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Brief report
Scedosporium aurantiacum: First isolation in Argentina from a previously healthy patient after traumatic inoculation
Scedosporium aurantiacum: primer aislamiento en Argentina de un paciente previamente sano después de una inoculación por un traumatismo
Susana Carnovalea,
Corresponding author
susacarnov@hotmail.com

Corresponding author.
, Carolina Epelbaumb, Ruben Abrantesc, Susana Córdobac, Carla Cabreraa, Beatriz Caraccioloa,1
a Servicio de Microbiología, Hospital de Pediatría S.A.M.I.C. “Prof. Dr. Juan P. Garrahan” Ciudad Autónoma de Buenos Aires, Argentina
b Servicio de Infectología, Hospital de Pediatría S.A.M.I.C. “Prof. Dr. Juan P. Garrahan” Ciudad Autónoma de Buenos Aires, Argentina
c Departamento de Micología, INEI-ANLIS Dr. C.G. Malbrán, Ciudad Autónoma de Buenos Aires, Argentina
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Scedosporium aurantiacum</span>&#46; Sabouraud glucose agar&#46; A&#46; Front view&#46; B&#46; Reverse view&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0015" class="elsevierStylePara elsevierViewall">Species of <span class="elsevierStyleItalic">Scedosporium&#47;Lomentospora</span> &#40;<span class="elsevierStyleItalic">Lomentospora prolificans</span> formerly <span class="elsevierStyleItalic">Scedosporium prolificans</span>&#41; are widely distributed in nature&#46; They can be found in soils&#44; sewers&#44; standing waters&#44; streams&#44; especially in areas where human activity takes place&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In general they are saprophytes but they can cause opportunistic infections in immunocompromised and occasionally in immunocompetent patients&#44; which are difficult to treat due to high levels of resistance to antifungals<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">It is known that they cause trauma-associated infections in healthy individuals&#46; In immunocompromised patients&#44; the clinical manifestations range from local infection to lung colonization and severe invasive disease with mortality rates that may exceed 80&#37;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Currently 11 species are acknowledged within the genus <span class="elsevierStyleItalic">Scedosporium</span>&#58; <span class="elsevierStyleItalic">Scedosporium aurantiacum</span>&#44; <span class="elsevierStyleItalic">Scedosporium americanum</span>&#44; <span class="elsevierStyleItalic">Scedosporium minutisporum</span>&#44; <span class="elsevierStyleItalic">Scedosporium desertorum</span>&#44; <span class="elsevierStyleItalic">Scedosporium cereisporum</span>&#44; and <span class="elsevierStyleItalic">Scedosporium dehoogii</span>&#44; besides the <span class="elsevierStyleItalic">S&#46; apiospermum</span> complex which comprizes <span class="elsevierStyleItalic">Scedosporium angustum</span>&#44; <span class="elsevierStyleItalic">Scedosporium apiospermum</span>&#44; <span class="elsevierStyleItalic">Scedosporium boydii</span>&#44; <span class="elsevierStyleItalic">Scedosporium ellipsoideum</span> and <span class="elsevierStyleItalic">Scedosporium fusoideum</span><a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;10&#44;14</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Scedosporium boydii</span> and <span class="elsevierStyleItalic">S&#46; apiospermum</span> are the most frequently isolated species in our environment&#46; They are among the most commonly recovered fungi from the respiratory secretions of patients with chronic lung diseases such as cystic fibrosis &#40;CF&#41;&#46; Lung colonization of patients with cystic fibrosis by <span class="elsevierStyleItalic">Scedosporium</span> spp&#46; is well established and the rate ranges between 0 and 21&#37;&#44; being the most frequent genus after <span class="elsevierStyleItalic">Aspergillus</span> spp<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">It has been reported that the lungs&#44; ears&#44; and sinuses are the main sites of <span class="elsevierStyleItalic">S&#46; aurantiacum</span> infection<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a>&#46; In Argentina&#44; South America&#44; two <span class="elsevierStyleItalic">S&#46; aurantiacum</span> isolates recovered from the sputum of patients with CF have been reported&#46; One isolate belonged to a patient from the city of Buenos Aires who had traveled to Egypt and Europe and the other one belonged to a patient from the province of Santa Fe&#44; Argentina<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a>&#46; Moreover&#44; in the United States of America&#44; a single clinical case of <span class="elsevierStyleItalic">S&#46; aurantiacum</span> infection