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To the best of our knowledge&#44; this is the first case of human infection with this kind of organism reported to date&#46;</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&#44; purple plaque on the left hand &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The lesion was painless and the patient could recall no history of injury at that site&#46; He had undergone bilateral lung transplantation 4 months previously and was receiving immunosuppressive therapy &#40;500<span class="elsevierStyleHsp" style=""></span>mg mycophenolate mofetil&#44; 1<span class="elsevierStyleHsp" style=""></span>mg tacrolimus&#44; and 15<span class="elsevierStyleHsp" style=""></span>mg prednisone daily&#41;&#46; A skin biopsy was taken for histopathological examination and microbiological culture&#46; Histopathology revealed suppurative&#44; granulomatous inflammation in the dermis and hypodermis&#46; The lesion was composed of lymphocytes&#44; epithelioid macrophages&#44; multinucleated giant cells&#44; and aggregates of neutrophils in the center of the granulomas &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Periodic acid-Schiff &#40;PAS&#41; stain revealed round-shaped&#44; occasionally septate&#44; fungal structures within the cytoplasm of some giant cells that were associated with extracellular fungal hyphae &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</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&#46; Velvety&#44; yellowish-white colonies with an olive-green reverse&#44; suggesting the presence of dematiaceous fungi&#44; developed after 12 days of incubation&#46; Microscopic examination of these colonies revealed brown&#44; septate hyphae without conidia&#46; The diagnosis was infection with <span class="elsevierStyleItalic">Alternaria</span> species&#46; The patient was treated with 100<span class="elsevierStyleHsp" style=""></span>mg itraconazole twice a day for 6 months&#44; leading to complete resolution of the lesion&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Forty months later the patient developed four reddish&#44; nodular skin lesions on the lower left leg &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; A biopsy of one of these lesions was performed&#44; and histopathology revealed suppurative&#44; granulomatous inflammation in the dermis&#46; Grocott&#8217; methenamine silver nitrate staining showed diffusely distributed fungal elements &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Samples were subcultured on Sabouraud dextrose agar and produced fast-growing&#44; fungal colonies with an olive-green undersurface&#46; Direct species differentiation was hampered by the absence of conidia&#44; and so molecular techniques were used&#46; DNA was extracted from the biopsy and the Internal Transcribed Spacer &#40;ITS&#41; 1&#8211;2 region&#44; which includes the 5&#46;8S ribosomal DNA gene&#44; was amplified using universal primers ITS1-4&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The sequence obtained &#40;552 base pairs&#41; was compared with those in the GenBank DNA database &#40;<a id="intr0005" class="elsevierStyleInterRef" href="http://www.ncbi.nlm.nih.gov/">www&#46;ncbi&#46;nlm&#46;nih&#46;gov</a>&#41;&#46; This sequence showed 98&#37; homology with a strain of <span class="elsevierStyleItalic">A&#46; triticina</span>&#46; The colonies were then transferred to Czapek agar &#40;Difco&#41; and analyzed by microscope&#44; which revealed oval&#44; brown conidia with horizontal and longitudinal septa&#46;</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&#44; Madrid&#44; a center with an extensive microorganism database&#46; Analyses performed there using molecular techniques confirmed our own findings&#46; The ribosomal RNA gene sequences of ITS1-5&#46;8S and ITS-2 regions of the clinical isolate described here &#40;isolate HUMV 59512&#41; have been deposited in GenBank &#40;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>&#41;&#46;</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&#44; which resulted in complete resolution of all cutaneous lesions&#46; No recurrences have been reported after 25 months of follow-up&#46;</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&#44; only a few of which have been involved in human or animal infections&#46; The most common species implicated in human disease are <span class="elsevierStyleItalic">Alternaria alternata</span> and <span class="elsevierStyleItalic">Alternaria infectoria</span>&#44; although in many reported cases of alternariosis the species has not been determined&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">A&#46; triticina</span>&#44; the species isolated from the cultures in the present case&#44; has not been previously described as a human pathogen&#46; To the best of our knowledge&#44; this is the first such case reported in the literature&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">A&#46; triticina</span> is a plant pathogen that causes leaf blight on wheat&#46; It was first identified in India in 1962 and continues to cause significant wheat crop