e-Clinical case
Cutaneous Infection with Alternaria triticina in a Bilateral Lung Transplant Recipient
Infección cutánea por Alternaria triticina en un paciente con trasplante bilateral de pulmón
M.C. González-Velaa, S. Armestob, F. Unda-Villafuertec, J.F. Val-Bernala,
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a Departamento de Anatomía Patológica, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria e IFIMAV, Santander, Spain
b Servicio de Dermatología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Spain
c Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
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González-Vela, S. Armesto, F. Unda-Villafuerte, J.F. Val-Bernal" "autores" => array:4 [ 0 => array:3 [ "nombre" => "M.C." "apellidos" => "González-Vela" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "S." "apellidos" => "Armesto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "F." "apellidos" => "Unda-Villafuerte" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:4 [ "nombre" => "J.F." "apellidos" => "Val-Bernal" "email" => array:2 [ 0 => "apavbj@humv.es" 1 => "valbernal@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" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Departamento de Anatomía Patológica, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria e IFIMAV, Santander, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infección cutánea por <span class="elsevierStyleItalic">Alternaria triticina</span> en un paciente con trasplante bilateral de pulmón" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1280 "Ancho" => 950 "Tamanyo" => 262067 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Numerous fungi, thick-walled budding cells, and oval-shaped structures (Grocott 400×).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The incidence of phaeohyphomycoses, opportunistic infections caused by dematiaceous molds,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> has increased in recent years. Fungi belonging to the genus <span class="elsevierStyleItalic">Alternaria</span> are increasingly associated with opportunistic mycosis in immunocompromised hosts.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The most common clinical manifestations are cutaneous and subcutaneous infections, as well as oculomycosis, rhinosinusitis, and onychomycosis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The most important risk factors for cutaneous and subcutaneous infections are Cushing syndrome and solid organ transplant.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> We report a case of cutaneous infection by <span class="elsevierStyleItalic">Alternaria triticina</span> in a bilateral lung transplant patient. To the best of our knowledge, this is the first case of human infection with this kind of organism reported to date.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case description</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 60-year-old man presented with a crusted, purple plaque on the left hand (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The lesion was painless and the patient could recall no history of injury at that site. He had undergone bilateral lung transplantation 4 months previously and was receiving immunosuppressive therapy (500<span class="elsevierStyleHsp" style=""></span>mg mycophenolate mofetil, 1<span class="elsevierStyleHsp" style=""></span>mg tacrolimus, and 15<span class="elsevierStyleHsp" style=""></span>mg prednisone daily). A skin biopsy was taken for histopathological examination and microbiological culture. Histopathology revealed suppurative, granulomatous inflammation in the dermis and hypodermis. The lesion was composed of lymphocytes, epithelioid macrophages, multinucleated giant cells, and aggregates of neutrophils in the center of the granulomas (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Periodic acid-Schiff (PAS) stain revealed round-shaped, occasionally septate, fungal structures within the cytoplasm of some giant cells that were associated with extracellular fungal hyphae (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Fungal cultures were performed on Sabouraud dextrose agar. Velvety, yellowish-white colonies with an olive-green reverse, suggesting the presence of dematiaceous fungi, developed after 12 days of incubation. Microscopic examination of these colonies revealed brown, septate hyphae without conidia. The diagnosis was infection with <span class="elsevierStyleItalic">Alternaria</span> species. The patient was treated with 100<span class="elsevierStyleHsp" style=""></span>mg itraconazole twice a day for 6 months, leading to complete resolution of the lesion.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Forty months later the patient developed four reddish, nodular skin lesions on the lower left leg (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). A biopsy of one of these lesions was performed, and histopathology revealed suppurative, granulomatous inflammation in the dermis. Grocott’ methenamine silver nitrate staining showed diffusely distributed fungal elements (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Samples were subcultured on Sabouraud dextrose agar and produced fast-growing, fungal colonies with an olive-green undersurface. Direct species differentiation was hampered by the absence of conidia, and so molecular techniques were used. DNA was extracted from the biopsy and the Internal Transcribed Spacer (ITS) 1–2 region, which includes the 5.8S ribosomal DNA gene, was amplified using universal primers ITS1-4.