in a patient with lung cancer&#44; which was recovered from bronchoalveolar lavage fluid and lung biopsy has been reported<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Below we present the isolation and identification of <span class="elsevierStyleItalic">Scedosporium aurantiacum</span> from a 4-year-old previously healthy female patient from San Antonio de Areco &#40;Province of Buenos Aires&#44; Argentina&#41;&#44; who exhibited a penetrating trauma in her left eye caused by a kitchen utensil while she was playing with a friend&#46; After being assessed by an ophthalmologist&#44; the patient was referred to our institution&#46; A surgery procedure was performed on the left eye for corneal trauma&#46; The postoperative treatment included antibacterial eyedrops&#44; intravenous treatment and prednisolone&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Ten days after the procedure&#44; an ultrasound study was performed&#44; confirming the presence of images compatible with inflammatory membranes and probable retinal detachment&#46; Infectious endophthalmitis was taken into consideration&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">As a result of the poor evolution of the clinical picture with a marked lack of improvement in the local and systemic treatments applied&#44; endophthalmitis of probable mycotic origin was suspected&#46; Vitrectomy of the left eye and intravitreal injections of amphotericin and vancomycin were the treatments performed&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The vitreous humor was sent to our laboratory for mycological analysis&#46; The fresh microscopic examination with potassium hydroxide &#40;KOH&#41; 40&#37; was negative&#46; The material was cultured in Sabouraud glucose agar &#40;Britania S&#46;A&#46;&#41; and incubated at 28<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; The development of a filamentous fungus that was subcultivated was obtained 48<span class="elsevierStyleHsp" style=""></span>h later&#46; After 15 days of incubation a cotton-like colony with a brown center developed&#46; It was whitish towards the edges on the obverse and greyish brown on the reverse with a striking diffusible light yellow pigment &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figs&#46; 1A and B</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">With regard to micromorphology&#44; conidiogenic cells &#40;annelids&#41; emerge from undifferentiated hyphae&#44; cylindrical to slightly flask-shaped&#44; with single-celled conidia heads&#44; smooth-walled&#44; sub-hyaline&#44; ovoids or sub-cylinders compatible in shape and size with the genus <span class="elsevierStyleItalic">Scedosporium</span><a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; although these characteristics were not sufficient for identification at species level&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The isolates were sent to the Department of Mycology of INEI-ANLIS &#8220;Carlos G&#46; Malbr&#225;n&#8221; to perform susceptibility tests and a molecular study&#46; It was based on the sequence of the partial portion of the &#946;-tubulin gene &#40;<span class="elsevierStyleItalic">BT2</span>&#41;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4&#44;5</span></a>&#46; The similarity of the sequence obtained was searched in the NCBI GenBank database using the BLAST algorithm &#91;National Center for Biotechnology Information &#40;NCBI&#41; Internet homepage&#44; &#91;<a href="http://blast.ncbi.nlm.nih.gov/Blast.cgi">http&#58;&#47;&#47;blast&#46;ncbi&#46;nlm&#46;nih&#46;gov&#47;Blast&#46;cgi</a>&#93; with automatically adjusted parameters&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">A BLAST search using the <span class="elsevierStyleItalic">BT2</span> sequence &#40;584<span class="elsevierStyleHsp" style=""></span>bp&#41; identified our strain DMic 216397 &#40;GenBank Accession Number OK258096&#41; as <span class="elsevierStyleItalic">Scedosporium aurantiacum</span>&#44; showing 100&#37; similarity&#44; 97&#37; coverage and an E-value of 0&#46;0 with the <span class="elsevierStyleItalic">Scedosporium aurantiacum</span> strain CBS 101725 &#40;GenBank Accession Number GU126389<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a>&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Susceptibility tests were performed using the Reference Method M38-3er Ed&#46; of the Clinical and Laboratory Standards Institute &#40;CLSI&#41;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a>&#46; The results of the minimum inhibitory concentrations &#40;CIM&#41; were the following&#58; 8<span class="elsevierStyleHsp" style=""></span>mg&#47;l for amphotericin B&#44; 