yield losses on the Indian subcontinent&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The disease causes necrotic leaf lesions and in severe cases seeds become shriveled&#46; <span class="elsevierStyleItalic">Alternaria triticina</span> can be distinguished from other <span class="elsevierStyleItalic">Alternaria</span> species by agarose gel electrophoresis&#46;<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&#46; Cutaneous alternariosis has been described in organ transplant recipients and in patients with Cushing syndrome&#44; lymphoproliferative disorders&#44; and AIDS&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;7&#44;8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Two routes of cutaneous infection have been proposed&#58; exogenous&#44; following traumatic inoculation with fungal elements &#40;e&#46;g&#46;&#44; through injury with a plant spine&#41; or after colonization of pathologically altered skin&#59; and endogenous&#44; caused by inhalation of fungal conidia and subsequent systemic spread&#44; which eventually results in secondary cutaneous involvement&#46;<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&#46; Clinical features include verruciform&#44; eczematous&#44; or ulcerating plaques&#44; as well as vegetating or nodular lesions&#46;<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&#44; knees&#44; legs&#44; backs of the hands&#44; forearms&#44; and less frequently&#44; the face&#46; Histopathologically&#44; cutaneous <span class="elsevierStyleItalic">Alternaria</span> infections usually manifest with noncaseating granulomas and chronic inflammation in the dermis&#44; often with microabscesses&#46; Ulceration or pseudoepitheliomatous hyperplasia of the epidermis may be observed&#46; Melanized hyphae and round-to-oval refractile structures within the histiocytes are common features of fungal infections&#44; including phaeohyphomycoses&#46; Samaniego Gonz&#225;lez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> proposed that these refractile structures&#44; which may appear septate depending on type of section analyzed&#44; correspond to muriform conidia in culture&#44; and serve as a diagnostic clue in cases of cutaneous alternariosis&#46; However&#44; culture is essential for the correct identification of <span class="elsevierStyleItalic">Alternaria</span> species&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Treatment of cutaneous alternariosis is controversial&#46; Attenuation of immunosuppression or surgical excision of localized lesions can be sufficient to resolve the infection&#46;<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&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> However&#44; the dose and treatment duration are not well standardized&#46; In some cases&#44; surgery is necessary as an adjuvant to oral therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Relapses can occur even after long-term treatment&#46; In these types of cases&#44; voriconazole and liposomal amphotericin B may be an alternative treatment option&#46;</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&#46; A high index of suspicion is warranted when examining unusual skin lesions on exposed parts of the limbs of transplant recipients&#46; The diagnosis of cutaneous alternariosis requires a positive tissue culture and histological identification&#46; Early detection and treatment is important to avoid disseminated cutaneous lesions&#46;</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&#46;</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&#44; and that all the patients included in this study were appropriately informed and gave their written informed consent&#46;</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&#46;</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&#46;</p></span></span>"
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            0 => "Feohifomicosis"
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        "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&#44; violaceous plaque on the left hand&#46; Based on histopathology and microbiological culture the patient was diagnosed with infection by <span class="elsevierStyleItalic">Alternaria</span> species&#46; Treatment with itraconazole led to complete resolution of the skin lesion&#46; Forty months later he developed four reddish&#44; nodular&#44; skin lesions on the left leg&#46; Analysis of a biopsy from one of these lesions using histopathologic and molecular techniques identified a mold that shared 98&#37; homology with a strain of <span class="elsevierStyleItalic">Alternaria triticina</span>&#46; <span class="elsevierStyleItalic">Alternaria</span> species belong to a group of dematiaceous fungi that cause opportunistic infections in humans&#46; The incidence of these infections is increasing&#44; mainly in transplant centers&#46; To the best of our knowledge&#44; this is the first reported case of a human infection caused by <span class="elsevierStyleItalic">A&#46; triticina</span>&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de un hombre de 60 a&#241;os en tratamiento