ID Case Conference

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ID Case Conference

• September 4, 2007
• Yvonne L. Ballard

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Case

• CC right foot pain
• HPI
• 44yo WF with DM presented to vascular surgery
  clinic with right foot pain, at first metatarsal
• Original injury in 04/07, when pts toe got stuck
  on a fringe in carpet, causing a fallpt
  developed ulcer of right first toe, which
  progressively got worse

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• PMH
• Diabetes Mellitus
• Hypertension
• CHF
• Morbid Obesity
• Medications
• Glucophage
• Insulin 70/30
• Lasix
• Lisinopril
• Neurontin
• Spironolactone
• Zocor
• Celexa
• Aspirin

• SocHx
• Smokes 1ppd
• No Etoh, illicits
• No pets
• No recent travel
• NKDA
• FamHx
• CAD

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Sequence of Events

• 6/28/07 Pt reports increasing pain to right
  first MTP, with associated color changes of the
  toe
• 7/5/07 Seen in Vasc Surg clinic, and admitted to
  hospital
• Xray Osteomyelitis of first great toe, and
  grossly displaced calcaneal cuboid joint
• Arterial duplex ABIs of 0.49 and 0.59 in the
  anterior and posterior tibial arteries
• 7/9 Angiography and stenting of R SFA
• 7/10 Repeat Xray showed multiple displaced
  fractures at the mid foot level, and 3rd and 4th
  metatarsals

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(No Transcript)
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• 7/6 bedside debridement (resection of
  superficial necrotic skin only in the region of
  the first toe)
• 7/11 Discharged home on IV antibiotics
  Vancomycin, Zosyn
• (stop date of 8/15/07)
• 7/24 Amputation of first right toe
• 8/16 re-admitted for new black eschar in middle
  of her wound, with increased drainage
• 8/16 wound debridement (down to bone) and biopsy
  sent to Micro

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Physical Exam, 8/21

• Vitals Tm 36.1, BP 107/62, P 56
• Physical Exam
• Gen NAD
• CV RRR
• Resp CTA B/L
• Ext large surgical wound on right foot, wound
  from amputation shows small black area at base
  without purulence

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Labs, 8/21

• WBC 10.3
• Hct 36.5
• Plt 137
• LFTs WNL
• Coags WNL

• BUN/Cr 20/1.5
• ESR 45

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• 8/21 Discharged home with IV Abx
• Vancomycin
• Ertapenem
• Posaconazole

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Discussion
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• 8/16 Biopsy Results
• 4 Candida parapsilosis
• HOWEVERThere was a significant amount of mould
  growing UNDER the Candida on the plate

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Alternaria alternata

• One of the causative agents of phaeohyphomycosis
• Emerging opportunistic pathogen in
  immunosuppressed patients
• Is ubiquitous common laboratory contaminant

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Phaeohyphomycosis

• Immunocompetent
• Cutaneous
• Subcutaneous
• Brain abcesses
• Sinusitis
• Immunocompromised
• Fungemia
• Disseminated disease

• Other Described Cases
• Meningitis
• Pneumonia
• Prosthetic valve endocarditis
• Peritoneal dialysis catheter infection
• Osteomyelitis
• Septic Arthritis

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Alternaria alternata

• A fungus commonly isolated from plants, soil,
  food, and indoor air environment
• Produces a melanin-like pigment
• A. alternata is the most common species of 50
  species in the Alternaria genus
• Colonizes the paranasal sinuses, leading to
  chronic hypertrophic sinusitis

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Alternaria alternata

• Onychomycosis
• Sinusitis
• Ulcerated cutaneous infections
• Keratitis
• Visceral infections
• Osteomyelitis

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Patient Characteristics

• See table in
• Lyke KE, Miller NS, Towne L, Merz WG.
• A case of cutaneous ulcerative alternariosis
  rare association with diabetes mellitus and
  unusual failure of itraconazole treatment.
• Clin Infect Dis. 2001 Apr 1532(8) 1178-87. Review

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Other species

• A. chartarum
• A. dianthicola
• A. geophilia
• A. infectoria
• A. stemphyloides
• A. teunissima

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Images

• To view images of the fungus,
• go to Doctor Fungus at
• http//www.doctorfungus.org/index.htm

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Macroscopic Features

• Grows rapidly on potato glucose agar (at 25 C)
• Colony flat, downy/woolly
• Covered by grayish, short aerial hyphae
• Initially greyish white, later turns greenish
  black or olive brown with light border

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Microscopic Features

• Septate brown hyphae
• Simple or branched large conidia, with transverse
  and longitudinal septations
• May produce germ tubes
• Ovoid, darkly pigmented, smooth or roughened
• End is round, tapers at apex (beak-like
  appearance)

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Histopathologic Features

• HE stain
• Dark colored filamentous hyphae
• Fontana-Masson silver stain
• Specific to melanin

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Susceptibilities

• No standardized in vitro susceptibility testing
• Caspofungin shown to be active in vitro
• Voriconazole
• Generated lower MICs than Itraconazole

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Treatment Case Reports

• Systemic -azoles
• Intralesional Ampho B and surgical excision
• Immunotherapy

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Search PubMed

• Alternaria alternata infections
• Case reports
• Reviews
• Differential Diagnosis
• Drug Therapy