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The sequence obtained (552 base pairs) was compared with those in the GenBank DNA database (<a id="intr0005" class="elsevierStyleInterRef" href="http://www.ncbi.nlm.nih.gov/">www.ncbi.nlm.nih.gov</a>). This sequence showed 98% homology with a strain of <span class="elsevierStyleItalic">A. triticina</span>. The colonies were then transferred to Czapek agar (Difco) and analyzed by microscope, which revealed oval, brown conidia with horizontal and longitudinal septa.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The strain was also sent for analysis to the Instituto Nacional de Salud Carlos III, Madrid, a center with an extensive microorganism database. Analyses performed there using molecular techniques confirmed our own findings. The ribosomal RNA gene sequences of ITS1-5.8S and ITS-2 regions of the clinical isolate described here (isolate HUMV 59512) have been deposited in GenBank (accession number <a id="intr0010" class="elsevierStyleInterRef" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=search&db=nucleotide&doptcmdl=genbank&term=GU318225">GU318225</a>).</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was treated twice per day for 10 months with 200<span class="elsevierStyleHsp" style=""></span>mg oral voriconazole, which resulted in complete resolution of all cutaneous lesions. No recurrences have been reported after 25 months of follow-up.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Alternaria</span> is a very large and complex genus that encompasses hundreds of species, only a few of which have been involved in human or animal infections. The most common species implicated in human disease are <span class="elsevierStyleItalic">Alternaria alternata</span> and <span class="elsevierStyleItalic">Alternaria infectoria</span>, although in many reported cases of alternariosis the species has not been determined.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">A. triticina</span>, the species isolated from the cultures in the present case, has not been previously described as a human pathogen. To the best of our knowledge, this is the first such case reported in the literature.</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">A. triticina</span> is a plant pathogen that causes leaf blight on wheat. It was first identified in India in 1962 and continues to cause significant wheat crop yield losses on the Indian subcontinent.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The disease causes necrotic leaf lesions and in severe cases seeds become shriveled. <span class="elsevierStyleItalic">Alternaria triticina</span> can be distinguished from other <span class="elsevierStyleItalic">Alternaria</span> species by agarose gel electrophoresis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Most cases of human <span class="elsevierStyleItalic">Alternaria</span> infection involve immunocompromised individuals. Cutaneous alternariosis has been described in organ transplant recipients and in patients with Cushing syndrome, lymphoproliferative disorders, and AIDS.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7,8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Two routes of cutaneous infection have been proposed: exogenous, following traumatic inoculation with fungal elements (e.g., through injury with a plant spine) or after colonization of pathologically altered skin; and endogenous, caused by inhalation of fungal conidia and subsequent systemic spread, which eventually results in secondary cutaneous involvement.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Cutaneous alternariosis can range from local skin lesions to invasive and disseminated infection. Clinical features include verruciform, eczematous, or ulcerating plaques, as well as vegetating or nodular lesions.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Skin lesions can be single or multiple and usually develop on exposed sites or bone prominences such as the feet, knees, legs, backs of the hands, forearms, and less frequently, the face. Histopathologically, cutaneous <span class="elsevierStyleItalic">Alternaria</span> infections usually manifest with noncaseating granulomas and chronic inflammation in the dermis, often with microabscesses. Ulceration or pseudoepitheliomatous hyperplasia of the epidermis may be observed. Melanized hyphae and round-to-oval refractile structures within the histiocytes are common features of fungal infections, including phaeohyphomycoses. Samaniego González et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> proposed that these refractile structures, which may appear septate depending on type of section analyzed, correspond to muriform conidia in culture, and serve as a diagnostic clue in cases of cutaneous alternariosis. However, culture is essential for the correct identification of <span class="elsevierStyleItalic">Alternaria</span> species.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Treatment of cutaneous alternariosis is controversial. Attenuation of immunosuppression or surgical excision of localized lesions can be sufficient to resolve the infection.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Many antifungal drugs have been used with varying degrees of success and itraconazole is considered the treatment of choice.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> However, the dose and treatment duration are not well standardized. In some cases, surgery is necessary as an adjuvant to oral therapy.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Relapses can occur even after long-term treatment. In these types of cases, voriconazole and liposomal amphotericin B may be an alternative treatment option.