaeacremonium species is categorized between the Acremonium and the Phialophora species.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Phaeacremonium spp are opportunistic pathogens that can cause subcutaneous infections; eumycetomas; osteoarthritis; osteomyelitis; or disseminated infection such as fungemia and endocarditis. They are usually preceded by traumatic inoculation. Subcutaneous infections are common in rural workers who are in contact with contaminated soils, thorns, splinters, or other objects causing the trauma.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Because of the presence of splinters in the lesions, it is believed that retaining the contaminated material is needed to cause the lesion; however, other cases have been reported where no foreign body was ever found. Infections due to these fungi have been reported worldwide, although they are more common in tropical and subtropical climates. They are more prevalent in immunosuppressed patients, but they can also be seen in individuals without any predisposing factors.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The identification of the species is based on its morphological and culture characteristics, though, at times, this identification is not easy. The management of most patients with localized infections is deep surgical resection and it is usually enough.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> In some cases, antifungal therapy has been administered too. Phaeacremonium fuscum is one of those species that can cause cutaneous and subcutaneous affectation in humans. Its maximum growth occurs at temperatures of 98.6<span class="elsevierStyleHsp" style=""></span>°F compared to the 86<span class="elsevierStyleHsp" style=""></span>°F of other species. Its capacity of growth at 98.6<span class="elsevierStyleHsp" style=""></span>°F suggests it can survive at body temperature.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Mc Grogan et al. described the first case of mycetoma due to Phaeoacremonium fuscum in a kidney transplant recipient.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In sum, Phaeoacremonium fuscum is a rare cause of cutaneous or subcutaneous fungal infection mainly affecting immunosuppressed patients, being the complete resection of the lesion with curative purposes important in cases in which the infection is localized as it was the case with our patient. As we mentioned above, these cases are usually preceded by traumatic inoculation and even though in our case, the patient had no recollection of any prior traumas, we cannot rule it out, or the fact that the patient experienced local reactivation in the context of his immunosuppressive therapy.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical description" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Progression" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Final comment" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Blanco-Vidal MJ, López-Soria L, Monzón-de la Torre A, Montejo-Baranda JM. Nódulos cutáneos en trasplantado hepático. Enferm Infecc Microbiol Clin. 2018;36:140–141.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 713 "Ancho" => 950 "Tamanyo" => 83621 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dark cotton-like colonies in Sabouraud-dextrose agar medium after 10 days of incubation at 86<span class="elsevierStyleHsp" style=""></span>°F.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 630 "Ancho" => 950 "Tamanyo" => 139844 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Microscopic analysis with lactophenol blue solution (×400). Conidiogenous cells with funnel-shaped collarets, and cylindrical conidia.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "EUCAST Technical Note on the method for the determination of broth dilution minimum inhibitory concentrations of antifungal agents for conidia-forming moulds" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Subcommittee on Antifungal Susceptibility Testing of the ESCMID European Committee for Antimicrobial Susceptibility Testing" "etal" => true "autores" => array:6 [ 0 => "J.L. Rodriquez-Tudela" 1 => "J.P. Donnelly" 2 => "M.C. Arendrup" 3 => "S. Arikan" 4 => "F. Barchiesi" 5 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 0 | 4 |
| 2024 October | 13 | 4 | 17 |
| 2024 September | 14 | 3 | 17 |
| 2024 August | 17 | 5 | 22 |
| 2024 July | 13 | 4 | 17 |
| 2024 June | 7 | 3 | 10 |
| 2024 May | 9 | 9 | 18 |
| 2024 April | 11 | 7 | 18 |
| 2024 March | 27 | 1 | 28 |
| 2024 February | 22 | 1 | 23 |
| 2024 January | 6 | 3 | 9 |
| 2023 December | 15 | 1 | 16 |
| 2023 November | 27 | 4 | 31 |
| 2023 October | 38 | 2 | 40 |
| 2023 September | 7 | 0 | 7 |
| 2023 August | 12 | 1 | 13 |
| 2023 July | 19 | 3 | 22 |
| 2023 June | 21 | 0 | 21 |
| 2023 May | 46 | 3 | 49 |
| 2023 April | 31 | 1 | 32 |
| 2023 March | 55 | 2 | 57 |
| 2023 February | 48 | 9 | 57 |
| 2023 January | 52 | 1 | 53 |
| 2022 December | 29 | 4 | 33 |
| 2022 November | 29 | 8 | 37 |
| 2022 October | 25 | 7 | 32 |
| 2022 September | 29 | 5 | 34 |
| 2022 August | 29 | 7 | 36 |
| 2022 July | 17 | 9 | 26 |
| 2022 June | 17 | 6 | 23 |
| 2022 May | 25 | 3 | 28 |
| 2022 April | 14 | 9 | 23 |
| 2022 March | 30 | 11 | 41 |
| 2022 February | 33 | 6 | 39 |
| 2022 January | 47 | 9 | 56 |
| 2021 December | 66 | 13 | 79 |
| 2021 November | 49 | 9 | 58 |
| 2021 October | 29 | 6 | 35 |
| 2021 September | 40 | 12 | 52 |
| 2021 August | 35 | 10 | 45 |
| 2021 July | 24 | 8 | 32 |
| 2021 June | 22 | 11 | 33 |
| 2021 May | 18 | 7 | 25 |
| 2021 April | 18 | 11 | 29 |
| 2021 March | 13 | 9 | 22 |
| 2021 February | 7 | 9 | 16 |
| 2021 January | 13 | 7 | 20 |
| 2020 December | 8 | 8 | 16 |
| 2020 November | 16 | 8 | 24 |
| 2020 October | 13 | 6 | 19 |
| 2020 September | 11 | 12 | 23 |
| 2020 August | 10 | 5 | 15 |
| 2020 July | 18 | 9 | 27 |
| 2020 June | 17 | 7 | 24 |
| 2020 May | 14 | 7 | 21 |
| 2020 April | 4 | 0 | 4 |
| 2020 March | 14 | 3 | 17 |
| 2020 February | 17 | 3 | 20 |
| 2020 January | 12 | 3 | 15 |
| 2019 December | 20 | 4 | 24 |
| 2019 November | 13 | 2 | 15 |
| 2019 October | 11 | 1 | 12 |
| 2019 September | 8 | 2 | 10 |
| 2019 August | 12 | 4 | 16 |
| 2019 July | 9 | 13 | 22 |
| 2019 June | 18 | 8 | 26 |
| 2019 May | 50 | 14 | 64 |
| 2019 April | 24 | 1 | 25 |
| 2019 March | 2 | 1 | 3 |
| 2019 February | 7 | 0 | 7 |
| 2019 January | 5 | 2 | 7 |
| 2018 December | 5 | 1 | 6 |
| 2018 November | 2 | 1 | 3 |
| 2018 October | 12 | 6 | 18 |
| 2018 September | 4 | 0 | 4 |
| 2018 August | 5 | 1 | 6 |
| 2018 February | 10 | 0 | 10 |
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