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;l for itraconazole&#44; 0&#46;25<span class="elsevierStyleHsp" style=""></span>mg&#47;l for voriconazole&#44; 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;l for posaconazole&#44; and 2<span class="elsevierStyleHsp" style=""></span>mg&#47;l for isavuconazole&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">To date&#44; the CLSI has not yet established clinical or epidemiological cut-off points for the genus&#46; The results obtained coincide with the data published by Heath et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a>&#44; who studied 27 isolates of <span class="elsevierStyleItalic">S&#46; aurantiacum</span> and obtained a MIC range of 2&#8211;16<span class="elsevierStyleHsp" style=""></span>mg&#47;l for amphotericin&#44; 0&#46;25&#8211;2<span class="elsevierStyleHsp" style=""></span>mg&#47;l for itraconazole&#44; 0&#46;03&#8211;0&#46;5 for voriconazole and 0&#46;125&#8211;1 for posaconazole&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Systemic antibiotic therapy with amphotericin B was initiated and after the confirmation of the etiological agent&#44; it was decided to change to voriconazole&#44; which led to a favorable clinical outcome<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The geographical distribution of the species of the <span class="elsevierStyleItalic">Scedosporium apiospermum</span> complex is universal&#46; <span class="elsevierStyleItalic">S&#46; aurantiacum</span> was only reported in Australia and some European regions<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a>&#46; It has been reported that it colonizes the airways of patients mainly in these countries where there is a large number of patients with CF<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a>&#46; Another report describes the isolation of <span class="elsevierStyleItalic">S&#46; aurantiacum</span> from a brain abscess in a 2011 tsunami survivor in Japan<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In Australia&#44; <span class="elsevierStyleItalic">S&#46; aurantiacum</span> was recovered from more than 50&#37; of the environmental isolates studied&#44; while <span class="elsevierStyleItalic">S&#46; apiospermum</span> and <span class="elsevierStyleItalic">S&#46; dehoogii</span> are predominant in Austria and France&#44; respectively&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In addition&#44; <span class="elsevierStyleItalic">S&#46; aurantiacum</span> is characteristic of agricultural areas in western France&#46; <span class="elsevierStyleItalic">S&#46; boydii</span> is the most frequent species &#40;62&#37;&#41; in a French cohort&#44; followed by <span class="elsevierStyleItalic">S&#46; apiospermum</span> &#40;24&#37;&#41;&#44; <span class="elsevierStyleItalic">S&#46; aurantiacum</span> &#40;10&#37;&#41;&#44; and <span class="elsevierStyleItalic">S&#46; minutisporum</span> &#40;4&#37;&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In a study carried out in Germany in patients with CF&#44; <span class="elsevierStyleItalic">S&#46; apiospermum</span> was the most frequent species &#40;49&#37;&#41; followed by <span class="elsevierStyleItalic">S&#46; boydii</span> &#40;29&#37;&#41;&#44; <span class="elsevierStyleItalic">L&#46; prolificans</span> &#40;12&#37;&#41;&#44; <span class="elsevierStyleItalic">S&#46; aurantiacum</span> &#40;5&#37;&#41; and <span class="elsevierStyleItalic">S&#46; minutisporum</span> &#40;5&#37;&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Conversely&#44; <span class="elsevierStyleItalic">L&#46; prolificans</span> was the most frequent species isolated in patients with CF in northern Spain&#46; In Australia&#44; the most frequent species appears to be <span class="elsevierStyleItalic">S&#46; aurantiacum</span> followed by <span class="elsevierStyleItalic">L&#46; prolificans</span> and <span class="elsevierStyleItalic">S&#46; apiospermum</span>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Scedosporium</span> species can cause keratitis in immunocompetent hosts usually after corneal trauma with a clinical presentation similar to other types of keratitis&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Endophthalmitis has also been described in immunocompetent individuals secondary to surgery&#44; traumatic inoculation&#44; intravenous drug addiction and contiguous extension from an adjacent site<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Mycological diagnosis in these cases is classically based on direct microscopic examination with KOH from clinical samples and culture in appropriate media&#46; On microscopic examination&#44; however&#44; the hyaline and branched