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The genus <span class="elsevierStyleItalic">Alternaria</span> belongs to a group of dematiaceous fungi that cause phaeohyphomycoses and are increasingly associated with opportunistic mycoses in immunocompromised hosts. A high index of suspicion is warranted when examining unusual skin lesions on exposed parts of the limbs of transplant recipients. The diagnosis of cutaneous alternariosis requires a positive tissue culture and histological identification. Early detection and treatment is important to avoid disseminated cutaneous lesions.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their hospitals concerning the publication of patient data, and that all the patients included in this study were appropriately informed and gave their written informed consent.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appears in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres372229" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec351355" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres372230" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec351354" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case description" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interest" ] 9 => array:2 [ "identificador" => "xack94292" "titulo" => "Acknowledgement" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec351355" "palabras" => array:4 [ 0 => "Phaehyphomycoses" 1 => "Organ transplantation" 2 => "Cutaneous alternariosis" 3 => "<span class="elsevierStyleItalic">Alternaria triticina</span>" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec351354" "palabras" => array:4 [ 0 => "Feohifomicosis" 1 => "Trasplante de órganos" 2 => "Alternariosis cutánea" 3 => "<span class="elsevierStyleItalic">Alternaria triticina</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We report the case of a 60-year-old man who was receiving immunosuppressive therapy for a bilateral lung transplant and presented with a crusted, violaceous plaque on the left hand. Based on histopathology and microbiological culture the patient was diagnosed with infection by <span class="elsevierStyleItalic">Alternaria</span> species. Treatment with itraconazole led to complete resolution of the skin lesion. Forty months later he developed four reddish, nodular, skin lesions on the left leg. Analysis of a biopsy from one of these lesions using histopathologic and molecular techniques identified a mold that shared 98% homology with a strain of <span class="elsevierStyleItalic">Alternaria triticina</span>. <span class="elsevierStyleItalic">Alternaria</span> species belong to a group of dematiaceous fungi that cause opportunistic infections in humans. The incidence of these infections is increasing, mainly in transplant centers. To the best of our knowledge, this is the first reported case of a human infection caused by <span class="elsevierStyleItalic">A. triticina</span>.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de un hombre de 60 años en tratamiento inmunosupresor por un trasplante pulmonar bilateral que presentó una placa violácea costrosa en la mano. Se diagnosticó de infección por <span class="elsevierStyleItalic">Alternaria</span> spp mediante estudio histopatológico y cultivo microbiológico. El tratamiento con itraconazol condujo a la resolución completa de la lesión cutánea. Cuarenta meses más tarde el paciente desarrolló 4 lesiones nodulares rojizas en la pierna izquierda. Las muestras obtenidas de una de las lesiones fueron estudiadas mediante histopatología y técnicas moleculares. La secuencia de ADN que se obtuvo del germen causal mostraba una homología del 98% con una cepa de <span class="elsevierStyleItalic">Alternaria triticina</span>. Las especies de <span class="elsevierStyleItalic">Alternaria</span> forman parte del grupo de hongos que componen las feohifomicosis susceptibles de causar infecciones oportunísticas humanas. La incidencia de estas infecciones está aumentando, sobre todo en centros de trasplante. De acuerdo con nuestra información el presente caso es el primero en el que A. triticina es causante de una infección humana.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1668 "Ancho" => 1108 "Tamanyo" => 200980 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Crusted, purple plaque on the left hand.</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" => 1502 "Ancho" => 1108 "Tamanyo" => 511944 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Florid, suppurative, granulomatous inflammation in the dermis and hypodermis (hematoxylin–eosin, original magnification 100×).</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" => 1279 "Ancho" => 950 "Tamanyo" => 219627 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Round, fungal structures within a granuloma. One of the round structures is septate (periodic acid-Schiff 1000×).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1266 "Ancho" => 950 "Tamanyo" => 108850 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Reddish nodular skin lesion on the left leg.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1280 "Ancho" => 950 "Tamanyo" => 262067 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Numerous fungi, thick-walled budding cells, and oval-shaped structures (Grocott 400×).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chromoblastomycosis and phaeohyphomycosis: new concepts, diagnosis, and mycology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.R. 