inmunosupresor por un trasplante pulmonar bilateral que present&#243; una placa viol&#225;cea costrosa en la mano&#46; Se diagnostic&#243; de infecci&#243;n por <span class="elsevierStyleItalic">Alternaria</span> spp mediante estudio histopatol&#243;gico y cultivo microbiol&#243;gico&#46; El tratamiento con itraconazol condujo a la resoluci&#243;n completa de la lesi&#243;n cut&#225;nea&#46; Cuarenta meses m&#225;s tarde el paciente desarroll&#243; 4 lesiones nodulares rojizas en la pierna izquierda&#46; Las muestras obtenidas de una de las lesiones fueron estudiadas mediante histopatolog&#237;a y t&#233;cnicas moleculares&#46; La secuencia de ADN que se obtuvo del germen causal mostraba una homolog&#237;a del 98&#37; con una cepa de <span class="elsevierStyleItalic">Alternaria triticina</span>&#46; Las especies de <span class="elsevierStyleItalic">Alternaria</span> forman parte del grupo de hongos que componen las feohifomicosis susceptibles de causar infecciones oportun&#237;sticas humanas&#46; La incidencia de estas infecciones est&#225; aumentando&#44; sobre todo en centros de trasplante&#46; De acuerdo con nuestra informaci&#243;n el presente caso es el primero en el que A&#46; triticina es causante de una infecci&#243;n humana&#46;</p>"
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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,
Autor para correspondencia
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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    "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&#44; opportunistic infections caused by dematiaceous molds&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> has increased in recent years&#46; Fungi belonging to the genus <span class="elsevierStyleItalic">Alternaria</span> are increasingly associated with opportunistic mycosis in immunocompromised hosts&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The most common clinical manifestations are cutaneous and subcutaneous infections&#44; as well as oculomycosis&#44; rhinosinusitis&#44; and onychomycosis&#46;<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&#46;<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&#46; To the best of our knowledge&#44; this is the first case of human infection with this kind of organism reported to date&#46;</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&#44; purple plaque on the left hand &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The lesion was painless and the patient could recall no history of injury at that site&#46; He had undergone bilateral lung transplantation 4 months previously and was receiving immunosuppressive therapy &#40;500<span class="elsevierStyleHsp" style=""></span>mg mycophenolate mofetil&#44; 1<span class="elsevierStyleHsp" style=""></span>mg tacrolimus&#44; and 15<span class="elsevierStyleHsp" style=""></span>mg prednisone daily&#41;&#46; A skin biopsy was taken for histopathological examination and microbiological culture&#46; Histopathology revealed suppurative&#44; granulomatous inflammation in the dermis and hypodermis&#46; The lesion was composed of lymphocytes&#44; epithelioid macrophages&#44; multinucleated giant cells&#44; and aggregates of neutrophils in the center of the granulomas &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Periodic acid-Schiff &#40;PAS&#41; stain revealed round-shaped&#44; occasionally septate&#44; fungal structures within the cytoplasm of some giant cells that were associated with extracellular fungal hyphae &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</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&#46; Velvety&#44; yellowish-white colonies with an olive-green reverse&#44; suggesting the presence of dematiaceous fungi&#44; developed after 12 days of incubation&#46; Microscopic examination of these colonies revealed brown&#44; septate hyphae without conidia&#46; The diagnosis was infection with <span class="elsevierStyleItalic">Alternaria</span> species&#46; The patient was treated with 100<span class="elsevierStyleHsp" style=""></span>mg itraconazole twice a day for 6 months&#44; leading to complete resolution of the lesion&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Forty months later the patient developed four reddish&#44; nodular skin lesions on the lower left leg &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; A biopsy of one of these lesions was performed&#44; and histopathology revealed suppurative&#44; granulomatous inflammation in the dermis&#46; Grocott&#8217; methenamine silver nitrate staining showed diffusely distributed fungal elements &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Samples were subcultured on Sabouraud dextrose agar and produced fast-growing&#44; fungal colonies with an olive-green undersurface&#46; Direct species differentiation was hampered by the absence of conidia&#44; and so molecular techniques were used&#46; DNA was extracted from the biopsy and the Internal Transcribed Spacer &#40;ITS&#41; 1&#8211;2 region&#44; which includes the 5&#46;8S ribosomal DNA gene&#44; was amplified using universal primers