hyphae are similar to those of the genera <span class="elsevierStyleItalic">Aspergillus</span> or <span class="elsevierStyleItalic">Fusarium</span>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The identification of species of the genus <span class="elsevierStyleItalic">Scedosporium</span> is often difficult to carry out due to the similarity of their morphological characteristics&#46; Currently&#44; molecular or matrix-assisted laser identification by desorption&#47;ionization time of flight mass spectrometry &#40;MALDI-TOF&#47;MS&#41; is mandatory for reliable identification&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Nucleotide sequence-based analysis is the gold standard for the identification of these fungi&#46;&#160;Sequencing of rDNA ITS regions allows the proper identification of the main species of <span class="elsevierStyleItalic">Scedosporium&#47;Lomentospora</span> while the &#946;-tubulin partial gene &#40;<span class="elsevierStyleItalic">BT2</span>&#41; is necessary to differentiate closely related species<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Isolates of <span class="elsevierStyleItalic">Scedosporium&#47;Lomentospora</span> present limited susceptibility to all current antifungal drugs&#46; Species of <span class="elsevierStyleItalic">Scedosporium</span> are resistant to 5-flucytosine and amphotericin B&#44; as well as to first-generation triazoles&#44; fluconazole and itraconazole&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In addition&#44; they have reduced susceptibility to equinocandins&#44; in particular to caspofungin and anidulafungin&#46; Voriconazole proved to be the most effective antifungal in the treatment against <span class="elsevierStyleItalic">Scedosporium</span> spp<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">9&#44;11</span></a> and the European guidelines recommend it as a first-line drug for treatment along with surgery&#44; when it is possible to perform it<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Although several cases of traumatic <span class="elsevierStyleItalic">Scedosporium</span> spp&#46; infections have been documented in our region&#44; no cases of <span class="elsevierStyleItalic">S&#46;aurantiacum</span> have been reported so far<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">This is the first report in Argentina and the Americas of an isolation of <span class="elsevierStyleItalic">S&#46; aurantiacumin</span> from a previously healthy patient with a traumatic infection without a history of previous trips abroad&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflict of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "highlights" => array:2 [
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      "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0005" class="elsevierStylePara elsevierViewall">First case of <span class="elsevierStyleItalic">S&#46; aurantiacum</span> in our country from a pediatric patient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0010" class="elsevierStylePara elsevierViewall">Improved methods are necessary for the identification of species of this genus&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Voriconazole proved to be most effective antifungal in the treatment and led to a favorable clinical outcome&#46;</p></li></ul></p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Scedosporium&#47;Lomentospora</span> species are widely distributed in nature&#46; They are generally saprophytes&#44; but can cause opportunistic infections in immunocompromised patients and occasionally in immunocompetent patients that are difficult to treat due to high levels of antifungal resistance&#46; The distribution of <span class="elsevierStyleItalic">Scedosporium&#47;Lomentospora</span> species shows regional differences&#46; <span class="elsevierStyleItalic">Scedosporium boydii and Scedosporium apiospermum</span> are the most frequently isolated species in our region&#44; whereas <span class="elsevierStyleItalic">Scedosporium aurantiacum</span> is more common in other regions&#46; We describe the first isolation in Argentina of <span class="elsevierStyleItalic">S&#46; aurantiacum</span> in a vitreous humor infection from a previously healthy patient after traumatic injury in her left eye&#46; Due to the suspicion of fungal endophthalmitis&#44; a mycological study of the vitreous humor was performed&#46; The culture allowed the isolation of <span class="elsevierStyleItalic">S</span>&#46; <span class="elsevierStyleItalic">aurantiacum</span>&#46; The patient was treated with voriconazole with favorable clinic evolution<span class="elsevierStyleBold">&#46;</span></p></span>"