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De Bièvre" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Mycol Med" "fecha" => "1991" "volumen" => "1" "paginaInicial" => "50" "paginaFinal" => "58" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Alternaria infections: laboratory diagnosis and relevant clinical features" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F.J. Pastor" 1 => "J. Guarro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1469-0691.2008.02024.x" "Revista" => array:6 [ "tituloSerie" => "Clin Microbiol Infect" "fecha" => "2008" "volumen" => "14" "paginaInicial" => "734" "paginaFinal" => "746" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18727797" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Amplification and direct sequencing of fungal ribosomal RNA genes for phylogenetics" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T.J. White" 1 => "T. Bruns" 2 => "S. Lee" 3 => "J. Taylor" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "PCR protocols: a guide to methods and applications" "paginaInicial" => "315" "paginaFinal" => "322" "serieFecha" => "1990" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leaf blight of wheat caused by a new species of <span class="elsevierStyleItalic">Alternaria</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. Prasada" 1 => "A.S. Prabhu" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Indian Phytopathol" "fecha" => "1962" "volumen" => "15" "paginaInicial" => "292" "paginaFinal" => "293" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Identification of <span class="elsevierStyleItalic">Alternaria species</span> on wheat by pathogenicity assays and sequencing" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D. Mercado Vernes" 1 => "M.E. Renard" 2 => "E. Duveiller" 3 => "H. Maraite" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Plant Pathol" "fecha" => "2006" "volumen" => "55" "paginaInicial" => "485" "paginaFinal" => "493" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous alternariosis in transplant recipients: clinicopathologic review of 9 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Gilaberte" 1 => "R. Bartralot" 2 => "J.M. Torres" 3 => "F.S. Reus" 4 => "V. Rodriguez" 5 => "A. Alomar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2004.10.875" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2005" "volumen" => "52" "paginaInicial" => "653" "paginaFinal" => "659" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15793517" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clave diagnóstica en alternariosis cutánea" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E. Samaniego González" 1 => "V. Crespo Erchiga" 2 => "Gómez Moyano" 3 => "A. Sanz Trelles" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Iberoam Micol" "fecha" => "2008" "volumen" => "25" "paginaInicial" => "264" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19071900" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous infection with <span class="elsevierStyleItalic">Alternaria alternata</span> complicating immunosuppression: successful treatment with itraconazole" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K.M. Acland" 1 => "R.J. Hay" 2 => "R. Groves" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "1998" "volumen" => "138" "paginaInicial" => "354" "paginaFinal" => "356" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9602891" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous phaeohyphomycosis due to <span class="elsevierStyleItalic">Alternaria alternata</span> responding to itraconazole" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.B. Duffill" 1 => "K.E. Coley" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "1993" "volumen" => "18" "paginaInicial" => "156" "paginaFinal" => "158" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8481994" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Phaeohyphomycosis due to <span class="elsevierStyleItalic">Alternaria</span> species in transplant recipients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.D. Boyce" 1 => "P.J. Deziel" 2 => "C.C. Otley" 3 => "M.P. Wilhelm" 4 => "A.J. Eid" 5 => "N.L. Wengenack" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1399-3062.2009.00482.x" "Revista" => array:6 [ "tituloSerie" => "Transpl Infect Dis" "fecha" => "2010" "volumen" => "12" "paginaInicial" => "242" "paginaFinal" => "250" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20002611" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack94292" "titulo" => "Acknowledgement" "texto" => "<p id="par0095" class="elsevierStylePara elsevierViewall">We thank Manuel Cuenca Estrella and Emilia Mellado of the Instituto Nacional de Salud Carlos III in Madrid for confirmation of the identity of the fungus.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/00017310/0000010500000008/v1_201409260036/S000173101300402X/v1_201409260036/en/main.assets" "Apartado" => array:4 [ "identificador" => "24962" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "e-Casos clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00017310/0000010500000008/v1_201409260036/S000173101300402X/v1_201409260036/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S000173101300402X?idApp=UINPBA000044" ]
| año/Mes | Html | Total | |
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| 2015 Mayo | 24 | 1 | 25 |
| 2015 Abril | 18 | 1 | 19 |
| 2015 Marzo | 9 | 2 | 11 |
| 2015 Febrero | 14 | 1 | 15 |
| 2015 Enero | 5 | 0 | 5 |
| 2014 Diciembre | 13 | 0 | 13 |
| 2014 Noviembre | 7 | 0 | 7 |
| 2014 Octubre | 29 | 1 | 30 |
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