Case and Research Letters
Bullous Necrotic Purpura Caused by Scedosporium apiospermum Presenting With a Sporotrichoid Pattern
Púrpura bullonecrótica de distribución esporotricoide por Scedosporium apiospermum
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Lesiones nodulares y ulceradas de distribución esporotricoide en antebrazo. C y D) Lesiones en resolución en forma de máculas purpúricas y restos costrosos en dorso de mano y antebrazo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Company-Quiroga, C. Martínez-Morán, A. Moreno, J. Borbujo" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Company-Quiroga" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Martínez-Morán" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Moreno" ] 3 => array:2 [ "nombre" => "J." 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B, Fibrosis and proliferation of nevus cells with marked intracytoplasmic melanin pigmentation and melanophages in the dermis, with no signs of malignancy.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Sardoy, M.B. Bidabehere, M.L. Gubiani, B.A. Pinardi" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Sardoy" ] 1 => array:2 [ "nombre" => "M.B." "apellidos" => "Bidabehere" ] 2 => array:2 [ "nombre" => "M.L." 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"apellidos" => "Borbujo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731017305094" "doi" => "10.1016/j.ad.2017.05.019" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731017305094?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018300611?idApp=UINPBA000044" "url" => "/15782190/0000010900000004/v1_201805040442/S1578219018300611/v1_201805040442/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letters</span>" "titulo" => "Bullous Necrotic Purpura Caused by <span class="elsevierStyleItalic">Scedosporium apiospermum</span> Presenting With a Sporotrichoid Pattern" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">To the Editor:</span>" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "374" "paginaFinal" => "376" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Company-Quiroga, C. Martínez-Morán, A. Moreno, J. Borbujo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Company-Quiroga" "email" => array:1 [ 0 => "j.companyquiroga@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Martínez-Morán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Moreno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Borbujo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Púrpura bullonecrótica de distribución esporotricoide por <span class="elsevierStyleItalic">Scedosporium apiospermum</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 600 "Ancho" => 900 "Tamanyo" => 71634 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Fungal culture with white-grayish colonies that gradually take on a brownish color.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Fungal infection is increasingly frequent among immunocompromised patients and is involved in potentially fatal conditions, mainly as a result of the baseline status of the patient affected. Recent years have seen reports of cases caused by less common fungi that are highly resistant to antifungal drugs. Such cases require a high index of suspicion and rapid initiation of treatment to prevent the expected outcome.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of an 82-year-old man who came to the emergency department at our center with a 6-week history of pruriginous skin lesions that first appeared on the dorsum of the left hand and progressed upwards. The patient had previously been a heavy smoker, and his history was remarkable for type 2 diabetes mellitus, prostate cancer (for which he was receiving palliative treatment), and chronic lymphatic leukemia. He was receiving treatment with insulin glargine and oxycodone/naloxone. He reported that his condition had worsened despite topical antifungal treatment and various oral antibiotics that were started by his primary care physician, as well as local treatments. He denied having fever and relevant systemic symptoms. The examination revealed a well-defined erythematous-violaceous plaque on the dorsum of the left hand. The plaque was slightly infiltrated, with multiple pustular and crusted lesions on the surface, and was spreading in a sporotrichoid pattern over the dorsum of the forearm, where ulcerated lesions alternated with fluctuant violaceous nodules that were seeping purulent exudate (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> A and B). The most notable findings of the laboratory workup performed in the emergency department were a minimum increase in C-reactive protein concentration (0.8<span