ITS1-4&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The sequence obtained &#40;552 base pairs&#41; was compared with those in the GenBank DNA database &#40;<a id="intr0005" class="elsevierStyleInterRef" href="http://www.ncbi.nlm.nih.gov/">www&#46;ncbi&#46;nlm&#46;nih&#46;gov</a>&#41;&#46; This sequence showed 98&#37; homology with a strain of <span class="elsevierStyleItalic">A&#46; triticina</span>&#46; The colonies were then transferred to Czapek agar &#40;Difco&#41; and analyzed by microscope&#44; which revealed oval&#44; brown conidia with horizontal and longitudinal septa&#46;</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&#44; Madrid&#44; a center with an extensive microorganism database&#46; Analyses performed there using molecular techniques confirmed our own findings&#46; The ribosomal RNA gene sequences of ITS1-5&#46;8S and ITS-2 regions of the clinical isolate described here &#40;isolate HUMV 59512&#41; have been deposited in GenBank &#40;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>&#41;&#46;</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&#44; which resulted in complete resolution of all cutaneous lesions&#46; No recurrences have been reported after 25 months of follow-up&#46;</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&#44; only a few of which have been involved in human or animal infections&#46; The most common species implicated in human disease are <span class="elsevierStyleItalic">Alternaria alternata</span> and <span class="elsevierStyleItalic">Alternaria infectoria</span>&#44; although in many reported cases of alternariosis the species has not been determined&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">A&#46; triticina</span>&#44; the species isolated from the cultures in the present case&#44; has not been previously described as a human pathogen&#46; To the best of our knowledge&#44; this is the first such case reported in the literature&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">A&#46; triticina</span> is a plant pathogen that causes leaf blight on wheat&#46; It was first identified in India in 1962 and continues to cause significant wheat crop yield losses on the Indian subcontinent&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The disease causes necrotic leaf lesions and in severe cases seeds become shriveled&#46; <span class="elsevierStyleItalic">Alternaria triticina</span> can be distinguished from other <span class="elsevierStyleItalic">Alternaria</span> species by agarose gel electrophoresis&#46;<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&#46; Cutaneous alternariosis has been described in organ transplant recipients and in patients with Cushing syndrome&#44; lymphoproliferative disorders&#44; and AIDS&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;7&#44;8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Two routes of cutaneous infection have been proposed&#58; exogenous&#44; following traumatic inoculation with fungal elements &#40;e&#46;g&#46;&#44; through injury with a plant spine&#41; or after colonization of pathologically altered skin&#59; and endogenous&#44; caused by inhalation of fungal conidia and subsequent systemic spread&#44; which eventually results in secondary cutaneous involvement&#46;<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&#46; Clinical features include verruciform&#44; eczematous&#44; or ulcerating plaques&#44; as well as vegetating or nodular lesions&#46;<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&#44; knees&#44; legs&#44; backs of the hands&#44; forearms&#44; and less frequently&#44; the face&#46; Histopathologically&#44; cutaneous <span class="elsevierStyleItalic">Alternaria</span> infections usually manifest with noncaseating granulomas and chronic inflammation in the dermis&#44; often with microabscesses&#46; Ulceration or pseudoepitheliomatous hyperplasia of the epidermis may be observed&#46; Melanized hyphae and round-to-oval refractile structures within the histiocytes are common features of fungal infections&#44; including phaeohyphomycoses&#46; Samaniego Gonz&#225;lez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> proposed that these refractile structures&#44; which may appear septate depending on type of section analyzed&#44; correspond to muriform conidia in culture&#44; and serve as a diagnostic clue in cases of cutaneous alternariosis&#46; However&#44; culture is essential for the correct identification of <span class="elsevierStyleItalic">Alternaria</span> species&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Treatment of cutaneous alternariosis is controversial&#46; Attenuation of immunosuppression or surgical excision of localized lesions can be sufficient to resolve the infection&#46;<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&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> However&#44; the dose and treatment duration are not well standardized&#46; In some cases&#44; surgery is necessary as an adjuvant to oral therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Relapses can occur even after long-term treatment&#46; In these types of cases&#44; voriconazole and liposomal