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        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Las especies de <span class="elsevierStyleItalic">Scedosporium&#47;Lamentospora</span> se encuentran ampliamente distribuidas en la naturaleza&#46; En general son sapr&#243;fitas&#44; pero pueden causar infecciones oportunistas de dif&#237;cil tratamiento debido a sus altos niveles de resistencia a los antif&#250;ngicos en individuos inmunocomprometidos y&#44; ocasionalmente&#44; en personas inmunocompetentes&#46; La distribuci&#243;n de las especies de <span class="elsevierStyleItalic">Scedosporium&#47;Lamentospora</span> muestra diferencias regionales&#46; <span class="elsevierStyleItalic">Scedosporium boydii</span> y <span class="elsevierStyleItalic">S&#46; apiospermum</span> son las especies m&#225;s frecuentemente aisladas en nuestra regi&#243;n&#44; mientras que en otras <span class="elsevierStyleItalic">S&#46; aurantiacum</span> es m&#225;s com&#250;n&#46; Presentamos el primer aislamiento en Argentina de <span class="elsevierStyleItalic">S&#46; aurantiacum</span> de una infecci&#243;n de humor v&#237;treo de un paciente previamente sano que sufri&#243; una lesi&#243;n traum&#225;tica&#46; El paciente fue tratado con voriconazol y tuvo una evoluci&#243;n cl&#237;nica favorable&#46;</p></span>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Scedosporium aurantiacum</span>&#46; Sabouraud glucose agar&#46; A&#46; Front view&#46; B&#46; Reverse view&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Lactophenol cotton blue stain of <span class="elsevierStyleItalic">Scedosporium aurantiacum</span>&#46; Conidiogenous cells&#44; producing ovoid-shaped conidia&#44; either individually or in small groups&#46;</p>"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "<span class="elsevierStyleItalic">Scedosporium</span> spp&#46; from clinical setting in Argentina with proposal of the new pathogenic species <span class="elsevierStyleItalic">Scedosporium americanum</span>"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:11 [
                            0 => "R&#46; Abrantes"
                            1 => "N&#46; Refojo"
                            2 => "A&#46; Hevia"
                            3 => "J&#46; Fernandez"
                            4 => "G&#46; Isla"
                            5 => "S&#46; Cordoba"
                            6 => "M&#46;F&#46; Davalos"
                            7 => "S&#46; Lubovich"
                            8 => "I&#46; Maldonado"
                            9 => "G&#46; Davel"
                            10 => "A&#46; Stchigel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "J Fungi"
                        "fecha" => "2021"
                        "volumen" => "7"
                        "paginaInicial" => "160"
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                ]
              ]
            ]
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              "identificador" => "bib0085"
              "etiqueta" => "2"
              "referencia" => array:1 [
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                      "titulo" => "CLSI Standards M38 Reference method for broth dilution antifungal susceptibility testing of filamentous fungi"
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                        "editorial" => "Clinical and Laboratory Standards Institute&#44; CLSI"
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                      ]
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                ]
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              "identificador" => "bib0090"
              "etiqueta" => "3"
              "referencia" => array:1 [
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            3 => array:3 [
              "identificador" => "bib0095"
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              "referencia" => array:1 [
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                      "titulo" => "Molecular typing of Australian <span class="elsevierStyleItalic">Scedosporium</span> isolates showing genetic variability and numerous <span class="elsevierStyleItalic">S&#46; aurantiacum</span>"
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                          "etal" => false
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3201/eid1402.070920"
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                            "web" => "Medline"
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                        ]
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es en pt

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