class="elsevierStyleHsp" style=""></span>mg/dL) and mild neutrophilia (8980/μL) without leukocytosis. The chest radiograph revealed a cavitated nodule in the middle field of the left lung. A review of the tests carried out in primary care revealed a fungal culture in which <span class="elsevierStyleItalic">Scedosporium apiospermum</span> complex was isolated, with a minimum inhibitory concentration of 1 for voriconazole. The patient was diagnosed with sporotrichoid lymphocutaneous fungal infection and admitted because of possible disseminated infection while immunosuppressed. Treatment was started with oral voriconazole at 400<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h on day 1 and 200<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h on the following days. Histopathology revealed a sinus tract filled with hyperkeratotic material, with a pustule on the surface. Periodic acid-Schiff staining revealed mytotic structures in the form of spores and hyphae with clear 45° branching (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Tissue culture confirmed isolation of <span class="elsevierStyleItalic">S apiospermum</span> and was negative for bacteria and mycobacteria. The antifungal susceptibility profile confirmed sensitivity to voriconazole. The result of polymerase chain reaction assay with <span class="elsevierStyleItalic">Sporothrix schenckii</span> and mycobacteria was negative. The patient's skin complaint progressed favorably, with crusting lesions that replaced the pustules on the dorsum of the hand and ulcerated lesions instead of nodules on the forearm. Computed tomography of the chest confirmed the presence of a cavitated nodule in the left lower lobe and other, smaller nodules that were probably fungal in origin (given the patient's baseline status and after agreement with his family, we decided against further testing). Nevertheless, the possibility of endocarditis with septic embolism was ruled out using transthoracic echocardiography. During admission, the most remarkable observation was severe voriconazole-induced hyponatremia, which resolved gradually with fluid and electrolyte therapy and temporary suspension of the drug. Onset of self-limiting episodes of visual hallucinations necessitated cranial computed tomography, which ruled out fungi in the parenchyma. Therefore, the episodes were considered part of a multifactorial confusional state. The favorable laboratory outcome and clinical course led us to discharge the patient after reintroducing voriconazole. The bullous and nodular lesions disappeared after 22 days of intravenous treatment, leaving residual purpuric lesions (<a class="elsevierStyleCrossRef" href="#fig0005">Figs. 1</a>C and D), and the follow-up radiograph revealed complete cavitation of the lung nodule.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S apiospermum</span> is a ubiquitous mold found throughout the world. It is isolated in rural soil, contaminated water, and cattle and bird excrement. It mainly infects immunosuppressed patients,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> in whom it more frequently disseminates through the bloodstream. The main routes of transmission are direct inoculation via the skin and inhalation of spores.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> The main targets are the skin, the lungs, and the central nervous system.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> The most widely reported skin manifestations are bullous necrotic purpura<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3,4</span></a> and the spirotrichoid form,<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5,6</span></a> both of which occurred together in the case we present. A high index of suspicion, early diagnosis, and rapid initiation of treatment are essential if we are to improve a prognosis that is already poor. Although histology was unable to identify the pathogen, it was complemented with a positive culture (whitish colonies that progress to grayish and brownish colonies [<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>]) in order to establish the diagnosis. In addition, the extension study reveals the presence of invasive fungal infection.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> Therefore, skin involvement is essential for identification of the condition and for the need to speed up therapeutic procedures (see above). Monotherapy with voriconazole is postulated as the antifungal drug of choice depending on the resistance detected,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> although dosing and duration of treatment have not been established. Despite efforts made to date, mortality continues to be high (40%-100% depending on the series).