amphotericin B may be an alternative treatment option&#46;</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&#46; A high index of suspicion is warranted when examining unusual skin lesions on exposed parts of the limbs of transplant recipients&#46; The diagnosis of cutaneous alternariosis requires a positive tissue culture and histological identification&#46; Early detection and treatment is important to avoid disseminated cutaneous lesions&#46;</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&#46;</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&#44; and that all the patients included in this study were appropriately informed and gave their written informed consent&#46;</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&#46;</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&#46;</p></span></span>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de un hombre de 60 a&#241;os en tratamiento inmunosupresor por un trasplante pulmonar bilateral que present&#243; una placa viol&#225;cea costrosa en la mano&#46; Se diagnostic&#243; de infecci&#243;n por <span class="elsevierStyleItalic">Alternaria</span> spp mediante estudio histopatol&#243;gico y cultivo microbiol&#243;gico&#46; El tratamiento con itraconazol condujo a la resoluci&#243;n completa de la lesi&#243;n cut&#225;nea&#46; Cuarenta meses m&#225;s tarde el paciente desarroll&#243; 4 lesiones nodulares rojizas en la pierna izquierda&#46; Las muestras obtenidas de una de las lesiones fueron estudiadas mediante histopatolog&#237;a y t&#233;cnicas moleculares&#46; La secuencia de ADN que se obtuvo del germen causal mostraba una homolog&#237;a del 98&#37; con una cepa de <span class="elsevierStyleItalic">Alternaria triticina</span>&#46; Las especies de <span class="elsevierStyleItalic">Alternaria</span> forman parte del grupo de hongos que componen las feohifomicosis susceptibles de causar infecciones oportun&#237;sticas humanas&#46; La incidencia de estas infecciones est&#225; aumentando&#44; sobre todo en centros de trasplante&#46; De acuerdo con nuestra informaci&#243;n el presente caso es el primero en el que A&#46; triticina es causante de una infecci&#243;n humana&#46;</p>"
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                          ]
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                          "etal" => true
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                            0 => "M&#46; Gilaberte"
                            1 => "R&#46; Bartralot"
                            2 => "J&#46;M&#46; Torres"
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                            5 => "A&#46; Alomar"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2004.10.875"
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                    0 => array:2 [
                      "titulo" => "Clave diagn&#243;stica en alternariosis cut&#225;nea"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "E&#46; Samaniego Gonz&#225;lez"
                            1 => "V&#46; Crespo Erchiga"
                            2 => "G&#243;mez Moyano"
                            3 => "A&#46; Sanz Trelles"
                          ]
                        ]
                      ]
                    ]
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                      "titulo" => "Cutaneous infection with <span class="elsevierStyleItalic">Alternaria alternata</span> complicating immunosuppression&#58; successful treatment with itraconazole"
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                          "etal" => false
                          "autores" => array:3 [
                            0 => "K&#46;M&#46; Acland"
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                      ]
                    ]
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                      "titulo" => "Cutaneous phaeohyphomycosis due to <span class="elsevierStyleItalic">Alternaria alternata</span> responding to itraconazole"
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                        0 => array:2 [
                          "etal" => false
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                          "etal" => true
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                            3 => "M&#46;P&#46; Wilhelm"
                            4 => "A&#46;J&#46; Eid"
                            5 => "N&#46;L&#46; Wengenack"
                          ]
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                    ]
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                      "doi" => "10.1111/j.1399-3062.2009.00482.x"
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                        "fecha" => "2010"
                        "volumen" => "12"
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        "identificador" => "xack94287"
        "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&#46;</p>"
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ISSN: 15782190
Idioma original: Inglés
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