<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8,9</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">We present a case of opportunistic infection by <span class="elsevierStyleItalic">S apiospermum</span>, a little-known pathogen with a peculiar clinical presentation that has not yet been reported in Spain. A multidisciplinary approach is essential owing to the poor baseline status of affected patients, the need to use highly toxic drugs, and the eventual associated systemic complications. In this sense, the dermatologist may play a fundamental role in early diagnosis and survival.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "Références" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Company-Quiroga J, Martínez-Morán C, Moreno A, Borbujo J. Púrpura bullonecrótica de distribución esporotricoide por <span class="elsevierStyleItalic">Scedosporium apiospermum</span>. Actas Dermosifiliogr. 2018;109:374–376.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1949 "Ancho" => 1400 "Tamanyo" => 417063 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A and B, Well-defined infiltrated erythematous-violaceous plaque on the dorsum of the hand, with pustular and crusted lesions on the surface. Nodular and ulcerated lesions distributed in a sporotrichoid fashion on the forearm. C and D, Lesions resolving in the form of purpuric macules and crusted debris on the dorsum of the hand and forearm.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1273 "Ancho" => 900 "Tamanyo" => 294715 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Sinus tract filled with hyperkeratotic material, with a pustule on the surface (hematoxylin-eosin, original magnification ×20). B, Mycotic structures in the form of spores and hyphae with 45° branching (Periodic acid–Schiff).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 600 "Ancho" => 900 "Tamanyo" => 71634 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Fungal culture with white-grayish colonies that gradually take on a brownish color.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Références" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous <span class="elsevierStyleItalic">Pseudallescheria boydii/Scedosporium apiospermum Complex</span> (Molecular type: <span class="elsevierStyleItalic">Scedosporium apiospermum</span> [Clade 4] infection: A case report and literature review of cases from Japan" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 8 | 15 |
| 2024 October | 84 | 56 | 140 |
| 2024 September | 107 | 39 | 146 |
| 2024 August | 129 | 58 | 187 |
| 2024 July | 102 | 45 | 147 |
| 2024 June | 89 | 31 | 120 |
| 2024 May | 85 | 36 | 121 |
| 2024 April | 91 | 33 | 124 |
| 2024 March | 92 | 32 | 124 |
| 2024 February | 61 | 37 | 98 |
| 2024 January | 62 | 29 | 91 |
| 2023 December | 66 | 17 | 83 |
| 2023 November | 70 | 26 | 96 |
| 2023 October | 80 | 37 | 117 |
| 2023 September | 92 | 33 | 125 |
| 2023 August | 52 | 16 | 68 |
| 2023 July | 96 | 36 | 132 |
| 2023 June | 72 | 26 | 98 |
| 2023 May | 77 | 17 | 94 |
| 2023 April | 78 | 18 | 96 |
| 2023 March | 73 | 25 | 98 |
| 2023 February | 68 | 23 | 91 |
| 2023 January | 47 | 32 | 79 |
| 2022 December | 58 | 43 | 101 |
| 2022 November | 32 | 27 | 59 |
| 2022 October | 23 | 21 | 44 |
| 2022 September | 25 | 30 | 55 |
| 2022 August | 28 | 28 | 56 |
| 2022 July | 25 | 32 | 57 |
| 2022 June | 23 | 23 | 46 |
| 2022 May | 53 | 30 | 83 |
| 2022 April | 89 | 39 | 128 |
| 2022 March | 99 | 57 | 156 |
| 2022 February | 81 | 32 | 113 |
| 2022 January | 64 | 44 | 108 |
| 2021 December | 61 | 46 | 107 |
| 2021 November | 87 | 40 | 127 |
| 2021 October | 63 | 54 | 117 |
| 2021 September | 49 | 33 | 82 |
| 2021 August | 53 | 31 | 84 |
| 2021 July | 33 | 26 | 59 |
| 2021 June | 42 | 24 | 66 |
| 2021 May | 46 | 49 | 95 |
| 2021 April | 80 | 44 | 124 |
| 2021 March | 66 | 34 | 100 |
| 2021 February | 72 | 30 | 102 |
| 2021 January | 47 | 16 | 63 |
| 2020 December | 47 | 27 | 74 |
| 2020 November | 26 | 18 | 44 |
| 2020 October | 35 | 18 | 53 |
| 2020 September | 74 | 18 | 92 |
| 2020 August | 23 | 23 | 46 |
| 2020 July | 34 | 22 | 56 |
| 2020 June | 46 | 34 | 80 |
| 2020 May | 25 | 15 | 40 |
| 2020 April | 29 | 18 | 47 |
| 2020 March | 40 | 14 | 54 |
| 2020 February | 2 | 0 | 2 |
| 2020 January | 2 | 0 | 2 |
| 2019 December | 7 | 0 | 7 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 9 | 0 | 9 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 7 | 1 | 8 |
| 2019 April | 7 | 0 | 7 |
| 2019 March | 12 | 2 | 14 |
| 2019 February | 2 | 0 | 2 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 4 | 0 | 4 |
| 2018 October | 12 | 0 | 12 |
| 2018 September | 2 | 0 | 2 |
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